1

Care Plan Assessment

Jordynn Towner
Delaware Technical Community College
NUR320: Health Assessment
 2

Holistic assessments allow the nurse to learn about their patients as a whole, instead of
just defining them by their medical diagnosis. This allows for an individualized plan of care to be
created specifically for each patient. After my assessment with my patient I was able to create his
individualized care plan, which will be summarized below.

The first problem identified for my patient was difficulty falling and staying asleep. This
was labeled as a problem because the patient reported sleeping only 6-7 hours, waking up
multiple times per night and taking up to an hour to fall asleep. Without adequate rest at night the
patient can experience fatigue the following day. My patient reported needed to drink coffee in
the morning to wake up and make it through the work day. Not getting enough sleep can affect
concentration and overall health. The first intervention that would be implemented for this
problem includes avoiding alcohol and caffeine 4-6 hours prior to bedtime. “These substances
act as stimulants and interfere with the ability to fall asleep” (Centre for Clinical Interventions,
2018). The same thought process can be used for avoiding exercise right before trying to sleep, it
can stimulate the body and make it harder to relax and fall asleep. The bed and bedroom need to
be used only for sleep and sex, this will train the mind that when the patient gets in bed it is time
to sleep. Going along with that idea is the intervention of avoiding bright screens 2-3 hours prior
to bed, this included phones, computers and TV’s. Harvard did a study on the effects on patient’s
sleep when they look at different colored lights prior to bed, blue light is emitted by phones,
computers, etc. The results concluded “The blue light suppressed melatonin for about twice as
long as the green light and shifted circadian rhythms by twice as much (3 hours vs. 1.5 hours)”
(Harvard, 2018). Melatonin is the hormone that helps regulate the sleep cycle, so if it is
suppressed there will be difficulties falling asleep. Since my patient is having trouble falling
asleep, instead of just continuing to lay in bed aimlessly he should get up and do something
relaxing until he feels sleepy. This activity should not involve any bright lights or stimulation,
such as sitting on the couch, meditating, etc. The goals for my patient regarding this problem
include sleeping 7-9 hours per night uninterrupted and taking less than 20 minutes to fall asleep.
A side effect of reaching those goals is the patient would feel more rested in the morning and
need less coffee. These interventions would be evaluated by patient reports on how he is
sleeping, keeping a sleep journal would be a good way to track information. If these
interventions were unsuccessful, then referral to a sleep center would be the next step and
information for those is included on the care plan.
 3

The second problem identified through the holistic assessment is that the patient is not
eating a heart healthy, well-balanced diet. This was crucial because the patient has a family
history of cardiac diseases. The patient admits to eating out multiple times per week and eating
frozen meals if someone doesn’t prepare meals for him. Both of those options are high in
sodium, which can increase the risk for hypertension and heart disease. The priority intervention
for this problem is adding more fruits, vegetables and whole grains to the patient’s diet. “Heart
disease and cancer share a common risk factor: chronic inflammation. A plant-based diet with
plenty of vegetables, fruits and beans seems to decrease inflammation” (AICR, 2014). Some
simple changes that can be made include cauliflower crust pizza over regular crust, or zucchini
noodles instead of typical pasta. Transitioning to a heart healthy diet includes cutting out those
meals high in sodium, this can start with packing homemade lunches and snacks to avoid eating
out at fast food restaurants. Also, my patient needs to find some easy, healthy recipes he can
make himself for those nights when dinner isn’t prepared for him. These interventions will be
evaluated by patient report of how many times he is eating out per week. I would also
recommend the patient keep a food journal so his food choices can be analyzed in regard to a
heart healthy diet. Since eating healthy may be a new feat, meeting with a registered dietician is
always an option. They would be able to analyze the patient’s current food intake and provide
meal plans for the future. Provided in the care plan is a registered dietician located minutes away
from where the patient lives.
Lastly identified was a problem that the patient was at risk for, which was risk for
inactivity or inadequate amount of exercise. The patient reported that when the weather is nice he
is active 5x per week for at least 30 minutes through riding his bike. When inclement weather
hits he states it is harder to get that exercise done. Interventions for this problem include
experimenting with other forms of aerobic exercise, besides biking. “Aerobic exercise also helps
relax blood vessel walls, lower blood pressure, burn body fat, lower blood sugar levels, reduce
inflammation, boost mood, and raise "good" HDL cholesterol” (Harvard, 2017). Examples of
other aerobic exercises include walking, jogging and swimming. Though not the same as aerobic
exercise, strength training is another option. “Strengthening your muscles not only makes you
stronger, but also stimulates bone growth, lowers blood sugar, assists with weight control,
improves balance and posture, and reduces stress and pain in the lower back and joints”
(Harvard, 2017). Since I was able to learn through my holistic assessment that my patient enjoys
 4

