Delaware Technical Community College

Nur 320 Health Assessment

RN to BSN program: Plan of Care Chart

STUDENT NAME: Makenzie D. Lee DATE: July 28, 2019

NURSING PLAN OF CARE:

Patient: Andrea F., 52 yo women
Identified Identified goal or Plan/ Interventions: Projected Community Resources/ Referrals:
problem/need: outcome: (Provide rationale/ Evaluation/ (Must be actual resources from the
(include supporting and cited evidence Outcomes: (How client’s community. Include Name,
subjective and to justify the will you measure address, web address, and phone
objective data) rationale) that it worked?) number)
Insomnia: Goals: Interventions: Evaluation: Resources:

-A.F. states “I toss -A.F. will report -A.F. will exclude -A.F. has reported Delaware Sleep Disorder Centers:
and turn frequently higher quality sleep any caffeinated decreasing caffeine Stockton Building
throughout the indicated by a food/drinks at least intake prior to bed, 261 Chapman Road
night” decrease in daytime four to six hours as well as decreasing Suite 100
restlessness and before bed stimulation from Newark, DE 19702
-When asked how fatigue at least four television and Phone: (877) 335-7533
many times times per week Caffeine is a cellphone use
throughout the week stimulant. Caffeine “How to Sleep Better”
A.F. feels tired, she -A.F. will report a also directly blocks -A.F. has states that (printable PDF for pt)
responded, “Pretty decreased Adenosine (the she has had https://www.helpguide.org/
much every day” restlessness at night byproduct of decreased her articles/sleep/getting-better-sleep.htm
(noting feelings of (i.e “tossing and metabolism that daytime napping
exhaustion daily causes sleepiness), leading to decreased
regardless of turning”) at least thus causing times of awakening
activity) four times per week awakening during night
-A.F. states she -A.F. will wake up (Peters, 2019)
wakes up frequently less than two times -A.F. will go to bed -A.F. has had a
throughout the night per night at least by 8:30pm at least difficult time
four times per week four nights per week committing to an
-A.F. states she goes earlier bedtime,
to bed around 10 pm -A.F. will avoid however states it is a
daily distraction (i.e. personal goal to
cellphone or continue to work on
-At the end of the television use) 30
conducted interview minutes prior to bed,
A.F. stated “Great, as well as avoiding
now I can go take thus distractions if
my nap!” awoken during the
night
-A.F. was observed
yawning, as well as Television and
eye rubbing cellphones act as
stimulants. The lights
-A.F. states that she emitted suppress
tends to use her melatonin. If awoken
cellphone frequently during the night for
when unable to sleep greater than 15
minutes, get out of
-A.F. drinks at least bed and perform a
three caffeinated non-stimulating
soda’s per day activity. By avoiding
lights, your body will
not assume it is time
to wake up
(Smith, Robinson, &
Segal, 2019)
 -A.F. will decrease
daytime napping
with intent to
optimize night time
sleeping
Napping may make
difficulty sleeping at
night worse. Limit
naps to 15-20
minutes early in the
afternoon
(Smith, Robinson, &
Segal, 2019)
Risk for Skin Goals: Interventions: Evaluations: Resources:
Cancer:
-A.F. will limit -A.F. will limit -A.F. has seen a -Skin Cancer Foundation
-A.F. is at an overall sun exposure to sun dermatologist and https://www.skincancer.org/prevention
increased risk of exposure between 10am and has committed to /sun-protection/prevention-guidelines
acquiring skin 4pm at least five annual appointments.
cancer as a family -A.F. will see a days a week Her dermatologist -Healthy Delaware
history exists: her dermatologist has cleared her for https://www.healthydelaware.org/
father had skin annually Between 10am and any signs of skin Individuals/Cancer/Skin
cancer 4pm the suns cancer at this time
-A.F. will perform ultraviolent rays are -Helen F. Graham
-A.F. admits to self-skin most harmful -A.F. has Cancer Center & Research Institute
excessive sun assessments at least (Skin Cancer incorporated the use 4701 Ogletown Stanton Rd
exposure, stating “I once per month. Foundation, 2019) of a daily SPF Newark, DE 19713
go to the beach moisturized in her Phone: (302) 623-4500
every weekend -A.F. will morning routine
during the summer” incorporate an SPF -Premier Dermatology &
“I spend 6-8 hours in moisturizer daily of -A.F. has not yet Cosmetic Surgery
the sun at the beach SPF 15 of higher decreased her 537 Stanton Christiana Rd.
every Saturday” weekend summer Newark, DE 19713
 It is imperative to sun exposure, Phone: (302) 633-7550
-When asked what protect your skin however, has
type of skin from the sun year incorporated low
protectant is used round SPF sunscreen. She
while at the beach, (Healthy Delaware, states she is
A.F. stated she does 2019) encouraged to
not use sunblock and improve this aspect
additionally uses an Sun exposure in the of her health;
accelerant winter poses the however, she admits
same risks as UVA she needs more work
-A.F. states she does rays are still present
not use an SPF (WebMD, 2019)
moisturizer

-A.F. states she has a -A.F. will avoid

tanning bed in her tanning, especially
home UV tanning beds.
Additionally, A.F.
-A.F. is Caucasian, will wear sunglasses
however a dark skin that protect against
completion is noted. UVA and UVB
Sun spots are when outside
present on her face
and shoulders. Ultraviolent
radiation from the
sun is extremely
damaging to the skin,
particularly the
epidermis.
(Healthy Delaware,
2019)
 UV rays cause
damage and the
breakdown of elastin
fibers within the skin.
Sun exposure causes
decrease in the
skin’s immune
function
(WebMD, 2019)
Migraines: Goals: Interventions: Evaluations: Reference:

-A.F. states she has -A.F. will achieve a -A.F. will decrease -A.F. has seen Dr. -Dale Sutherland, MD
suffered from migraine free day at her overall stress Sutherland and is an 26744 John J. Williams Highway,
migraines for over least three times per level established pt. A Suite 4
20 years week combination of her Millsboro, DE 19966
Additional, or degenerative disc Phone: (302) 231-1152
-A.F. experienced a increased, stress can disease and her
cervical neck cause worsening cervical fracture has -Delaware Acupuncture & Nutrition
fracture secondary to migraines led to pinched nerves 30 Omega Drive
a motor vehicle (Mayo Clinic, 2019) in her neck. Dr. Building J
crash in her early Sutherland has Newark, DE 19713
20’s -A.F. will utilize performed multiple Phone: (302) 273-2807
non-pharmacological nerve blocks in her
-A.F. has been techniques to neck
diagnosed with promote pain relief
Degenerative Disc -A.F. has utilized
Disease Relaxation non-pharmacological
techniques and methods of pain
-A.F. states she biofeedback have relief at initial onset
experiences a been proven to of a headache prior
migraine at least five eliminate stress and to resorting in
out of seven days a therefore decrease medication. A.F.
week the precedence of attempted seeing a
migraines. chiropractor but
Acupuncture has reports the pain
also been shown to increased (she has
aid in relief since stopped seeing
(Mayo Clinic, 2019) the chiropractor and
has continued with
-A.F. will not use Dr. Sutherland)
OTC Excedrin
Migraine medication -A.F. has tried a
more than ten times prescription migraine
per month medication, however
it did not prove
Utilizing OTC useful in her
medications in
excess may cause -A.F. has
medication overuse. additionally utilized
This may actually OTC medication
cause a headache such as NSAIDs,
when attempting to Excedrin Migraine,
stop the medication and prescription pain
(Mayo Clinic, 2019) relief
 References:
Healthy Delaware. (2019). Retrieved from https://www.healthydelaware.org/Individuals/Cancer/Skin
Mayo Clinic. (2019). Migraine. Retrieved from https://www.mayoclinic.org/diseases-conditions/migraine-headache/diagnosis-
treatment/drc-20360207
Peters, B. (2019). How long should you wait between caffeine and bedtime? Verywell Health. Retrieved from
https://www.verywellhealth.com/how-long-should-you-wait-between-caffeine-and-bedtime-3014980
Smith, M., Robinson, L., & Segal, R. (2019). How to sleep better. Help Guide. Retrieved from
https://www.helpguide.org/articles/sleep/getting-better-sleep.htm
Skin Cancer Foundation. (2019). Retrieved from https://www.skincancer.org/prevention/sun-protection/prevention-guidelines
WebMD. (2019). Cosmetic procedures: Sun exposure and skin cancer. Retrieved from https://www.webmd.com/beauty/sun-exposure-
skin-cancer#1