Health History Plan of Care Form

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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.

 

 

Sample Solution

  1. Identify the areas for focused assessment. This involves identifying the areas of the health history that are most relevant to the client’s current health status and needs. For example, if the client is experiencing shortness of breath, the nurse would focus on the respiratory assessment data.
  2. Perform a brief overview of those areas of strength and weakness noted from health history. This involves summarizing the data from the health history that indicates the client’s strengths and weaknesses. For example, if the client has a strong support system, this would be considered a strength. If the client has a history of smoking, this would be considered a weakness.
  3. Expand on areas identified as strengths related to the person’s overall health. This involves providing more detail about the client’s strengths and how they contribute to their overall health. For example, if the client has a strong support system, this could mean that they have people to help them with their care, provide emotional support, and help them stay motivated.
  4. Support your conclusions with data from the credible evidence (peer reviewed journal or credible website). This involves citing the sources of the data that you used to support your conclusions. This is important to do so that other nurses can verify your findings and use them to develop their own plans of care.

Here is an example of how to analyze assessment data to develop a plan of care:

Client: John Smith, a 65-year-old man with a history of hypertension, diabetes, and coronary artery disease.

Health history: Mr. Smith reports that he has been feeling shortness of breath with exertion for the past few weeks. He also reports that he has been coughing up blood.

Areas for focused assessment: Respiratory, cardiovascular, and hematologic systems.

Strengths: Mr. Smith has a strong support system in place. He has a wife who is able to help him with his care, and he has a close group of friends who check in on him regularly. He is also motivated to take care of his health and is willing to follow the nurse’s instructions.

Supportive evidence: A study published in the Journal of the American Medical Association found that people with strong social support are more likely to adhere to their treatment plans and have better health outcomes. Another study published in the Annals of Family Medicine found that people with a history of smoking are more likely to develop lung cancer.

Plan of care: The nurse will focus on the following areas in her plan of care for Mr. Smith:

  • Managing his shortness of breath with medication and oxygen therapy.
  • Controlling his blood pressure and blood sugar levels.
  • Reducing his risk of heart attack and stroke.
  • Quitting smoking.
  • Promoting healthy lifestyle habits, such as eating a healthy diet and exercising regularly.

The nurse will also work with Mr. Smith to develop a support system to help him stay motivated and adhere to his treatment plan.

This is just an example of how to analyze assessment data to develop a plan of care. The specific areas of focus and interventions will vary depending on the individual client’s needs.

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