Example Of A Nursing Care Plan

Improved Essays
First Nursing Care Plan
Nursing diagnosis related to __________ Imbalanced nutrition related to consuming more than body requirements Subjective and Objective Data
This is evidenced by JS being over one hundred pounds the weight that is ideal for her height and weight. JS is sixty-four inches tall, weighs two hundred and forty-eight pounds, and has a body mass index of 44.9. JS also has verbalized that she overeats for comfort. Furthermore, she only eats two meals a day, has an increase in sedentary lifestyle, decrease in physical activity, decrease in the body’s ability to burn calories and consumes the same amount or even more calories than before. Finally, JS stated that she does not eat vegetables and eats a lot of processed sugar
…show more content…
She will also exhibit changes in eating habits and participate in physical exercise. There will be a decrease in weight and obtaining excellent maintenance of health.
Nursing Intervention
*Complete a food diary that is about what food was eaten that includes size, weight, calories, etc. This will help JS recognize what she is actually eating and what is going on emotionally or how she is feeling while eating.
*Explore and discuss emotions and events that go along with what is being eaten. This helps JS recognize if she is eating because she is physically hungry or if it is due to something emotional (Annesi & Mareno, 2015).
*Determine safe activity level and plan exercise program. Exercise will help lose weight, decrease appetite, while increasing energy.
*Work with client and develop an eating plan. This way you can ensure getting food from all the food groups. Plus, client is more likely to be successful at following an eating plan if the client helped develop it.
How you would evaluate the outcomes and goals
*JS will complete her food diary and document foods eaten, calories consumed and circumstances or emotions felt when eating. This journal will document a progression to choosing healthy foods in appropriate
…show more content…
She has had two falls with in the past year. Client exhibits improper use of rolling walker and has a sedentary lifestyle. The environment is cluttered. JS complaints of dizziness when changing positions to fast and is taking medicine for hypertension.
There will be no falls
Nursing Intervention
*Teach client how to properly use a wheeled walker. If used improperly will result in loss in balance resulting in a fall.
*Educate client on how throw rugs and objects on the floor can result in client losing balance and falling.
*Educate on the actions of medication and when to take diuretics to prevent urgency or problems with urinary incontinence especially at night (Saccomano & Ferrara, 2015).
*Educate on having adequate lighting especially at night. This will increase visibility-preventing falls to occur (Saccomano & Ferrara, 2015).

*JS will be taught how to slowly get up from lying to sitting, then sitting to standing to prevent dizziness.
*JS will be taught exercises to perform to build up strength and endurance. (Saccomano & Ferrara,

Related Documents

  • Superior Essays

    “The nursing process is a systematic method that directs the nurse” through various steps in caring for patients (Taylor, 2011). The nursing process has five parts consisting of assessment, analysis, planning, implementation, and evaluation. These parts are not always as separate as they may seem. Sometimes some of the various parts are done simultaneously. All the parts work as a unit to strive to bring the patient to the healthiest state for that patient. The nursing process is based on a loop…

    • 1251 Words
    • 6 Pages
    Superior Essays
  • Great Essays

    definitions of nursing no matter what occupation they are. However, for nurses themselves, they may have a deeper understanding of the word “Nursing”. I have been working as LPN for only 5 months so far. It is not a long time experience, but I feel my understanding of nursing have changed. I cleared remember when I came to school, I chose nursing as my major without a hesitation. Many of my friends didn’t understand why I made such a choice because the county I came from, china, nursing is a profession…

    • 1029 Words
    • 5 Pages
    Great Essays
  • Improved Essays

    Nursing Critical Thinking

    • 665 Words
    • 3 Pages

    and analyses nursing practice 1.6 maintains accurate, comprehensive and timely documentation of assessments, planning, decision-making, actions and evaluations to become a professional nurse, critical thinking is embedded in a nurse’s every day routine. In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Wilkinson,2011…

    • 665 Words
    • 3 Pages
    Improved Essays