INSTITUTE OF NURSING AND ALLIED HEALTH SCIENCES

BACHELOR OF SCIENCE IN NURSING

NURSING CARE PLAN
Client’s Name: John Smith
Care Plan by: Princess Charlm Kuan
Date Initiated:
ASSESSMENT HEALTH PROBLEM/ GORDON’S LEVEL OF CARE PLAN OF CARE NURSING EVALUATION
NURSING FUNCTIONAL INTERVENTIONS/
DIAGNOSIS HEALTH ACTIVITIES
PATTERN/NEED
SUBJECTIVE CUES  Impaired  Health Acute  Improve  Assess and  Client shows
physical Perception- physical monitor vital slight
mobility Health mobility through signs physical
OBJECTIVE CUES: related to Management exercise and regularly. mobility
chorea, Pattern physical  Administer improvement
Client has an rigidity, and  Nutritional- therapy. medications  Client shows
abnormal posture dystonia. Metabolic  Improve as ordered by
communicati
with twisting and  Impaired Pattern communication physician to
on
jerky movements communicatio  Elimination through speech manage the
n related to Pattern therapy and symptoms of improvement
making him unable
dysarthria and  Activity- assistive Huntington’s with the use
to sit still. Patient
cognitive Exercise devices. disease, such of assistive
also suffers from
impairment. Pattern  Prevent falls as chorea, devices.
dysthartria and is
slightly incoherent.  Risk for injury  Sleep-Rest through regular depression,  Client shows
related to Pattern monitoring and and anxiety, improved
Patient also has
uncontrolled  Cognitive- use of assistive monitor also nutrition and
difficulty walking.
movements, Perceptual devices. for any has gained
Patient also is very adverse
cognitive Pattern  Ensure
skinny and seemed
anxious and sad. impairment,  Self- adequate effects. weight
and behavioral Perception- nutrition  Provide  Client shows
VITAL SIGNS taken changes. Self-Concept through emotional improvement
as follows:  Anxiety related Pattern monitoring and support by in social
to the  Role- interventions actively interaction
progression of Relationship such as soft listening, with people
T: the disease Pattern foods or a providing
with the
and its impact  Sexuality- feeding tube if reassurance,
PR: necessary. same
on daily living. Reproductive and
 Imbalanced  Encourage counseling. condition.
RR: Pattern
nutrition: less  Coping-Stress social  Encourage
BP: 140/100 than body Tolerance engagement exercise and
requirements Pattern through physical
CR: 120 bpm
related to activities and therapy to
O2 SAT: dysphagia and support groups. improve
loss of  Provide support mobility and
appetite. and education reduce the
 Disturbed for caregivers. risk of falls.
sensory  Encourage
perception use of
related to assistive
changes in devices such
cognitive as walkers or
function. wheelchairs
 Ineffective to support
coping related mobility.
to the  Provide
emotional and speech
physical therapy and
impact of the assistive
disease. devices such
as
communicatio
 n boards to
support
communicatio
n.
 Use
environmental
modifications
such as grab
bars and non-
slip mats to
reduce the
risk of falls.
 Monitor and
adjust diet as
needed to
ensure
adequate
nutrition, such
as soft foods
or a feeding
tube if
necessary.
 Encourage
participation
in social
activities and
support
groups.
 Provide
education and
support for
caregivers,
including
 respite care
and referrals
to community
resources.

Reference/s:
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales.