UNIVERSITY OF SOUTH ALABAMA

COLLEGE OF NURSING Student Name: _________________

ADULT HEALTH NURSING
NURSING PLAN OF CARE Date: _________________

NURSING DIAGNOSIS
ASSESSEMENTS
NANDA diagnosis?
(Subjective/Objective
Related factors noted?
Data pertinent to this
Evidence if an “actual”
nursing diagnosis)
problem?
NURSING
INTERVENTIONS
Administering, demonstrating
and performing treatments, &
teachings pertinent to
diagnosis)
EVIDENCE
IMPLEMENTATION EVALUATION
SUPPORTING
Explain how State outcome achievement in
PRACTICE (Rationale)
interventions were met behavioral terms. Note:
(Cite source: Author & or explain why they Continue , Change (specify),
Page #) List full reference were not. Discontinue POC
separately.

Risk for loneliness R/T
Subjective:
living by self, widowed,
physical limitations,
inability to participate in
“I live alone”
usual activities
“I have 4 daughters
but they do not come
visit very often; only
1 comes often”
OUTCOME
“My husband died 2
STATEMENTS
years ago”
Measurable? Realistic?
Time element noted?
Pertinent to diagnosis?
Ongoing Assessments: 1. Involvement with 1. Met – Evaluate achievement of
patients goals and objectives:
others reduces the risk of family
loneliness (Doenges, members
1. A.b.c. Assess for Moorhouse, & Murr, visted at
Goal was met a.e.b.
family 2013, p.595). 1000
members/visitors in A. patient verbalized
2. Met –
the patient’s room 2. Indicators of distress  that she will call
patient was
q4h related to feelings of  family more often
assess at
2. A.b. Evaluate sleep loneliness and low self­ 0700, 1100, B. patient expresses
and appetite esteem are loss/gain of  and 1400 that she did not feel
disturbances q4h sleep and loss/gain of  with vitals, lonely, especially
appetite (Doenges,  had no with the company
3. A.b. Assess for any
Moorhouse, & Murr,  appetite of friendly staff
major weight loss or
2013, p.594). 
weight gain once per 3. Met – C. patient
shift assessed at acknowledged she

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 UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING Student Name: _________________
ADULT HEALTH NURSING
NURSING PLAN OF CARE Date: _________________
“I used to have a
By 09/013/2016 at 1900 0800 and would like to
sewing business but 3. Malnourishment, 
the patient will have patient has become involved in
my arthritis keeps me Prioritized Interventions: obesity, or being 
reduced risk for loneliness lost approx. some type of social
from doing that now” underweight may be a 
AEB: 7 lbs since group
sign of loneliness  admission
A. Acknowledge a 1. A.b.c. Establish a (Doenges, Moorhouse, & 
Objective: way to comfortable client- Murr, 2013, p.598). Evaluate the effectiveness of
communicate patient relationship. each intervention:
1. Met –
with family
Flat affect visited and
members during
2. A.b.c. Encourage talked with
shift (phone 1. effective – patient
Seemed sad and patient involvement 1. Once nurse client  patient on
calls, visits) opened up more
withdrawn in special interest relationship is established, personal
B. Verbalizes no level at 1000 about what
groups, such as client may feel free to talk bothered her after
Extreme fatigue feelings of music, meditation, and 1300
about feeling sin context  we spoke more
isolation and chair yoga of an empathetic  2. Met – personally
Has lost 7 lbs since loneliness during
3. A.b.c. Discuss and relationship (Doenges,  patient
coming into hospital shift 2. effective – patient
encourage patient to Moorhouse, & Murr,  expressed
C. Patient interest in brightened up when
become involved in a 2013, p.594). 
acknowledges chair yoga I mentioned chair
support group or yoga
two activities she therapeutic 2. Involvement with  3. Met –
can participate in discussion group others reduces the risk of  3. effective – patient
patient
to decrease pertaining to her expressed interest
loneliness (Doenges,  expressed
loneliness conditions in social groups,
Moorhouse, & Murr,  some
(support groups, and she spoke to
2013, p.595).  interest in
senior center) RN about groups in
groups to
stop the hospital
3. Social groups and/ or  community
therapeutic discussions  smoking
reduce the risk for 
loneliness and depression  Identify indicated changes to
(Perry, Potter, 178).  the POC: (May write on the
back of this page)

Nothing was modified in

relation to her loneliness;
however, the patient did
receive information
regarding social groups she
can participate in

This study source was downloaded by 100000815334799 from CourseHero.com on 06-25-2022 03:19:07 GMT -05:00
 UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING Student Name: _________________
ADULT HEALTH NURSING
NURSING PLAN OF CARE Date: _________________

References

Doenges, L.E., Moorhouse, M.F., & Murr, A.C. (2008) Nurse’s pocket guide: diagnoses, prioritized interventions, and rationales. (11th ed.).
Philadelphia, Pennsylvania: F.A Davis Company.

Potter, P.A. & Perry, A.G. (2014). Clinical nursing skills and techniques. (8th. Ed.). St. Louis: Elsevier.

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