CARE PLAN SAMPLES

COMPILED BY: SAMMY

DATE NURSING OBJECTIVES/ NURSHING ORDERS NURSING INTERVENTION EVALUATION

DIAGNOSES OUTCOME CRITERIA

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

vii. Serve food warm viii. Patient’s served

viii. Serve attractive and ix. Vitamins B complex

nutritious meal to patient administered as ordered

ix. Administer multivite or

vitamin B complex ordered
06/03/2012 Inadequate Patient/relatives will 1. Educate patient/relatives 1. Patient/relatives educated on 06/03/19
knowledge related gain knowledge about on the disease condition the disease condition
2:00pm to lack of health the disease condition 1:30pm
education on the within 50minutes as 2. Ensure that relatives 2. Patient/relatives made to
understand the causes, signs understand the disease Goals fully met,
disease condition evidenced by; evidenced by;
(amoebic and symptoms and condition (amoebic dysentery)
dysentery) Patient being able to prevention of amoebic Patient/relatives
explain the causes, dysentery 3. patient/relatives educated on
the importance of proper hand being able to explain
signs and symptoms the disease condition
and prevention of their 3. Educate patient/relatives washing after defecation
on the need for proper hand to ward-inmates
daughter’s condition 4. patient/relatives educated on
soap and water after
defecation the importance of washing
fruits and vegetables before use
4. Educate patient/relations
to always wash fruits and 5. Patient/relatives educated on
vegetables thoroughly personal and environmental
before cooking and eating hygiene

5. Educate them on personal

and environmental hygiene
Date/time Nursing diagnosis Objectives/outcome Nursing orders Nursing intervention Evaluation
criteria

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

06/03/19 Ineffective Patient will regain her [Link] patient [Link] was reassured 06/03/19
breathing pattern normal breathing pattern
12:30pm 2. Remove all irritating 2. all irritating objects were 1:30pm
(dyspnoea) within 2 hours as
related to evidenced by; objects from the removed from the environment
decrease oxygen environment
[Link] of normal 3. patient was encouraged to
perfusion 3. encourage patient to take more copios fluid
breath rate and sound
take more copious fluid
2. Patient breathing 4. prescribed cough mixture
normally. 4. administer prescribed was served
cough mixture
06/03/19 Anxiety related to Patient will regain her 1. Reassure patient that [Link] was reassured 06/03/19
unknown mood within 1hour as she will be better soon.
12:30pm outcome of evidenced by cheerful 2. disease condition was 1:30pm
disease. facial expression and 2. explain disease to her explained to her
relating well with ward in- 3. encourage her to ask 3. patient was encouraged to
mates, and staff. questions ask questions Goal fully met, patient
looked cheerful and
4. answer all questions in 4. Questions were answered in related 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

(fever39.1 c)0
thermoregulation  Open nearby windows for  Tepid sponging was
related to within 24hrs as fresh air to circulate done. Goal fully met.

inflammation of evidenced by around the patient.  Nearby windows were Patient temperature

the scrotum temperature recorded  Check temperature opened. was reduced to

within normal regularly to see if the  Temperature was normal after

range(36.2 0c-37.2 0c) fever is reducing monitored subsequence

 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.  Cold compress was Goal fully met as

the scrotum. pain reduced.  Apply cold compress to applied. patient verbalizing

affected part.  Prescribed medications that pain has been

 Serve prescribed was served. reduced and being

medications. comfortable in bed

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 aid quick healing.  Good nutrition was Goal fully met as

without scar.  Serve prescribed provided. wound healed with

medication  Prescribed antibiotics no scar and patient is

were served. able to walk without

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 around the affect area.  Tight cloths were Goal fully met as
patient could walk
 walk normal  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 procedures to patient. patient.
expression  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 to Patient will be relieved of 1. Reassure patient [Link] was reassured 06/03/19
unknown outcome of anxiety within 1 hour as
12:30pm disease evidenced by; 2. Educate patient [Link] was educated 1:30pm
about disease process about disease process
patient verbalizing Patient verbalized
absence of anxiety and 3. Encourage to ask [Link] was absence of anxiety and
patient cheerful facial question and express encouraged to ask there was cheerful facial
expression. fears openly. question expression. Therefore
goal fully met
4. provide simple frank 4. Simple frank and
and clear answers and clear answers were
questions and clam given to patient.
patient /family fears
5. Relatives were
5. allow relatives to allowed to visit.
visit

