Nursing Care Plan Sample 7

Nursing Related Learning Experience Manual
GORDON’S FUNCTIONAL HEALTH PATTERN
Functional Health Cue Cluster Inference Diagnostic Statement Priority Rationale

Pattern
1. Health Perception & Subjective: Risk for fall Risk for trauma rt history Low 2 The patient is at risk for
Management N/a of fall falling injuries and trauma
because of dementia and
Objective: deteriorated mental status.
 Patient was diagnosed She uses a walker and
with Alzheimer’s 4 needs to be provided safety
1/2 years ago measure when ambulating
 Patient had a cancer
operation on her colon
a year ago.
 Patient stays in
Dementia unit
 Patient uses walker
2. Nutrition / Subjective: Not a problem Not a problem Not a problem No data provided
Metabolism N/a
Objective:
N/a
3. Elimination Pattern Subjective: Not a problem Not a problem Not a problem No data provided
N/a
Objective:
N/a
4. Activity / Exercise Subjective: Wandering Wandering rt cognitive Moderate Caregiver reports patient
“She find it hard to dress impairment secondary to wandering at night. The
herself” Patient’s caregiver Alzheimer’s amb patient patient is at risk for harm
reported frequent walking around at during wandering and must
night be given assistance and
“Many times during the watched over
night she’s walk around,
turning all the lights on,
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

sitting in the chair, coming Impaired walking Impaired walking rt High 1 Patient has difficulty
back into the bed, bursting insufficient muscle walking and walks slowly.
into song” Reported by strength amb use of walker She uses a walker and
caregiver and requirement of must be provided
assistance during assistance during
“I’m so tired” ambulation ambulation, transferring
and performing activities
Objective: to prevent falling injuries.
 Patient uses walker
 Patient sometimes
doesn’t want to get
dressed and wants to
stay in her pajamas
 Patient is assisted
with getting up and
ambulating
 Patient’s gait is slow
5. Sleep / Rest Subjective: Not a problem Not a problem Not a problem Not enough data provided
 Caregiver reports
patient walks around
at night
Objective:
N/a
6. Cognitive / Subjective: Impaired memory Impaired memory rt High 2 Patient has problem with
Perceptual “I wasn’t feeling too well a neurologic disturbances memory and was
little while ago. And I told secondary to Alzheimer’s diagnosed of Alzheimer’s.
them I was pregnant” amb inability to recall She must be provided
information assistance to prevent
“I think she’s living her complications and be
teenage years.” Patient’s provided with care.
caregiver said
“Mum constantly asked for

the time whilst staring at
the clock, and she’d also
find it hard to dress

herself” Reported by
patient’s caregiver
“I even took photos of her

dressed in outfits and
printed them out but she
still got muddled”
Reported by caregiver
“She wondered out with a

minimum of night dresses
on, walked into the garage,
couldn’t get past the
garage door, sat on the
concrete floor and started
to call out” Reported by
caregiver
“Oh, I want you out of this

house. I own this house.
You shouldn’t be here. I
want you out and I want
you out today. And if you
don’t go, I’m going to call
the police”
“I had a husband a minute

ago”
Objective:
 Patient doesn’t retain a
lot in the daily life
 Patient has sometimes
episodes of slight
aggression
7. Self – Perception / Subjective: Not a problem Not a problem Not a problem Not enough data provided
Self - Concept N/a
Objective:
 Patient is very
humorous and giggles
 Patient loves music,
sings along and comes
alive
8. Role / Relationship Subjective: Caregiver role strain Caregiver role strain rt Low 1 The patient’s caregiver
“ I wasn’t getting much patient’s illness severity reports lack of sleep and
sleep at night and I could amb report of disturbed concern of continuous care
see that if this continued sleep pattern could lead him to be sick.
for a much length of time, The patient’s condition
I would be sick too” also gets worsen, making it
Caregiver reported harder for caregiver to take
care of patient.
Objective:
 Patient’s husband
cared for her until her
condition got worse
 Patient is assisted by
her husband
 Patient had made
relationship with other
residents
 Patient reintroduces
other male resident as
her husband
 Patient’s caregiver
cries after sending
patient to sleep
9. Sexuality / Subjective: Not a problem Not a problem Not a problem No data provided
Reproductive N/a
Objective:
N/a
10. Coping – Stress Subjective Not a problem Not a problem Not a problem No data provided
Tolerance N/a:
Objective:
N/a
11. Value Belief Subjective: Not a problem Not a problem Not a problem No data provided
N/a
Objective:
N/a

