Posted: May 1st, 2025

Miami Dade College Geriatric Depression – Care Plan and Teaching Plan Forms

Care Plan & Teaching Plan Form

The following table provides information to utilize in developing your nursing care plan. Each column in the Care Plan Form should include the appropriate information. You are expected to develop 3 Nursing Diagnoses with the supporting documentation as noted on the page below. The first Nursing Diagnosis of the Care Plan Form should be the priority nursing diagnosis. Before completing the Care Plan Form visit DocuCare and chart the patient assessment.

You MUST use the patient information that I entered in the DOCUCARE to complete this. I attached the word document below. You may add more information as needed. Please use the Care Plan & Teaching Plan Form. Both must be filled out and attached separately.

Teaching & Learning Plan
The following table provides information to utilize in developing your Teaching & Learning Plan. Each column in the teaching and learning plan form should include the
appropriate information related to the individual client needs identified in the Nursing Care Plan. You are expected to develop 3 Teaching Objectives with the supporting
documentation as noted on the page below. Any questions that you have concerning Teaching & Learning Plan should be directed to your instructor.
Teaching Objective(s)
After identifying the teaching
needs during the assessment, the
objective should be created.
The objectives are the main
ideas that you want your
learner(s) to understand and
apply after the teaching
experience. Two or three
objectives should be identified
for the teaching experience.
Each objective should start with
the stem below:
The learner (client) will …
Content
(Evidence-based with references)
Once the objectives for the teaching plan have
been created, content must be selected.
Depending on what is being taught, a reference to
where the content was found should be identified.
Content should be applicable to the audience.
Considerations on the use of terminology and
complexity should be incorporated into the
selection of the content.
The teacher will discuss …
Teaching & Learning
Method(s)
(How are you going to teach)
Time Frame
When determining how to share
the content during the teaching
experience, be sure to think about
the various learning styles.
Learning styles may include
auditory, visual and cognitive.
The following are some examples
of presentation formats:
The amount of time
for the teaching
experience will
depend on the
individual and the
amount of content
presented.
Consider timing of
when the teaching
experience will take
place. If during
discharge, allow
10-15 minutes
depending on the
amount and
complexity of the
content.
•
•
•
•
•
•
•
Diagrams
Charts
Videos
Handouts
Brochures
Hands on Simulation
Demonstration of skills
The material will be presented by
…
Evaluation of
Learning
(How long)
This teaching
experience will take
…
Evaluation of learning
occurs after the
content has bene
presented. Evaluation
can be a verbal
acknowledgement,
return demonstration
or the completion of a
brief survey. The
type of evaluation is
dependent upon the
type of teaching and
the type of content
presented.
The teaching
experience will be
successful if the
learner is able to …
Student Name:
Instructor: ________________________________
Client Code:
Nursing Diagnosis Priority #
Date:
Grade:
Teaching & Learning Plan
Assessment of Client’s
Readiness to Learn
Physical
Complexity of task
Environmental effects
Health status
Gender
Emotional
Anxiety level
Support system
Motivation
Frame of mind
Developmental stage
Experiential
Level of aspiration
Past coping mechanisms
Cultural background
Description of Findings:
Description of Findings:
Description of Findings:
Conclusion of Findings of the
Readiness to Learn
Knowledge
Description of Findings:
Present knowledge base
Cognitive ability
Learning disabilities
Learning styles (Visual, Auditory,
Reading)
Move forward with teaching
Hold teaching plan- describe rationale and discuss strategies to prepare the client for teaching.
Cultural Considerations
Description of findings and how to incorporate into the teaching plan.
Teaching Objective(s)
Content
(Evidence-based with references)
Teaching & Learning
Method(s)
(How are you going to teach)
Time Frame
Evaluation of
Learning
(How long)
(How is success of the
teaching measured)
(1) The learner will
(2) The learner will
(3) The learner will
Care Plan Form
The following table provides information to utilize in developing your nursing care plan. Each column in the Care Plan Form
should include the appropriate information. You are expected to develop 3 Nursing Diagnoses with the supporting documentation as
noted on the page below. The first Nursing Diagnosis of the Care Plan Form should be the priority nursing diagnosis. Before
completing the Care Plan Form visit DocuCare and chart the patient assessment.
PRIORITY Nursing Diagnosis
Behaviors
Subjective (Non-observable)
Subjective Data should be clear, concise and specific
to the
Nursing Diagnosis
Objective (Observable)
Objective Data should be clear, concise and specific to
the Nursing Diagnosis
Example Subjective Data- what the family relates,
states or reports.
Example Objective Data- what is observed or
measured. May include the client’s behavior, vital
signs, lung sounds, urine output, laboratory data,
diagnostic testing (etc.) as related to the specific
nursing diagnosis.
Subjective Data:
Objective Data:
Stimuli
Focal Stimuli- Individual needs, the level of family adaptation, and changes in the family environment
Contextual Stimuli-Influences the situation- Coping Mechanisms, diagnosis, symptom severity and co-morbidities
Residual Stimuli- Beliefs, behaviors and personal experiences
_____ Focal Stimuli
_____Contextual Stimuli
_____ Residual Stimuli
Describe:
