CLIENT CARE PLAN
Student: Amanda Neidrauer
Date: 11/17/23
Assessment
(Nursing Diagnosis)
Worded Correctly
Plan
(1 Goal & 3 or more
Outcomes)
Age: 71
Diagnosis: Hypernatremia
Implementation
Rationale
(Expected Nursing Care)
Priority #__1___
Acute Confusion r/t
electrolyte
imbalance aeb alert
and oriented x1 to
person, difficulty
initiating purposeful
behavior, and
combative behavior
Goal: Improved cognitive
function
Outcomes:
1. Patient will be oriented to
person, place, and time, and
following commands by
discharge.
2. Patient will verbalize
importance of repositioning
every 1-2 hours by
discharge.
Head to toe assessment every 12 hours
Assess patient’s mental status every 4
hours
Assess risk factors and underlying
conditions that contribute to an altered
mental state upon admission.
Assist in correcting fluid and electrolyte
imbalance by administering fluids as
ordered.
Monitor sodium level daily
3. Patient will be compliant
with staff by letting them
perform necessary hygiene
care and assessments every
12 hours.
Daily weights
Constantly reorient the patient during
hospital stay.
Provide a calm environment while
admitted.
Implement seizure precautions
Reference: & Pg. # Nursing Diagnosis Handbook pg. 242-247
-establish a baseline mental
status and perform cognitive
assessment to be able to
identify subtle changes in
cognition and behavior
-Identifying risks and possible
causes will help formulate a
care plan that can prevent
confusion and changes in
mentation.
- Fluid and electrolyte
imbalances can cause acute
confusion, therefore
addressing and correcting can
help resolve acute confusion.
-Ensure adequate fluid intake
-Confusion can cause
agitation and cause a safety
issue.
-Prevent overstimulation
-while correcting a high
sodium level, there is a risk of
overcorrecting. Low sodium
can cause seizures due the
shift of water into brain cells.
Evaluation of
Each Outcome
State if met,
partially
met/not met &
why
1. Not met –
Patient is only
oriented to
person and not
following
demands
2. Not met –
Patient does not
reposition
himself in bed,
and refuses help
to reposition
from staff.
3. Not met –
Patient tried
punching staff
during routine
hygiene care
Assessment
(Nursing Diagnosis)
Worded Correctly
Plan
(1 Goal & 3 or more
Outcomes)
Implementation
Rationale
(Expected Nursing Care)
Priority #__2__
Risk for Imbalanced
Fluid Volume
Risk Factors:
Inadequate fluid
intake, glucose level
of 119, and having a
double amputation
of lower limbs.
Goal: Maintain fluid
balance.
Head to toe assessment every 12 hours
Monitor vital signs every 8 hours
Outcomes:
1. Patient will drink 4
ounces of nectar
consistency fluids
every hour between
7am and 7pm.
Obtain a nutrition assessment upon admission
Assess skin turgor/ mucous membranes every 8
hours
Monitor fluid input/output daily
2. Patient will have
blood glucose between Offer 4 oz of nectar consistency fluid every
70-99 by discharge.
hour between 7am-7pm
3. Patient will comply Monitor BUN/CR levels daily
with being
repositioned/turned
Monitor sodium levels daily
every 1-2 hours during
admission.
Montor glucose level every 6 hours
Administer insulin/dextrose as ordered to
control diabetes
-Obtain a baseline
-Assess for changes from
baseline
-Learn what is normal
nutritional intake for
patient
-Assess for dehydration
-Ensure adequate fluid
intake/not losing too much
fluid
-Prevent dehydration
-Assess kidney function
-Assess hydration status
-Assess if
hyper/hypoglycemic
-Control blood sugar
Educate patient on importance of
turning/repositioning every 1-2 hours during
admission
-Encourage
movement/prevent pressure
ulcers
Turn/reposition patient every 1-2 hours
-Prevent pressure ulcers
Reference & Pg. #: Nursing Diagnosis Handbook pg. 427- 430
Evaluation of Each
Outcome
State if met,
partially met/not
met & why
1. Not met – patient
drank a few sips of
water during wake
hours
2. Not met – Patient
did not have a
glucose test before
being discharged.
3. Met – Patient
allowed staff to
reposition him and
turn him onto his
side to relieve
pressure off of his
coccyx.
Assessment
(Nursing Diagnosis)
Worded Correctly
Plan
(1 Goal & 3 or
more
Outcomes)
Implementation
Rationale
(Expected Nursing Care)
Priority #__3___
Deficient Knowledge r/t
high sodium level aeb
sodium level of 151
caused by inadequate fluid
intake, refusal of
medications, and refusal
of health assessment
Goal: Efficient
knowledge
Educate the patient of importance of intaking
2000 ml of fluid per day in order to remain
hydrated
Outcomes:
1. Patient will have a Offer 4 oz of nectar consistency fluid every
sodium level of 136- hour between 7am-7pm
147 by discharge
Monitor sodium level daily
2. Patient will take
all medications as
Educate the patient on the importance of taking
prescribed during
all prescribed medications as ordered to
hospital stay
maintain stable
3. Patient will allow
staff to perform a
head-to-toe
assessment every 12
hours
Administer medications as ordered
Educate the patient of the importance of a headto-toe assessment
Perform head-to-toe assessment every 12 hours
-Knowing how many
mls of fluid he should
be getting each day can
help him set a goal for
himself and recognize
when he is not getting
enough fluids
-prevent dehydration
-Assess hydration
status
-Knowing the risks of
not taking prescribed
medications and the
benefits of following
the medication regimen
can encourage the
patient to take all meds
as ordered
-Teaching the patient in
order to obtain a
baseline, to be able to
spot changes or
improvements in his
health, we need to
perform a head-to-toe
assessment
-Obtain baseline
Reference & Pg. #: Nursing Diagnosis Handbook pg. 614 - 616
Evaluation of Each
Outcome
State if met,
partially met/not
met & why
1. Met – Patient had
a sodium level of
143 by discharge.
2. Not met – patient
refused all
medications on
11/17/23
3. Partially met –
Patient allowed one
head-to-toe
assessment over a
24-hour span before
discharge.