CARE PLAN SAMPLES UPDATED

COMPILED BY: SAMMY (0247693186)

DATE NURSING OBJECTIVES/OUTCOME NURSHING ORDERS NURSING INTERVENTION EVALUATION

DIAGNOSES CRITERIA

06/06/2019 Risk for Patient will maintain her i. Reassure i. patient/relatives reassured 06/03/19
imbalanced normal eating patient/relatives
10:00AM nutritional (less habits/appetite within ii. Mouth care encouraged 1:30pm
than body 1hour as evidenced by ii. Encourage on mouth
care iii. Best meal given to patient Goal fully met, evident by
requirement) patient eating more than
related to loss I. patient being able to iv. Soft nourishing diet
eat more than half of the iii. Give patient her best half of meal served and
of appetite meal provided to patient Nurse observing patient eat
food served.
half of the food served
II. Nurse observing iv. Provide soft nourishing v. Food served in bit and at
diet to patient regular intervals
patient eat half of the
food served v. Serve patient meal in vi. Fruits served to patient
bit and at regular interval vii. Patient’s food served warm
vi. Serve patient with viii. Patients’ served
fruits to increase the
appetite ix. Vitamins B complex
administered as ordered
vii. Serve food warm

viii. Serve attractive and

 nutritious meal to patient

ix. Administer multivite or

vitamin B complex
ordered

06/03/2012 Deficient Patient/relatives will 1. Educate 1. Patient/relatives educated on 06/03/19

knowledge gain knowledge about patient/relatives on the the disease condition
2:00pm related to lack the disease condition disease condition 1:30pm
of health within 50minutes as 2. Patient/relatives made to
2. Ensure that relatives understand the disease Goals fully met, evidence
education on evidenced by patient by patient/relatives being
the disease being able to explain the understand the causes, condition (amoebic dysentery)
signs and symptoms and able to explain the disease
condition causes, signs and 3. patient/relatives educated on condition to ward-inmates
(amoebic symptoms and prevention of amoebic
dysentery the importance of proper hand
dysentery) prevention of their washing after defecation
daughter’s condition 3. Educate
patient/relatives on the 4. patient/relatives educated on
need for proper hand soap the importance of washing
and water after defecation fruits and vegetables before use

4. Educate 5. Patient/relatives educated on

patient/relations to always personal and environmental
wash fruits and vegetables hygiene
thoroughly before cooking
and eating

5. Educate them on
personal and
 environmental hygiene

Date/time Nursing Objectives/outcome Nursing orders Nursing intervention Evaluation

diagnosis criteria

06/03/19 Impaired 1.Patient will 1.Reassure patient of 1. Patient was reassured. 06/03/19
comfort experience comfort competent care to allay
12:30pm (chest pain) within the next 2 hour doubt 2. Quiet environment was 2:30pm
related to as evidenced by provided.
2. provide a quiet goal fully met, patient
inflammator 3. Patient was told to stop any verbalized absence of pain
y process of a. Patient verbalizing environment
absence of chest pain activities that cause pain.
the condition 3. Tell patient to stop any
b. Relaxed facial activities that cause pain. 4. Diversional therapy was
expression and ensured
cheerful looking 4. Ensure diversional
therapy 5. prescribed analgesics were
served
 5. Serve prescribed
analgesics

06/03/19 Ineffective Patient will regain her 1.Reassure patient 1.Patient was reassured 06/03/19
breathing normal breathing
12:30pm 2. Remove all irritating 2. all irritating objects were 1:30pm
pattern pattern within 2 hours
(dyspnoea) as evidenced by; objects from the removed from the environment
related to environment
1.recording of normal 3. patient was encouraged to
decrease 3. encourage patient to take more copios fluid
oxygen breath rate and sound
take more copious fluid
perfusion 2. Patient breathing 4. prescribed cough mixture
normally. 4. administer prescribed was served
cough mixture

06/03/19 Anxiety Patient will regain her 1. Reasure patient that she 1.Patinet was reassured 06/03/19
related to mood within 1hour as will be better soon.
12:30pm unknown evidenced by cheerful 2. disease condition was 1:30pm
outcome of facial expression and 2. explain disease to her explained to her
disease. relating well with 3. encourage her to ask 3. patient was encouraged to
ward in-mates, and questions ask questions Goal fully met, patient
staff. looked cheerful and related
4. answer all questions in 4. Questions were answered in well with others
simple terms simple terms.
Date/ Nursing Objectives/ outcome Nursing orders Nursing intervention Evaluation
Time diagnosis criteria

