Nursing Care Plan Student Name: _____Caren Carlstedt_______________

Patient Initials: _L. B____ Age: __83___ Room: ___822_____ Primary Diagnosis: ____possible TIA__________________

Health Perception Nutrition Elimination Activity Sexuality

Health Management Metabolic Exercise Reproduction
Data: TIA Weight 193 lbs Lasix will increase water
Medical Diagnosis Hx of CVA Height 6’0” loss
Dx Procedures
Labs Pacemaker Diet- 100% intake Independent, occasional
Medications GI Bleed Diabetic diet SBA
Diabetes I &O daily Slight limit in mobility
Septoplasty due to left sided weakness
Cataract removal from previous stroke
polypectomy
cardiac catherization
Nursing
Diagnosis:
r/t
aeb

Outcomes X 3 1. 1. 1. 1. 1.

2. 2. 2. 2. 2.

3. 3. 3. 3. 3.

Nursing
Interventions:

Evaluation: 1. 1. 1. 1. 1.
Met or Unmet
Modifications
2. 2. 2. 2. 2.

3. 3. 3. 3. 3.

Values Sleep Sensory Perception Cognitive Role

Beliefs Rest Relationship
Data:
Medical Diagnosis
Dx Procedures
Labs
Medications

Nursing
Diagnosis:
r/t
aeb

Outcomes X 3 1. 1. 1. 1. 1.

2. 2. 2. 2. 2.

3. 3. 3. 3. 3.

Nursing
Interventions:

Evaluation: 1. 1. 1. 1. 1.
Met or Unmet
Modifications
2. 2. 2. 2. 2.

3. 3. 3. 3. 3.

Self Perception Coping Values Developmental Stage

Self Concept Stress Tolerance Beliefs (Erickson, Piaget)
Data:
Medical Diagnosis
Dx Procedures
Labs
Medications

Nursing
Diagnosis:
r/t
aeb

Outcomes X 3 1. 1. 1. 1.

2. 2. 2. 2.

3. 3. 3. 3.

Nursing
Interventions:

Evaluation: 1. 1. 1. 1.
Met or Unmet
Modifications
2. 2. 2. 2.

3. 3. 3. 3.