Nursing Care Plan Format
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
Date: November 12, 2050
Patient Information
Field | Details |
|---|
Patient Name | Clint Renner |
Age | 65 years |
Gender | Male |
Diagnosis | Hypertension, Diabetes Type 2 |
Assessment Data
Assessment Parameter | Findings | Date | Notes |
|---|
Blood Pressure | 160/95 mmHg | November 12, 2050 | Elevated; requires monitoring |
Blood Glucose | 180 mg/dL | November 12, 2050 | Above target range |
Pain Level | 4/10 | November 12, 2050 | Mild discomfort |
Nursing Diagnosis
Nursing Diagnosis | Rationale | Date | Priority Level |
|---|
Ineffective Health Maintenance | Patient is unable to maintain blood pressure and blood glucose within target ranges. | November 12, 2050 | High |
Goals and Expected Outcomes
Goal | Expected Outcome | Target Date | Evaluation |
|---|
Improve blood pressure control | BP to be 140/90 mmHg or lower | November 19, 2050 | Monitor BP weekly |
Achieve optimal glucose levels | Fasting blood glucose < 130 mg/dL | November 19, 2050 | Daily monitoring at home |
Nursing Interventions
Intervention | Rationale | Date | Expected Outcome |
|---|
Administer antihypertensive medication as prescribed | To lower blood pressure and prevent complications | November 12, 2050 | BP reduction |
Provide education on low-carb diet and exercise | To help control blood glucose and manage weight | November 12, 2050 | Improvement in blood glucose |
Evaluation and Follow-Up
Evaluation | Date | Status | Recommendations |
|---|
Blood pressure monitored weekly; goal not yet reached | November 19, 2050 | Ongoing | Continue antihypertensive medication and lifestyle adjustments |
Blood glucose trending down but not at target | November 19, 2050 | Ongoing | Adjust diet plan and review medication dosage |
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