Mode
Physiologic Mode is the individual’s physical health and functions. (Roy 2012)
Self-Concept Mode is the individual’s beliefs and feelings. (Roy 2012)
Role Function Mode involves the position one occupies in society and the behaviors associated with one’s position (role) in
society. (Roy 2012)
Interdependence Mode is associated with one relationships and interactions with others including the giving of love, respect
and value. This is a basic underlying need to nurture (Roy 2012).
_____ Physiologic Mode
_____ Self- Care Mode
_____ Role Function Mode
_____ Interdependence Mode
NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1.
2.
3.
4.
Choose a NANDA or Problem-Based Nursing Diagnosis
The statement should list only one diagnosis and be listed using the following format- problem followed by “Related
to (R/T) the disease process/ pathophysiology
Manifested by (signs & symptoms) is not part of the nursing diagnosis and should be written as a separate sentence.
Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes. Manifested by significant
other’s limited personal communication with client.
Write the PRIORITY Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and Manifested by
sentence including rationale below:
Goals/ Outcomes (Short-term/ Long-term) including Timelines/ Timeframes
1.
2.
3.
Each client should have one long-term and one short-term goal/ outcomes as part of the Care Plan.
Goal/ Outcome statements should be specific (related to the nursing diagnosis/ problem-based nursing diagnosis),
measurable, achievable (realistic for the client), clear and concise (don’t use increase or decrease without including
baseline data, timelines/ timeframes should be realistic and achievable.
Include a date or time at which the expected outcomes and nursing intervention are achieved or evaluated (should be
specific as “by discharge date” or “ongoing”).
Definitions:
Short-term Goals/ Outcomes: Those goals that are usually met before discharge or before transfer to a less acute level of care.
Long-term Goals/ Outcomes: Those goals that may not be achieved before discharge but require continued attention by client
and/or significant others as indicated.
Short-term Goal:
Long-term Goal:
Nursing Interventions and Scientific Rationales including Best Evidence with References
Three nursing interventions should be identified with each NANDA Nursing Diagnosis/ Problem-based Nursing Diagnosis.
Nursing interventions should be concise, clear, specific, individualized and accomplishable to client and/or family and
significant other.
Scientific rationales should address how the interventions are going to solve the problem identified and/or attain the outcomes.
The rationales should be specific to the intervention and summarized in your own words. There should be a rationale for each
of the three nursing interventions.
Nursing Intervention #1:
Rationale:
Nursing Intervention #2:
Rationale:
Nursing Intervention #3:
Rationale:
Evaluation of Client Goals/ Outcomes (Impact)
The Evaluation should address the client’s response to each of the three interventions and if any modifications were needed.
Evaluation Nursing Intervention #1:
Evaluation Nursing Intervention #2:
Evaluation Nursing Intervention #3:
Nursing Diagnosis #2
Behaviors
Subjective (Non-observable)
Subjective Data should be clear, concise and specific
to the
Nursing Diagnosis
Objective (Observable)
Objective Data should be clear, concise and specific to
the Nursing Diagnosis
Example Subjective Data- what the family relates,
states or reports.
Example Objective Data- what is observed or
measured. May include the client’s behavior, vital
signs, lung sounds, urine output, laboratory data,
diagnostic testing (etc.) as related to the specific
nursing diagnosis.
Subjective Data:
Objective Data:
Stimuli
Focal Stimuli- Individual needs, the level of family adaptation, and changes in the family environment
Contextual Stimuli-Influences the situation- Coping Mechanisms, diagnosis, symptom severity and co-morbidities
Residual Stimuli- Beliefs, behaviors and personal experiences
_____ Focal Stimuli
_____Contextual Stimuli
_____ Residual Stimuli
Describe:
Mode
Physiologic Mode is the individual’s physical health and functions. (Roy 2012)
Self-Concept Mode is the individual’s beliefs and feelings. (Roy 2012)
Role Function Mode involves the position one occupies in society and the behaviors associated with one’s position (role) in
society. (Roy 2012)
Interdependence Mode is associated with one relationships and interactions with others including the giving of love, respect
and value. This is a basic underlying need to nurture (Roy 2012).
_____ Physiologic Mode
_____ Self- Care Mode
_____ Role Function Mode
_____ Interdependence Mode
NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1.
2.
3.
4.
Choose a NANDA or Problem-Based Nursing Diagnosis
The statement should list only one diagnosis and be listed using the following format- problem followed by “Related
to (R/T) the disease process/ pathophysiology
Manifested by (signs & symptoms) is not part of the nursing diagnosis and should be written as a separate sentence.
Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes. Manifested by significant
other’s limited personal communication with client.
Write the Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and Manifested by sentence
including rationale below:
Goals/ Outcomes (Short-term/ Long-term) including Timelines/ Timeframes
1.
2.
3.
Each client should have one long-term and one short-term goal/ outcomes as part of the Care Plan.
Goal/ Outcome statements should be specific (related to the nursing diagnosis/ problem-based nursing diagnosis),
measurable, achievable (realistic for the client), clear and concise (don’t use increase or decrease without including