06/03/19 Ineffective Patient will regain  Remove tight cloths.  Tight cloths were 06/03/19

12:30pm thermoregulation normal  Do tepid sponging. removed. 1:30pm

0
(fever39.1 c)rela thermoregulation  Open nearby windows for  Tepid sponging was
ted to within 24hrs as Goal fully met.
fresh air to circulate done.
inflammation of evidenced by Patient temperature
around the patient.  Nearby windows were
the scrotum temperature recorded was reduced to
 Check temperature opened.
within normal normal after
regularly to see if the  Temperature was
range(36.2 0c-37.2 0c) subsequence
fever is reducing monitored
checking (36.50c).

06/03/19 Impaired Patient will regain his  Reassure patient of  Patient was reassured. 06/03/19

12:30pm comfort (pain) comfort within 24hrs competent health team.  Comfortable bed was 1:30pm
related to as evidenced by  Provide comfortable bed provided.
inflammation of patient verbalizing of of patient.
 the scrotum. pain reduced.  Apply cold compress to  Cold compress was Goal fully met as
affected part. applied. patient verbalizing
 Serve prescribed  Prescribed medications that pain has been
medications. was served. reduced and being
comfortable in bed

06/03/19 Impaired skin Patient will regain  Reassure patient  Patient reassured 07/03/19

12:30pm integrity related skin integrity within  Dress wound daily.  Daily wound dressing 1:30pm
to break in the period of  Provide good nutrition to done.
continuity. hospitalization as Goal fully met as
aid quick healing.  Good nutrition was
evidenced by wound wound healed with
 Serve prescribed provided.
healing without scar. no scar and patient is
medication  Prescribed antibiotics
able to walk without
were served.
restrictions.

Impaired Patient will be able to  Reassure patient.  patient was reassured 06/03/19
06/03/19 mobility related walk without any  Ensure adequate bed rest.  Adequate bed rest was 1:30pm
12:30pm to swelling of the restriction evidenced  Remove tight cloths ensured.
scrotum. by observing patient Goal fully met as
around the affect area.  Tight cloths were
walk normal patient could walk
 Serve prescribed removed.
freely.
medication.  Prescribed medications
were served.
DATE/ AGNOSES OBJECTIVES/ NURSING ORDERS NURSING EVALUATION
OUTCOME CRITERIA INTERVENTION
TIME

06/03/19 Anxiety related Patient will be relieved of 1.Reasure patient 1.Patinet was reassured 06/03/19
to unknown anxiety within 1 hour as
12:30pm outcome of evidenced by patient 2. educate patient about 2.Patinet was educated 1:30pm
disease verbalizing absence of disease process about disease process
Patient verbalized
anxiety and patient 3. Encourage to ask 3.paitnet was absence of
cheerful facial expression. question and express encouraged to ask anxiety and there
fears openly. question was cheerful
facial expression.
4. provide simple frank 4. Simple frank and Therefore goal
and clear answers and clear answers were fully met
questions and clam given to patient.
patient /family fears
5. Relatives were
5. allow relatives to allowed to visit.
visit

Impaired body Patient will be relieved of 1. Reasure 1. patient was reassured 06/03/19
comfort epigastric and abdominal patient/family that pain
06/03/19 (epigastric and pain within 2 hours as will be reduced. 2. patient advised to eat 1:30pm
abdominal pain) evidenced by ; in bit but in frequent
12:30pm 2. advise patient to eat interval Patient verbalized
related to minimal of
excessive gastric 1.Patient’s cheerful facial in bit but frequently
4. patient advised not to epigastric and
 secretion expression 3. Advice patient not to take spicy foods abdominal pains.
eat spicy food e.g. Therefore goal
2. Verbalization of ginger peppers. 5. patient advised not to partially met
minimal or absence of take alcohol
epigastric and abdominal 4.advice patient not to
pain. take alcohol 6. patient encouraged to
take in adequate fluid no
5. Encourage fluid dilute hydrochloric acid
intake. (HCL)

06/03/19 Risk for Patient fluid and electrolyte 1.support patient when 1.patine was supported 06/03/19
deficient fluid balance would be vomiting during vomiting
12:30pm volume related maintained within 2hours 1:30pm
to vomiting as evidenced by patient 2. encourage sips of 2. intake of sips was
water encouraged Goal were fully
verbalization of absence of met as patient is
vomiting. 3. reassure patient 3. patient was reassured able to eat