biking, an intervention could include the suggestion of getting an exercise bike. This could allow
for biking indoors during inclement weather. Another option would be for the patient to join a
gym, this would allow for exercise during cold, rainy or snowy weather. Included in the care
plan are multiple gyms located in the area where the patient lives, if the patient was
uncomfortable going to the gym daily they could consult with a physical trainer and get
customized home workouts created. These interventions could be evaluated by patient reports of
engaging in other forms of exercise.
My holistic assessment of my patient allowed me to gather information to identify areas
of improvement for my patient. Areas I could improve in include asking more questions about
topics I think could be potential problems for my patient. While completing my assessment I
should be evaluating the patient’s responses and coming up with potential health problems. If I
recognize problem areas I can ask more questions regarding that in order to gain more
information and complete a more thorough assessment. The importance of holistic health
assessments is immeasurable and they should be completed with every patient for optimal
outcomes.
 5

References

American Institute for Cancer Research (2014, Jan. 1). A heart-healthy diet may also prevent cancer.
Retrieved from http://web.a.ebscohost.com.libproxy.dtcc.edu/ehost/pdfviewer/pdfviewer?
vid=10&sid=dbaa15ea-d8eb-468e-ac00-b4319f782e2a%40sessionmgr4007

Centre for Clinical Interventions (2018). Sleep hygiene. Retrieved from

https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Sleep

Harvard Health Publishing (2018, Aug. 13). Blue light has a dark side. Retrieved from
https://www.health.harvard.edu/staying-healthy/blue-light-has-a-dark-side

Harvard Health Publishing (2011, Feb.). Overcoming insomnia. Retrieved from

https://www.health.harvard.edu/newsletter_article/overcoming-insomnia

Harvard Health Publishing (2017, Jan.) The 4 most important types of exercise. Retrieved from
https://www.health.harvard.edu/exercise-and-fitness/the-4-most-important-types-of-exercise
 6

Delaware Technical Community College

NUR 320 Health Assessment
RN to BSN program: Plan of Care Chart

STUDENT NAME: __Jordynn Towner______ DATE: _____04/27/20_______

Nursing plan of care

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

Patient Avoid Patient Delaware Sleep Disorder Centers

Difficulty will get 7- alcohol and will 118 Sandhill Dr Suite 201
falling/staying 9 hours of caffeine 4-6 report Middletown, DE 19709
asleep. uninterrup hours prior waking https://www.delsleep.net/
ted sleep to sleep. up fewer 1-877-335-7533
Patient reports it per night, “These to zero
takes him up to taking less substances times Bayhealth Sleep Center
an hour to fall than 30 act as each 100 South Main St
asleep. Patients minutes to stimulants night. Pt Suite 201
reports he only initially and interfere will Smyrna, DE 19977
sleeps about 6-7 fall asleep. with the consume https://www.bayhealth.org/sleep-center-
hours a night and Pt will ability to fall zero to smyrna
wakes up decrease asleep” one cups 855-873-4177
frequently during his (Centre for of coffee
that time. Pt consumpti Clinical per day.
reports he must on of Interventions Pt will
drink coffee to coffee, , 2018) report it
help wake up in limiting it taking
Avoid
the morning and to one cup him less
looking at
make it through per day. time to
bright
work during the fall
screens 2-3
day. asleep at
hours prior
night and
to going to
he’s
bed. “The
waking
blue light
up feel
suppressed
more
melatonin
refreshed
for about
.
twice as long
as the green
light and
 7

shifted
circadian
rhythms by
twice as
much (3
hours vs. 1.5
hours)”
(Harvard,
2018).

