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Using data gathered in your health history, develop a plan of care

Health History Plan of Care Form

Using data gathered in your health history, develop a plan of care.

1: Analyze Assessment Data:

Based on the health history information, identify the following:

A. Areas for focused assessment

Provide a brief overview of those areas of strength and weakness noted from health history.

B. Client’s strengths

Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the credible evidence (peer reviewed journal or credible website).

C. Areas of concern

Expand on areas previously identified as abnormal and those that place the person at a health risk. Support your observations with data from the evidence.

D. Health teaching topics

Identify health education needs. Support your statements with facts from the Health History and information from your credible evidence.

2: Nursing Plan of Care

Next, plan your care based on your analysis of your assessment data:

A. Diagnosis

Write two nursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility.

B. Plan

Write one goal and one measurable expected outcome related to each of your nursing diagnoses. Explain why this goal and outcome is a priority. Include cultural considerations for this client.

C. Intervention

Write as many nursing interventions that you need in order to achieve the outcome. Provide the rationale for each intervention listed.

D. Evaluation

You will not carry out your care plan so you cannot evaluate the effectiveness of your nursing interventions. Instead, comment on what you would look for in order to evaluate your effectiveness.

References

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