PROBLEM IDENTIFICATION
Problem (PES) Date Identified Time Date Resolved

Risk for trauma rt history of fall N/a N/a N/a
Wandering rt cognitive impairment N/a N/a N/a

secondary to Alzheimer’s amb patient
frequent walking around at night
Impaired walking rt insufficient muscle N/a N/a N/a

strength amb use of walker and
requirement of assistance during
ambulation
N/a N/a N/a
Impaired memory rt neurologic
disturbances secondary to Alzheimer’s
amb inability to recall information
Caregiver role strain rt patient’s illness N/a N/a N/a

severity amb report of disturbed sleep
pattern

PRIORITIZATION OF PROBLEMS
Nursing Diagnosis Prioritization Rationale

Impaired walking rt insufficient muscle strength amb use High 1 Patient has difficulty walking and walks slowly. She
of walker and requirement of assistance during uses a walker and must be provided assistance during
ambulation ambulation, transferring and performing activities to
prevent falling injuries.
High 2 Patient has problem with memory and was diagnosed of
Impaired memory rt neurologic disturbances secondary Alzheimer’s. She must be provided assistance to prevent
to Alzheimer’s amb inability to recall information complications and be provided with care.
Moderate 1 Caregiver reports patient wandering at night. The patient

Wandering rt cognitive impairment secondary to is at risk for harm during wandering and must be given
Alzheimer’s amb patient frequent walking around at assistance and watched over
night
Low 1 The patient’s caregiver reports lack of sleep and concern

Caregiver role strain rt patient’s illness severity amb of continuous care could lead him to be sick. The
report of disturbed sleep pattern patient’s condition also gets worsen, making it harder for
caregiver to take care of patient.
Low 2 The patient is at risk for falling injuries and trauma
Risk for trauma rt history of fall because of dementia and deteriorated mental status. She
uses a walker and needs to be provided safety measure
when ambulating

NURSING CARE PLAN
ASSESSMENT HEALTH NURSING DESIRED INTERVENTION EVALUATION REMARKS

PATTERN DIAGNOSIS OUTCOME
Subjective Cues: Activity- Note: Use P-E-S format Goal: Independent: Goal met Continue care and
Exercise assistance
The patient will be able 1. Present a safe environment: bed rails up, The patient was
Impaired walking rt to ambulate safely bed in a down position, important items be able to
insufficient muscle within 8 hours close by. ambulate safely
N/a strength amb use of Rationale: These measures promote a safe, with assistance
walker and requirement secure environment and may reduce risk and use of
of assistance during Objective: for falls. assistive device
ambulation
1. The patient will be 2. Execute passive or active assistive ROM The patient and
able to use assistive exercises to all extremities. caregiver
devices properly Rationale: Exercise enhances increased implements
Background Knowledge venous return, prevents stiffness, and strategies to
2. The patient and maintains muscle strength and stamina. It increase safety
Objective Cues caregiver will also avoids contracture deformation, which and prevent falls
Elderly people walk at a implement strategies to can build up quickly and could hinder
slower speed and tire increase safety and prosthesis usage. The patient did
 Patient uses more quickly because of prevent falls not have falling
walker loss of strength and mass 3. Provide foam or flotation mattress, injuries
 Patient is in leg muscles. With age, 3. The patient will not water or air mattress or kinetic therapy
assisted with there is a natural loss of have falling injuries bed, as necessary. The patient was
getting up and muscle mass that can Rationale: These equipment decrease be able to
ambulating lead to a loss of balance The patient will be able pressure on skin or tissues that can damage participate in
 Patient’s gait is and coordination and to participate in self- circulation, potentiating risk of tissue self-care
slow affect the way a person care activities ischemia or breakdown and decubitus activities
walk. (Mayo Clinic, formation.
2020)
4. Show the use of mobility devices, such
as walkers.
Rationale: These devices can compensate
for impaired function and enhance level of
activity. The goals of using such aids are to
promote safety, enhance mobility, avoid

falls, and conserve energy.
5. Help out with transfer methods by using

a fitting assistance of persons or devices
when transferring patients to bed, chair, or
stretcher.
Rationale: Learning the proper way to
transfer is necessary for maintaining
optimal mobility and patient safety.
6. Let the patient accomplish tasks at his or

her own pace. Do not hurry the patient.
Encourage independent activity as able and
safe.
Rationale: Healthcare providers and
significant others are often in a hurry and
do more for patients than needed. Thereby
slowing the patient’s recovery and
reducing his or her confidence.
7. Give positive reinforcement during

activity. Patients may be unwilling to
move or initiate new activity because of
fear of falling.
Rationale: This is to boost the patient’s
chances of recovering and to increase his
or her self-esteem.
8. Provide the patient of rest periods in

between activities. Consider energy-saving
techniques.
Rationale: Rest periods are essential to
conserve energy. The patient must learn
and accept his her limitations.
Rationale: Forced immobility may
heighten restlessness and irritability.