Make
bedroom
dark, don’t
leave TV on.

Keep a
regular sleep
schedule
daily.

If unable to
fall asleep in
less than 20
minutes, get
out of bed,
do
something
relaxing then
try again.
Also, use
bed for
sleeping and
sex only.
“This
technique
reconditions
people with
insomnia to
associate the
bedroom
with sleep
instead of
sleeplessness
and
frustration”
(Harvard,
2011).
 8

Not eating a heart Pt will Incorporate Have pt TKS Nutrition LLC

healthy, well- engage in more fruits, keep a 244 Manchester Way
balanced diet eating a vegetables journal Middletown, DE 19709
heart and whole of foods https://www.tksnutritionllc.com/home.ht
Pt reports he eats healthy, grains into eaten for ml
out multiple well- diet. “Heart a week – 302-897-2008
times per week. balanced disease and analyze
Pt reports he does diet. Pt cancer for all
not cook and if decrease share a major
girlfriend doesn’t the food
common
prepare meals he number of groups
will just eat times he
risk factor: and
frozen meals. Pt’s eats out chronic variety.
calculated BMI is per week. inflammatio Have pt
26.6, which is Pt’s BMI n. A plant- record
considered will based diet how
overweight. Pt’s decrease with plenty many
family medical to within of times
history includes the range vegetables, they eat
cardiac diseases. of 18.5- fruits and out per
24.9. beans week.
Have pt
seems to
weigh
decrease themselv
inflammatio es and
n” (AICR, calculate
2014). BMI.

Pack
homemade
lunches and
snacks to
decrease
need to eat
out.

Have a
couple easy,
healthy, go-
to recipes for
when
 9

girlfriend
isn’t
available to
cook.
Pt will Try other Pt will The Village Gym
Risk for find aerobic report 600 N Broad St
inactivity or different exercises, other Middletown, DE 19709
inadequate options for such as activities https://www.thevillagegym.com/
amount of exercises walking, he is 302-376-3060
exercise he can jogging, engaging
engage in swimming, in to stay Planet Fitness
Pt reports he is when etc. “Aerobic active. Pt 703 N Broad St
active for 30 biking is exercise also will join Middletown, DE 19709
minutes, 5x per not an helps relax a gym so https://www.planetfitness.com/gyms/mi
week when the option. blood vessel he is able ddletown-de
weather is nice Pt’s BMI walls, lower to 302-378-2777
and he can bike. will blood exercise
Pt reports that is decrease pressure, in YMCA
the only form of to within burn body inclemen 404 N. Cass St
activity he the range fat, lower t Middletown, DE 19709
engages in of 18.5- blood sugar weather. https://www.ymcade.org/locations/middl
consistently. Pt’s 24.9. levels, Pt’s BMI etown-ymca/
calculated BMI is reduce will 302-616-9622
26.6, which is inflammatio decrease
considered n, boost to within
overweight. mood, and the
raise "good" normal
HDL range.
cholesterol”
(Harvard,
2017).

Try strength
training
exercises.
“Strengtheni
ng your
muscles not
only makes
you stronger,
but also
stimulates
bone growth,
lowers blood
sugar, assists
with weight
control,
improves
balance and
posture, and
reduces
 10

stress and
pain in the
lower back
and
joints”(Harv
ard, 2017).

Get an
exercise bike
to be able to
work out
during
inclement
weather.
11