Sample Care Plan Template Page 10
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51Health Perception-Health Management Pattern
Vital Signs
BP: 118/56
Pulse: 84
RR: 14
Temp: 38 C (100.4 F)
Pain Scale Type: Non-verbal pain scale (patient is sedated)
If this person has pain, describe characteristics and cause (PQRST):
No obvious signs of pain. The patient does not have physiological signs (vital sign
changes of increased BP/RR). The patient also does not exhibit guarding or restlessness. He is
currently on continuous pain and sedative medications.
Nutritional-Metabolic Pattern:
Assess patient’s nutritional status, daily patterns, and alterations (e.g. economics, social, cultural,
religious):
The patient per his BMI of 29.6 is overweight and his diet pre-hospitalization was
regular. Before being intubated the patient did answer nutritional questions upon admission and
he admitted to “not taking good care of himself.” He admitted he was “unsure” of the last time
he at food and that he does not think he ate any solid food for like “three days”. The patient
admitted to alcohol dependency where he was drinking two pitchers of beer or 6-8 shots of
whiskey a day. The patient also stated because of the grief over his wives passing he has
experienced a loss of appetite.
The nutritionist assessment of the patient was he was malnourished with obvious
nutritional and vitamin deficiencies from his alcohol dependency. The nutritionist advised that
the patient be put on multivitamins, folic acid, and thiamine supplements. Also, while the patient
has been intubated he has been put on a continuous enteral nutrition feed at 55 ml/hr.
Elimination Pattern:
Assess abdomen, bowel pattern (including LBM), urinary patterns, and alterations (e.g. foley,
ostomy, tube/drains):
The patient’s abdomen upon assessment was non-tender, non-distended, not ridged and
not tympanic. The patient has a foley catheter inserted while sedated and his output is 32-175
cc’s per hour. His urine is amber colored. On the day of treatment the patient had not had a
bowel movement for two days. The patient’s bowel pattern was reported to the doctor during
grand rounds and Colace/lactulose was ordered to help stimulate a bowel movement.
Activity-Exercise Pattern:
Assess mobility/exercise patterns including gait, restraints, assistive devices, safety measures,
and musculoskeletal alterations.
Patient is currently on bedrest because he is under sedation for his alcohol withdrawal
syndrome. The nurse performs passive range of motion qShift. The patient has orders for 2-
point soft restraints on his upper extremities because of side effects from his alcohol withdrawal
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan/12/17/2012
Page 10
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