Diversional activity helps in refocusing
attention and promotes coping with
limitations.

ASSESSMENT HEALTH NURSING DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN DIAGNOSIS
Subjective: Cognitive- Impaired memory rt Goal: Independent: Goal Met Continue care for
Perception neurologic disturbances 1. Assess the patient’s ability to cope with patient
“I wasn’t feeling secondary to Alzheimer’s The patient will be able events, interests in surroundings and With assistance
too well a little amb inability to recall to interrupt non-reality- activity, motivation, and changes in from caregiver,
while ago. And I information based thinking with memory pattern. patient is able to
told them I was assistance from health Rationale: The elderly may have a distinguish
pregnant” care provider within 3 decrease in memory for more recent between reality-
Background knowledge: days. events, more active memory for past based and non-
“I think she’s living events, and more active memory for past reality based
her teenage years.” Alzheimer's disease is the Objectives: events and reminisce about the pleasant thinking.
Patient’s caregiver most common type of ones.
said dementia. It is a 1. patient will verbalize Prospective
progressive disease awareness of memory 2. Frequently orient patient to reality and caregivers are
“Mum constantly beginning with mild problems within 8 hours surroundings. Allow patient to have able to verbalize
asked for the time memory loss and familiar objects around him or her; use ways in which
whilst staring at the possibly leading to loss 2. patient will accept other items, such as a clock, a calendar, to orient patient
clock, and she’d of the ability to carry on limitations of condition and daily schedules, to assist in to reality, as
also find it hard to a conversation and and use resources maintaining reality orientation. needed
dress herself” respond to the effectively within 8 Rationale: To orient patient
Reported by environment. Alzheimer's hours patient is able to
patient’s caregiver disease involves parts of 3. Maintain a regular daily routine to response well
the brain that control 3. patient will accept prevent problems resulting from thirst, with
“I even took photos thought, memory, and explanations of hunger, lack of sleep, or inadequate interventions,
of her dressed in language.(CDC, 2020) inaccurate interpretation exercise. teachings and
outfits and printed within the environment Rationale: If the needs of patient are not action
them out but she within 8 hours met, it may cause the patient to become performed
still got muddled” agitated and anxious.
Reported by 4. patient will establish patient
caregiver methods to help in 4. Allow the patient the freedom to sit in a verbalizes
remembering essential chair near the window, utilize books and awareness of
“She wondered out things when possible magazines as desired. memory
with a minimum of within 8 hours Rationale: Validates the patient’s sense of problems
night dresses on, reality and assists the patient in
walked into the differentiating between day and night. patient accepts
garage, couldn’t get Respect for the patient’s personal space limitations
past the garage allows the patient to exert some control.
door, sat on the Patient
concrete floor and 5. Let the patient accomplish tasks at his establishes
started to call out” or her own pace. Do not hurry the patient. methods to help
Reported by Encourage independent activity as able remembering
caregiver and safe. with help of
Rationale: Healthcare providers and support system
“Oh, I want you out significant others are often in a hurry and
of this house. I own do more for patients than needed. Thereby
this house. You slowing the patient’s recovery and
shouldn’t be here. I reducing his or her confidence.
want you out and I
want you out today. 6. Label drawers, use written reminders
And if you don’t notes, pictures, or color-coding articles to
go, I’m going to assist patients.
call the police” Rationale: Assists the patient’s memory
by using reminders of what to do and the
“I had a husband a location of articles.
minute ago”
7. Enforce with positive feedback. Give
Objective: positive feedback when thinking and
 Patient doesn’t behavior are appropriate, or when patient
retain a lot in verbalizes that certain ideas expressed are
the daily life not based in reality.
 Patient has Rationale: Positive feedback increases
sometimes self-esteem and enhances desire to repeat
episodes of appropriate behavior.
slight
aggression 8. Explain simply. Use simple
explanations and face-to-face interaction
when communicating with patient. Do not
shout message into patient’s ear.
Rationale: Speaking slowly and in a face-
to-face position is most effective when
communicating with an elderly individual
experiencing a hearing loss.
9. Limit decisions that the patient makes.