4. monitor intake and 4. intake and output

output charging chart was maintained
and monitored
5. administer mouth
care after every episode 5. mouth was cleaned
of vomiting after vomiting

6. administer or replace
fluid as ordered

06/03/19 Impaired Patient will maintain 1.Ensure complete rest 1.patient was made to 06/03/19
physical mobility normal body posture and 2.provide safety by rest
12:30pm (dizziness related orientation within the 2 using side rails of the 1:30pm
2. bed side rails were
to the disease hours as evidenced by
process. patient verbalizing absence
of dizziness and ability to
walk around bed unaided
bed to prevent patient provided Goals were fully
from falling from bed met as patient
3. all harmful object moved about
3. Instruct patient not to were removed unaided without
move or get up injuries
unaided. 4. floor was always dry
4. remove all sharps
object and keep floor
dry
DATE/ NURSING NURSING NURSING ORDERS NURSING INTERVENTION EVALUATION
TIME DIAGNOSIS OBJECTIVES/OUT
COME CRITERIA

06/03/19 Hyperthermia- Patient’s fever will  Assist patient to  Tepid water was provided 06/03/19

12:30pm 37oc) related to be reduced to normal take tepid bath and patient took his bath 1:30pm
disease range of body  Serve patient cold  Cold drinks were served
condition temperature (36.5- drinks  Windows were opened, Goal fully met as
37oc) within 2 hours  Ventilate the room fans were also kept on for enough patient
as evidenced be: be opening the windows ventilation temperature

and put on fans  Patient was made recorded within

 Rechecking normal
 Make patient comfortable in bed
and recording
comfortable on bed  Antipyretics were served
normal
 Serve prescribed as ordered
temperature
antipyretics
of patient
Patient verbalise
 Patient body
he is confortable
being normal
on touch
 Patient
verbalizing he
is fine and
 comfortable

Date Nursing diagnosis Objectives/outcome Nursing orders Nursing intervention Evaluation

criteria

06/03/19 Impaired body Patient will be 1.Provide a 1.Comfortable bed provided 07/03/19
comfort related to relieved of pain and comfortable bed for
12:30pm pain and swelling swelling throughout patient to rest. 2. Patient reassured 1:30pm
of the left knee the period of 3. Cold compress applied Goal fully met.
hospitalization as 2. Explain disease
evidenced by; condition to patient 4.Disease condition explained Pain relieved.
3. reassure patient and swelling knee and
1.Patient verbalising 5. Affected leg measured and thigh subsided and
no more pain. family that pain will compared
be relieved. patient feel
2. Patient being able 6. Prescribed medications served. comfortable
to sleep soundly for 8 4. Apply cold
hours. compress on the
affected area
3. Verbalization of no
swelling at the 5. Elevate the affected
affected area. part to ensure blood
circulation.

6. Measure the width

of the affected leg and
compare.
 7. serve the prescribed
medication

06/03/19 Anxiety related to Patient will regain his 1.Rassure patient and 1. Patient and relatives reassured. 06/03/19
unknown outcome normal emotional relatives.
12:30pm and prognosis of state within 2 hours as 2. patient encouraged to express his 1:30pm Goal fully
the condition. evidenced by; 2. encourage patient to fears and doubts. met
express his fears and
1.Patient freely doubts. 3. Patient educated on disease Patient and
discussing with health condition. relatives anxiety
workers his disease 3. educate patient on relieved.
his condition 4. Patients who recovered from the
condition disease condition were introduced
2. Patient showing 4. Introduce other to him.
cheerful face. patients who have
recovered from the
same condition

06/03/19 Inadequate Patient will gain some 1. Educate patient 1.Patint educated 06/03/19
knowledge related knowledge about the
12:30pm to lack of health disease condition 2. Encourage him to 2.Patient encouraged to ask 1:30pm
education on the within 1 hour as ask questions during questions during health educations
health educations. Goal fully met.
disease condition evidenced by;
3. reassure patient. Patient understood
1.Patient recounting 3. provide simple answers to patient his condition
what his disease question
condition
4.Paient reassured.
2. patient asking
questions about his
 disease condition.

Date Nursing Objective/Outcome Nursing Orders Nursing Interventions Date/Time Of

Diagnosis Criteria Evaluation

06/03/19 Risk for Patient’s fluid and 1.Support patient when vomiting 1. Patient supported 16/09/14 at 10:30am.

12:30pm imbalanced electrolyte balance will Goals were fully met

2. Encourage sips of water at 2.Intake of sips encouraged
fluid be maintained within as evidenced by
frequent intervals.
3. Patient reassured
volume 2hours as evidenced by patient verbalizing
3. Reassure patient
related to patient verbalizing 4. Intake and output chart absence of vomiting

diarrhea and absence of vomiting 4. Monitor intake and output maintained and monitored and improvements in
 vomiting. and improvements in charting 5.mouth cleaned after vomiting skin turgor

skin turgor
5.Administer mouth care after 6. Medications served

every episode or vomiting

6. Administer or replace fluids as

ordered.

7.Administer antibiotics and

antidiarrheal as prescribed

06/03/19 Impaired Patient would maintain 1. Ensure complete bed rest. 1.Patient made to rest 06/03/19

12:30pm physical normal posture and 1:30pm . Goals were

2. Provide safety by raising side 2. bed side rails provided
mobility orientation within 2 fully met as patient
rails of the bed to prevent patient
3. Patient instructed not to moved about unaided
(dizziness) hours as evidenced by
from falling from bed.
move unaided.
related to patient verbalizing
3. instruct patient not to move or
the disease absence of dizziness 4. All harmful objects removed
get up unaided
process and ability to walk and floor was always dry.

4. Remove all sharps and objects

 around bed unaided and keep floor dry.

06/03/19 impaired Patient would be 1.ensure quiet environment for 1. Environment made suitable 06/03/19

12:30pm comfort relieved of malaise adequate rest to promote rest. 1:30pm

(malaise) within the period of

2.give energy given diet 2.Energy giving food given Goals fully met as
related to 2hours hours as
patient was able to
3. encourage to take exercise 3. Tolerant exercise ensured.
disease evidenced by patient
perform his daily self
with aid
condition and his ability to 4.Patient reassured care and he
perform self-care 4.reasure patient verbalized absence of
example Bathing.
general bodily

pains/weakness
 (malaise

DATE/ NURISNG OBJECTIVES/ NURSING ORDERS NURSING INTERVENTIONS EVALUATION

TIME DIAGNOSIS OUTCOME CRITERIA
06/03/19 Risk for Patient will maintain •Reassure patient of - Patient reassured of 06/03/19
imbalanced normal nutritional pattern maintaining normal maintaining normal nutritional
12:30pm nutrition(less within 1 hour as evidence nutritional status status. 1:30pm
than body by patient verbalizing •Ensure good• Good nourishing diet was ensured Goal fully met patent ate
requirement) return of appetite and nourishing diets • Oral hygiene ensured his food well and
related to observing patient eat his •Ensure frequent oral• Meals served in small quantity/bit confess the return of this
anorexia meals hygiene and frequent intervals. appetite
•serve meals in bit• Meals serve in a clean
and at frequent environment Sign;
intervals • Patient encouraged to eat meals
. and then after eating
•Serve meals in a • Vitamins served as orders
 clean environment
•Encourage patient to
eat meals by
thanking him after
eating
•Serve proscribed
vitamins as ordered
example vitamin B
complex
06/03/19
06/03/19 Disturbed Patient will regain his sleep •Give patient warm - Warm bath given before bed
sleep pattern pattern with 2 hours as bath before bed time time 2:30pm
12:30pm (insomnia) evidence by observing Goal fully met patient was
related to patient sleeping on bed and •Give warm drink like - Warm drink like Milo given observed to sleep
change in patient reporting absence Milo before bed before bed time throughout the night and
environment of pain. time. - Good ventilation ensured also reporting the absence of
and pain. - Patient reassured of being in pain
•Ensure good safe environment.
ventilation - Patient orientated to ward
•Reassure patient of environment.
being in safe
environment - A comfortable bed made for
•Orientate patient to the patient
ward environment
- Patient allowed to assume a
•Make a comfortable comfortable posture on bed
bed for the patient - All medication where serve as
orders
 •Allow patient to
assume comfortable
posture on bed
•Serve prescribe
medicine as ordered.

Date and Nursing diagnosis Objective/outcome Nursing orders Nursing interventions Evaluations
time criteria

14/10/2020 Ineffective Patient breathing pattern 1. Encourage patient to 1. Patient was 15/10/2020

2:40pm breathing patterns will be improved within assume a fowlers encouraged

to 2:40pm
related to 24hours as evidenced by position to minimized assume a fowlers
Goal fully met as
inflammation of the recording normal breath chest pain position to
evidenced by recording
lungs. rate and sound and 2. Apply warm compress on minimized chest pain
normal breath rate and
patient breathing patient chest to relieved 2. warm compress was
 normally pain applied on patient chest to sound and patient
3. Reassure patient to relieve relieved pain breathing normally
anxiety 3. Patient was reassured as
4. prescribed analgesics anxiety was relieved.
tablets cefuroxime 500mg 4. Prescribed analgesics
was administer tablets paracetamol 1gm
Monitor respiration rate 4 was administer
hourly Respiration rate was
monitored 4 hourly.

14/10/2020 Hyperthermia Patient will regain 1.Tepid sponge patient 1.Patient was tepid 15/10/2020
(38°C) related to normal body 2.Open window to provide sponged
at 2:40pm disturbance in the 2:40pm.
temperature(36.2°C – adequate ventilation 2.Adequate ventilation
thermoregulation
center in the brain. 37.2°C) within 24hours 3.Serve was ensured Goal fully met as
patient with cold
as evidenced by drinks 3.Patient was served evidenced by rechecking
rechecking and recording 4.Check with cold drinks fanta and recording normal
and record
normal temperature and temperature every 30 minutes 4.Temperature was temperature and patient
patient body being checked and recorded body being normal to
5.Cover patient with light every 30 minutes
normal to touch clothing’s touch.
5.Patient was covered
6.Reassure patient and relatives with light clothing’s
7.Serve antipyretics as ordered 6.Patient and relatives
were reassured
 7.Antipyretic was served
as ordered.

14/10/20 Deficient Knowledge Patient and family will 1. Establish rapport to gain 1. Rapport was established to 14/10/20
related to inadequate acquire knowledge on patient’s confidence and gain patients confidence and
2:50 pm 4:50 pm
information about heart failure within 2 cooperation. cooperation and also enhance
disease condition hours as evidenced by; an effective communication. Goal fully met as
2. Assess patient and
(predisposing factors 2. Patient’s level of evidenced by;
a. Patient and family family’s level of knowledge
management and knowledge about disease
repeating some lifestyle about condition. a. Patient and
complications) condition was assessed.
modification been family repeating
explained. 3. Definition, causes, signs some lifestyle
3. Educate patient/family on and symptoms, treatment modification been
b. Patient demonstrating
the predisposing factors, modalities and complication explained.
how to incorporate new
clinical manifestations, of heart failure were
health regimen into treatment and possible explained to patient in simple b. Patient
lifestyle. complications of his terms. demonstrating how
condition. to incorporate new
4. Patient was allowed to ask
health regimen into
4. Encourage patient to ask questions of which were
lifestyle.
questions which bothers him answered tactfully

5. Patient was helped to

integrate information into
daily life
5. Help patient to integrate
6. Reward was incorporated
information into daily life
into learning process.
6. Incorporate rewards into
7. Patient answered several
learning process.
questions been asked
7. Evaluate patient’s level of indicating that he
understanding about understands the condition
condition
14/10/20 Deficient Knowledge Patient and family will 1. Establish rapport to gain 1. Rapport was established to 14/10/20
related to inadequate acquire knowledge on patient’s confidence and gain patients confidence and
2:50 pm 4:50 pm
information about heart failure within 2 cooperation. cooperation and also enhance
disease condition hours as evidenced by; an effective communication. Goal fully met as
2. Assess patient and
(predisposing factors 2. Patient’s level of evidenced by;
a. Patient and family family’s level of knowledge
management and knowledge about disease
repeating some lifestyle about condition. a. Patient and
complications) condition was assessed.
modification been family repeating
explained. 3. Definition, causes, signs some lifestyle
3. Educate patient/family on and symptoms, treatment modification been
b. Patient demonstrating
the predisposing factors, modalities and complication explained.
how to incorporate new
clinical manifestations, of heart failure were
health regimen into b. Patient
treatment and possible explained to patient in simple
lifestyle. demonstrating how
complications of his terms.
to incorporate new
condition.
4. Patient was allowed to ask health regimen into
4. Encourage patient to ask questions of which were lifestyle.
questions which bothers him answered tactfully

5. Patient was helped to

 integrate information into
daily life

6. Reward was incorporated

5. Help patient to integrate
into learning process.
information into daily life
7. Patient answered several
6. Incorporate rewards into
questions been asked
learning process.
indicating that he
7. Evaluate patient’s level of understands the condition
understanding about
condition
Sammy(0247693186) Wishes You Best Of Luckꜝꜝꜝ
GOD HAS DONE IT ALREADY, ONLY YOUR PRESENCE IS NEEDED. (AMEN)