Impaired body comfort Patient will be relieved of 1. Reasure 1. patient was reassured 06/03/19
(epigastric and epigastric and abdominal patient/family that pain
06/03/19 abdominal pain) pain within 2 hours as will be reduced. 2. patient advised to eat 1:30pm
related to excessive evidenced by ; in bit but in frequent
12:30pm 2. advise patient to eat interval Patient verbalized
gastric secretion minimal of epigastric
[Link]’s cheerful facial in bit but frequently
expression 4. patient advised not to and abdominal pains.
3. Advice patient not to take spicy foods Therefore, goal partially
2. Verbalization of eat spicy food e.g. met
minimal or absence of ginger peppers. 5. patient advised not to
epigastric and abdominal take alcohol
pain. [Link] 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 deficient fluid Patient fluid and electrolyte [Link] patient when [Link] was supported 06/03/19
volume related to balance would be vomiting during vomiting
12:30pm vomiting maintained within 2hours 1:30pm
as evidenced by patient 2. encourage sips of 2. intake of sips was
water encouraged Goal were fully met as
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

and put on fans opened, fans were also normal

 Rechecking
 Make patient kept on for enough
and recording
comfortable on bed ventilation
normal
 Serve prescribed  Patient was
temperature
antipyretics made comfortable in Patient verbalise he
of patient
bed is confortable
 Patient body
 Antipyretics
being normal
were served as ordered
on touch
 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 [Link] a [Link] 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.
[Link] disease 3. Cold
compress swelling knee
verbalising no more condition to and thigh
pain. patient applied
subsided and
2. Patient being 3. reassure [Link] patient feel
able to sleep patient and condition comfortable
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 [Link] 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
[Link] 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 [Link] 06/03/19

12:30pm knowledge some knowledge patient educated 1:30pm
related to lack about the disease
of health condition within 1 2. Encourage [Link] Goal fully met.
education on the hour as evidenced him to ask encouraged to
questions during ask questions Patient
disease by; understood his
condition health during health
[Link] 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

[Link]
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 [Link] 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 [Link] 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

[Link] cleaned after vomiting
vomiting. turgor
[Link] mouth care after
6. Medications served
every episode or vomiting

6. Administer or replace fluids as

ordered.

[Link] antibiotics and

antidiarrheal as prescribed

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

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

2. Provide safety by raising side
 mobility orientation within 2 rails of the bed to prevent patient 2. bed side rails provided were fully met as

(dizziness) hours as evidenced by from falling from bed. patient moved

3. Patient instructed not to
related to patient verbalizing about unaided
3. instruct patient not to move or move unaided.
the disease absence of dizziness
get up unaided
4. All harmful objects removed
process and ability to walk
4. Remove all sharps and objects and floor was always dry.
around bed unaided
and keep floor dry.

06/03/19 impaired Patient would be [Link] 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

[Link] energy given diet [Link] 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
 disease and his ability to with aid [Link] reassured care and he

condition perform self-care verbalized absence of

[Link] patient
example Bathing. general bodily

pains/weakness

(malaise

DATE/ NURISNG OBJECTIVES/ NURSING ORDERS NURSING INTERVENTIONS EVALUATION

TIME DIAGNOSIS OUTCOME CRITERIA
06/03/19 Risk for imbalanced Patient will maintain •Reassure patient of - Patient reassured of 06/03/19
nutrition (less than body normal nutritional pattern maintaining normal maintaining normal nutritional
12:30pm requirement) related to within 1 hour as evidence nutritional status status. 1:30pm
 anorexia by patient verbalizing •Ensure good•Good nourishing diet was ensured Goal fully met
return of appetite and nourishing diets •Oral hygiene ensured patent ate his food
observing patient eat his •Ensure frequent oral• Meals served in small quantity/bit well and confess
meals hygiene and frequent intervals. the return of this
•serve meals in bit• Meals serve in a clean appetite
and at frequent environment
intervals •Patient encouraged to eat meals Sign;
. 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 sleep pattern Patient will regain his sleep •Give patient warm - Warm bath given before bed Goal fully met patient
(insomnia) related to pattern with 2 hours as bath before bed time time was observed to sleep
06/03/19 change in environment evidence by observing throughout the night
12:30pm and pain. patient sleeping on bed and •Give warm drink like - Warm drink like Milo given and also reporting the
patient reporting absence Milo before bed before bed time absence of pain
of pain. time. - Good ventilation ensured 06/03/19
- Patient reassured of being in
•Ensure good safe environment. 1:30pm
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 Wishes You Best Of Luckꜝꜝꜝ

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