Rationale: The patient may be unable to
make even the simplest choice decisions,
resulting in frustration and distraction. By
avoiding this, the patient has an increased
feeling of security.
10. Be supportive and convey warmth and

concern when communicating with the
patient.
Rationale: Patients frequently have
feelings of loneliness, isolation, and
depression, and they respond positively to
a smile, friendly voice, and gentle touch.
11. Express reasonable doubt if patient

relays suspicious beliefs in response to
delusional thinking. Discuss with the
patient the potential personal negative
effects of continued suspiciousness of
others.
Rationale: To discourage suspiciousness
of others.
12. Do not permit rumination of false

ideas. When this begins, talk to patient
about real people and real events.
Rationale: To avoid cultivation of false
ideas.
13. Inform the patient of care to be done,

with one instruction at a time.
Rationale: Patient require extended time
for processing information. Removal of
decision-making may facilitate improved

compliance and feelings of security.
14. Observe patient closely. Close

observation of patient’s behavior is
indicated if delusional thinking reveals an
intention for violence. patient safety is a
nursing priority.
Rationale: To provide safety for patient
and as well as care provider
Dependent:
1. Administer medication as ordered by
physician
Collaborative:
1. Collaborate with medical and
psychiatric providers in evaluating
orientation, attention span, ability to
follow directions
Rationale: To determine presence or
severity of impairment

ASSESSMENT HEALTH NURSING DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN DIAGNOSIS
Activity- Wandering rt cognitive Goal: 1. Provide for safe ambulation with Goal met Continue care for
Subjective: Exercise impairment secondary to comfortable and well-fitting clothes, shoes patient
Alzheimer’s amb patient Patient will be free of with nonskid soles and foot support, and Patient did not
“Many times during frequent walking around injury within 8 hours any necessary walking aids have injury
the night she’s walk at night Rationale: Falls in persons with AD are within
around, turning all Objectives: often related to a decline in vigor in
the lights on, sitting Background knowledge: 1. Environment will be persons who had been previously active Environment
in the chair, coming modified to enhance was modified to
back into the bed, According to Nanda the patient’s safety 2. Install bed alarms or pressure-sensitive enhance
bursting into song” definition of wandering doormats. patient’s safety
Reported by is the state in which an 2. Patient will remain Alerts the nurses of movement and helps
caregiver individual with dementia safe from environmental prevent injury to the patient. Patient remained
has meandering, aimless, hazards . safe from
Objective: or repetitive locomotion 3. During periods of inactivity, position environmental
that exposes him or her 3. Caregivers will the wanderer so that desirable hazards
N/a to harm. Dementia is ensure safety destinations, such as the bathroom, are
where a patient suffers precautions are within line of vision and undesirable Caregiver
from loss intellectual instituted and followed destinations (such as exits or stairwells) ensured safety
capacity due to damaged are out of sight. precautions are
brain neurons. Rationale: Functional, nonwandering instituted and
ambulation is possible even into late-stage followed
dementia and may be facilitated by
keeping appropriate visual cues accessible
4. If wandering takes a random or

haphazard route, reduce environmental
distractions and increase relevant
environmental cues. Note and eliminate
stimuli that distract the wanderer while in
route.
Rationale: Random pattern wandering
may be affected by environmental stimuli
5. Provide afternoon rest periods if

assessment reveals that random pattern

wandering worsens as the day progresses.
Rationale: The proportion of wandering
that is random increases as the day
progresses and may indicate fatigue.
6. Encourage the patient to participate in

activities if able to do so.
Rationale: Exercise helps to decrease
restlessness and may decrease potential
wandering.
7. Provide a regularly scheduled and

supervised exercise or walking program,
particularly if wandering occurs
excessively during the night or at times
that are inconvenient in the setting.
Rationale: While exercise or walking
programs do not reduce daytime
wandering, they have been shown to
reduce or eliminate nighttime wandering
and to decrease general agitation levels
8. Maintain a safe environment and

structured routine.
Allow the patient to wander within
boundaries in a safe environment.
Structure in the patient’s routine may
decrease wandering tendencies.
9. Avoid using restraints if at all possible.

Restraints can lead to injury, increase
agitation, anxiety, and cause
complications of immobility, feelings of
powerlessness, and tendency for
wandering.
Dependent:
1. Administer medication as ordered by
physician

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Nursing Related Learning Experience Manual

GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Cue Cluster Inference Diagnostic Statement Priority Rationale

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

“Mum constantly asked for

find it hard to dress

“I even took photos of her

“She wondered out with a

“Oh, I want you out of this

“I had a husband a minute

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

Problem (PES) Date Identified Time Date Resolved

Wandering rt cognitive impairment N/a N/a N/a

Impaired walking rt insufficient muscle N/a N/a N/a

Caregiver role strain rt patient’s illness N/a N/a N/a

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

Nursing Diagnosis Prioritization Rationale

Moderate 1 Caregiver reports patient wandering at night. The patient

Low 1 The patient’s caregiver reports lack of sleep and concern

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY