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Nursing Care Plan for a Patient with Chronic Diseases

Plan of Nursing Care

Suggested content of the assignment: Introduction:

Describe the background of the client.

Reasons for referring Community Nursing Service (CNS)

Main body: - The plan of the nursing care for the client:

You are suggested to utilize the approach of “Assessment (initial & f ocused assessment), Planning, Expected Patient/ Carers Outcomes, Interventions/ Education and & Evaluations” for each of the following aspects in your plan.

Physical status

Psycho-social Status

Home environment





Activities & Exercises


Community Resources

Initial and focused assessment based on the aspects of ten care elements as mentioned above.

You can collect the information/data from the provided case scenario. Subjective data is usually obtained from history taking (by interviewing the client) and documented into the record (such as discharge summary, nursing summary and the 1stvisit note). Since you did not conduct an actual interview with the client, it is not obviously to differentiate it.

You can provide the data (at least 4 especially for the selected top 3 health problems/issues)- no need to specify objective data or subjective data.

Under each care element, you describe the information/situation what you identify.

Please only refer to the content and be reminded do not write in table and point form. 

For example, in terms of Community Resources, the data does not mention about this, however, Community Resources are also vital for COPD patient, so we have to assess whether any community resources around patient’s home or we can introduce community resources to the patient

The actual and potential problems (Please list out all the problems and prioritize top three with reasons) (Saying why top three is important and others less important)

Plan the nursing care based on the top three prioritized health problems for the patient with relevant nursing skills


Set at least one goal, three expected outcomes ,2 interventions under each expected outcome with using SMART framework (Specific, Measurable, Achievable, Realistic, Time-bound)

Write at least 6 interventions in each health problem.

Each expected outcomes, and interventions should be support with references, and each intervention should support with rationales.

You can always refer to the nursing care plan book,

Education and advice(Intervention)

Please be reminded to write all the components in paragraph with references.

Ability to assess and monitor the disease

Reduce risk factor

Manage stable COPD

Empower self-image the COPD Exacerbation

Empowerment score

(similar to intervention ,skill-wise in this case, patient suffered from COPD ,we should teach the patient how to use aerochamber , take what medication, oxygen, breathing pattern, 88-93%SPO2, think how to control these situation at home aside from visiting the Emergency Department of the hospital, the patient should know the above information)

Clear description of the background of the case

Clear and appropriate initial and focused assessment for the case

Able to identify and prioritize top three health problems of the case

Able to plan the relevant nursing care

Able to suggest relevant education and use empowermentscore & learning contract.

Able to evaluate the plan of care of the case.

Accurate in-text citation, appropriate source and APA referencing style in the reference list.

Concise presentation, accurate grammar, and logical flow of discussion

The case to be studied was a client suffering from chronic diseases and requiring nursing procedures at home.

Students are given a referral letter for Community Nursing Service, a patient discharge summary by a doctor and a nursing discharge summary by a ward nurse (see attachment).

In the assignment, the students are going to act as outreach community nurses and completed the first home visit for the client.

Students need to perform the assessment and identify the problems of the patient at home in the community.

Students need to plan the nursing care (the top three prioritized health problems) for the patient with relevant nursing skills.

Students are required to suggest the related educational materials and empower the client with a learning contract.

Evaluations of the effectiveness of the plan of care should be included.

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