help me plss abt. (nursing care plan)

[dekciwozzehs]

1st time to do this..

Nursing care plan

in short term..

Assessment

Client have a history of hypertension

Subjective:

Objective:Blood pressure Systolic:130 Diastolic :80 130/90mmHG

Temp. 36.8Pulse R. 74bpmShe eats salty and fatty food

Diagnosis

Wellness diagnosis?How?

Planning

??

Implementation

> Explain the modification of life style, which is needed to lessen the existence or complication of the condition.> Teach her on how to have a proper diet Use visual aids such as diagrams, pictures, videotapes, audiotapes,> Discuss healthy lifestyle changes that promote wellness

Evaluation

??

[det01]

Subjective: Anything the patient said such as "I take medication for my HTN" or "they say I have HTN" or even "I know I have HTN, but I still eat salty/fatty foods"

Diagnosis:

Is patient overweight? If so:

Altered nutrition: more than body requirements r/t high sodium and fat intake secondary to lrefusal to comply with prescribed diet (unless she is unclear on the diet, then I would use lack of knowledge about proper diet) AEB weight, BMI, skin fold thickness statements about what she eats (fill in the AEB with data appropriate for your patient)

Planning: The patient will describe specific dietary modifications including sodium and fat intake and why she should limit these things in her diet. She will give specific examples of foods that should be avoided. She will be able to do this by the end of my clinical shift on dd/mm/yyyy at time that your clinical ends at.

Evaluation: Well this depends on how your patient recieved the information. Was she able to recite what the goal said to recite? If yes you write:

GOal met. Patient was able to describe a proper low sodium and low fat diet as well as give examples of foods to avoid.

If she was able to tell you why she needs to make the changes but not give examples of foods (or any other part of it) it would ,.go something like this..

Goal partialy met. Patient was able to describe a low sodium, low fat diet and the reason for it, but was unable to give examples of foods to avoid.

Continue interventions as above but add:

Bring in examples of food labels. Help her learn to read them and look for sodium and fat content.

Bring in pictures of food. Help her sort them into what is healthy for her and what she should avoid.

If the goal was not met:

Goal not met. Continue interventions as above but add:

the two things I mentioned above.

get a consult with a nutritionist.

you may also want to consider is she not learning or is she being noncompliant?

i don't know this patient, but also condider does she have the ability to learn new things this quickly?