CARE PLAN SAMPLES

COMPILED BY: SAMMY

DATE NURSING OBJECTIVES/OUTCOME NURSHING ORDERS NURSING EVALUATION

DIAGNOSES CRITERIA INTERVENTION

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

vi. Serve patient with vi. Fruits served to

fruits to increase the patient
appetite
vii. Patient’s food served
vii. Serve food warm warm

viii. Serve attractive and viii. Patients’ served

nutritious meal to patient
 ix. Administer multivite or ix. Vitamins B complex
vitamin B complex administered as ordered
ordered

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

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

4. Educate 4. patient/relatives
patient/relations to always educated on the
wash fruits and vegetables importance of washing
thoroughly before cooking fruits and vegetables
and eating before use

5. Educate them on 5. Patient/relatives

personal and educated on personal and
environmental hygiene 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 06/03/19

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

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

06/03/19 Anxiety Patient will regain her 1. Reasure patient 1.Patinet was 06/03/19
related to mood within 1hour as that she will be better reassured
12:30pm unknown evidenced by cheerful soon. 1:30pm
outcome of facial expression and 2. disease condition
disease. relating well with 2. explain disease to was explained to her
ward in-mates, and her Goal fully met,
3. patient was
staff. 3. encourage her to encouraged to ask patient looked
ask questions questions cheerful and
related well with
4. answer all 4. Questions were others
questions in simple answered in simple
terms 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 Goal fully met as
of patient.  Cold compress was
the scrotum. pain reduced. patient verbalizing
 Apply cold compress to applied.
that pain has been
 affected part.  Prescribed medications reduced and being
 Serve prescribed was served. comfortable in bed
medications.
06/03/19 Impaired skin Patient will regain  Reassure patient  Patient reassured 06/03/19

12:30pm integrity related skin integrity within  Dress wound daily.  Daily wound dressing 1:30pm
to break in the 1hour as evidenced  Provide good nutrition to done.
continuity. by wound healing Goal fully met as
aid quick healing.  Good nutrition was
without scar. wound healed with
 Serve prescribed provided.
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.
06/03/19 Anxiety related Patient will regain his  Reassure patient to allay  Patient was reassured.

12:30pm to unknown mood within 1hoour his anxiety.  Nursing procedures

outcome of the as evidenced by  Explain all nursing were explained to
disease condition cheerful facial
expression procedures to patient. patient.
 Introduce other patients  Other patients were
who are recovering from introduced to my
the same condition. patient.
 Give diversional therapy  Diversional therapy
given
DATE/ NURSING OBJECTIVES/ NURSING ORDERS NURSING EVALUATION
DIAGNOSES 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
expression 4. patient advised not to epigastric and
secretion 3. Advice patient not to take spicy foods abdominal pains.
2. Verbalization of eat spicy food e.g. Therefore goal
minimal or absence of ginger peppers. 5. patient advised not to partially met
epigastric and abdominal take alcohol
pain. 4.advice patient not to
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
DATE/ NURSING NURSING NURSING ORDERS NURSING EVALUATION
TIME DIAGNOSIS OBJECTIVES/OUT INTERVENTION
COME CRITERIA

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

12:30pm 37oc) related to be reduced to normal take tepid bath provided and patient 1:30pm
disease range of body  Serve patient cold took his bath
condition temperature (36.5- drinks  Cold drinks were Goal fully met as
37oc) within 2 hours  Ventilate the room served patient temperature

as evidenced be: be opening the windows  Windows were recorded within

  Rechecking and put on fans opened, fans were also normal
and recording  Make patient kept on for enough
normal comfortable on bed ventilation
temperature  Serve prescribed  Patient was
of patient antipyretics made comfortable in
Patient verbalise he
 Patient body bed
is confortable
being normal  Antipyretics
on touch were served as ordered
 Patient
verbalizing he
is fine and
comfortable

Date Nursing Objectives/outcome Nursing orders Nursing Evaluation

diagnosis criteria intervention

06/03/19 Impaired body Patient will be 1.Provide a 1.Comfortable 06/03/19

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

6. Measure the
width of the
affected leg and
compare.

7. serve the
prescribed
medication

06/03/19 Anxiety Patient will regain 1.Rassure 1. Patient and 06/03/19

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

06/03/19 Inadequate Patient will gain 1. Educate 1.Patint 06/03/19

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

4.Paient
reassured.
Date Nursing Objective/Outcome Nursing Orders Nursing Interventions Date/Time Of Sign

Diagnosis Criteria Evaluation

06/03/19 Potential for Patient’s fluid and 1.Support patient when vomiting 1. Patient supported 16/09/14 at

12:30pm fluid electrolyte balance will 10:30am. Goals

2. Encourage sips of water at 2.Intake of sips encouraged
volume and be maintained as were fully met as
frequent intervals.
3. Patient reassured
electrolyte evidenced by patient patient gained
3. Reassure patient
imbalance verbalizing absence of 4. Intake and output chart strength and was

related to vomiting and 4. Monitor intake and output maintained and monitored able to eat.

diarrhea and improvements in skin charting

5.mouth cleaned after vomiting
vomiting. 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

2. Provide safety by raising side 2. bed side rails provided
mobility orientation within 2 were fully met as
rails of the bed to prevent patient
3. Patient instructed not to patient moved
(dizziness) hours as evidenced by
from falling from bed.
move unaided. about 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.

around bed unaided 4. Remove all sharps and objects

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

comfort within the period of

2.give energy given diet 2.Energy giving food given Goals fully met as
(malaise) 2hours hours as
patient was able to
3. encourage to take exercise 3. Tolerant exercise ensured.
related to evidenced by patient
perform his daily self
with aid
disease and his ability to 4.Patient reassured care and he
condition 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 Disturbed Patient will regain his sleep •Give patient warm - Warm bath given before bed Goal fully met patient was
sleep pattern pattern with 2 hours as bath before bed time time observed to sleep
06/03/19 (insomnia) evidence by observing throughout the night and
12:30pm related to patient sleeping on bed and •Give warm drink like - Warm drink like Milo given also reporting the absence o
change in patient reporting absence Milo before bed before bed time pain 06/03/19
environment of pain. time. - Good ventilation ensured
and pain. - Patient reassured of being in 1:30pm
•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.

Sammy(0247693186) Wishes You Best Of Luckꜝꜝꜝ

GOD HAS DONE IT ALREADY, ONLY YOUR PRESENCE IS NEEDED. (AMEN)