Delaware Technical Community College
NUR 320 Health Assessment
RN to BSN program: Plan of Care Chart
STUDENT NAME: _Jessica Clukey____________________________________ DATE: ____4/23/2023__________
Nursing plan of care
Identified problem/need: Identified goal or Plan/ Interventions:
(include supporting outcome: (Provide rationale/ and
subjective and objective cited evidence to justify
data) the rationale)
Imbalanced nutrition, The patient will have a Nurse will provide
more than body weight loss of 10 pounds education on diet changes
requirements related to by the next visit in 6 including reducing calorie
excessive body weight as months. intake, including more
evidenced by a BMI of 40. fruits, vegetables, and
lean meats in his diet. The
patient will keep a diet log
to review at the next visit.
*Rationale: Decreasing
calories and eating a diet
consisting of lean meats,
fruits, and vegetables will
decrease the patient’s
Projected Evaluation/ Community Resources/
Outcomes: (How will you Referrals: (Must be actual
measure that it worked?) resources from the
client’s community.
Include Name, address,
web address, and phone
number)
The patient will be Referral to
weighed at the next office Nutrition/Dietitian:
visit on the scale.
Wendy M. Gibson,
Nutritionist/Dietitian, MS,
Review the diet log to RDN, CDE, LDN, CSSD
assess caloric intake and
intake of fruits and Contemporary Nutrition
vegetables. 301 NE Front Street
Milford DE 19963
Review the exercise log to
assess daily activity and 302-285-9538
tolerance.
 body weight. Link to CDC Activity Log:
https://www.cdc.gov/
Nurse will provide healthyweight/pdf/
education on exercise to physical_activity_diary_cd
include in daily activities c.pdf
including walking at a
moderate pace for 30
minutes each day and
keep a log of activity to
review at the next visit.

*Rationale: Daily exercise

will aid in weight loss and
improve cardiac function.
Disturbed sleep pattern The patient will verbalize The nurse will educate the The nurse will ask the Referral for a sleep study
related to difficulty the importance of patient on the importance patient to “teach back” to evaluate for sleep
breathing during sleep obtaining a sleep study to of obtaining a sleep study education provided during apnea:
and difficulty falling and evaluate for sleep apnea to evaluate for sleep the office visit and will
staying asleep as as a cause of symptoms by apnea as a cause of assess that the patient can Jay J. Dave, DO
evidenced by patient the end of the visit. symptoms. verbalize the need for a 111 Neurology Way
reports of breath holding, sleep study and the Milford DE 19963
waking up gasping for air, *Rationale: Untreated importance of keeping the
morning headaches, and sleep apnea increases the appointment for a sleep 302-422-0800
loud snoring. risk of stroke and heart study at end of the visit.
attack. It can contribute to
morning headaches and
daytime
hypersomnolence.