baseline data, timelines/ timeframes should be realistic and achievable.
Include a date or time at which the expected outcomes and nursing intervention are achieved or evaluated (should be
specific as “by discharge date” or “ongoing”).
Definitions:
Short-term Goals/ Outcomes: Those goals that are usually met before discharge or before transfer to a less acute level of care.
Long-term Goals/ Outcomes: Those goals that may not be achieved before discharge but require continued attention by client
and/or significant others as indicated.
Short-term Goal:
Long-term Goal:
Nursing Interventions and Scientific Rationales including Best Evidence with References
Three nursing interventions should be identified with each NANDA Nursing Diagnosis/ Problem-based Nursing Diagnosis.
Nursing interventions should be concise, clear, specific, individualized and accomplishable to client and/or family and
significant other.
Scientific rationales should address how the interventions are going to solve the problem identified and/or attain the outcomes.
The rationales should be specific to the intervention and summarized in your own words. There should be a rationale for each
of the three nursing interventions.
Nursing Intervention #1:
Rationale:
Nursing Intervention #2:
Rationale:
Nursing Intervention #3:
Rationale:
Evaluation of Client Goals/ Outcomes (Impact)
The Evaluation should address the client’s response to each of the three interventions and if any modifications were needed.
Evaluation Nursing Intervention #1:
Evaluation Nursing Intervention #2:
Evaluation Nursing Intervention #3:
Nursing Diagnosis #3
Behaviors
Subjective (Non-observable)
Subjective Data should be clear, concise and specific
to the
Nursing Diagnosis
Objective (Observable)
Objective Data should be clear, concise and specific to
the Nursing Diagnosis
Example Subjective Data- what the family relates,
states or reports.
Example Objective Data- what is observed or
measured. May include the client’s behavior, vital
signs, lung sounds, urine output, laboratory data,
diagnostic testing (etc.) as related to the specific
nursing diagnosis.
Subjective Data:
Objective Data:
Stimuli
Focal Stimuli- Individual needs, the level of family adaptation, and changes in the family environment
Contextual Stimuli-Influences the situation- Coping Mechanisms, diagnosis, symptom severity and co-morbidities
Residual Stimuli- Beliefs, behaviors and personal experiences
_____ Focal Stimuli
_____Contextual Stimuli
_____ Residual Stimuli
Describe:
Mode
Physiologic Mode is the individual’s physical health and functions. (Roy 2012)
Self-Concept Mode is the individual’s beliefs and feelings. (Roy 2012)
Role Function Mode involves the position one occupies in society and the behaviors associated with one’s position (role) in
society. (Roy 2012)
Interdependence Mode is associated with one relationships and interactions with others including the giving of love, respect
and value. This is a basic underlying need to nurture (Roy 2012).
_____ Physiologic Mode
_____ Self- Care Mode
_____ Role Function Mode
_____ Interdependence Mode
NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1.
2.
3.
4.
Choose a NANDA or Problem-Based Nursing Diagnosis
The statement should list only one diagnosis and be listed using the following format- problem followed by “Related
to (R/T) the disease process/ pathophysiology
Manifested by (signs & symptoms) is not part of the nursing diagnosis and should be written as a separate sentence.
Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes. Manifested by significant
other’s limited personal communication with client.
Write the Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and Manifested by sentence
including rationale below:
Goals/ Outcomes (Short-term/ Long-term) including Timelines/ Timeframes
1.
2.
3.
Each client should have one long-term and one short-term goal/ outcomes as part of the Care Plan.
Goal/ Outcome statements should be specific (related to the nursing diagnosis/ problem-based nursing diagnosis),
measurable, achievable (realistic for the client), clear and concise (don’t use increase or decrease without including
baseline data, timelines/ timeframes should be realistic and achievable.
Include a date or time at which the expected outcomes and nursing intervention are achieved or evaluated (should be
specific as “by discharge date” or “ongoing”).
Definitions:
Short-term Goals/ Outcomes: Those goals that are usually met before discharge or before transfer to a less acute level of care.
Long-term Goals/ Outcomes: Those goals that may not be achieved before discharge but require continued attention by client
and/or significant others as indicated.
Short-term Goal:
Long-term Goal:
Nursing Interventions and Scientific Rationales including Best Evidence with References
Three nursing interventions should be identified with each NANDA Nursing Diagnosis/ Problem-based Nursing Diagnosis.
Nursing interventions should be concise, clear, specific, individualized and accomplishable to client and/or family and
significant other.
Scientific rationales should address how the interventions are going to solve the problem identified and/or attain the outcomes.
The rationales should be specific to the intervention and summarized in your own words. There should be a rationale for each
of the three nursing interventions.
Nursing Intervention #1:
Rationale:
Nursing Intervention #2:
Rationale:
Nursing Intervention #3:
Rationale:
Evaluation of Client Goals/ Outcomes (Impact)
The Evaluation should address the client’s response to each of the three interventions and if any modifications were needed.
Evaluation Nursing Intervention #1:
Evaluation Nursing Intervention #2:
Evaluation Nursing Intervention #3:
Patient Health Information:
–
Name: Mary Johnson
Date of Birth: 2/14/1959
Age: 65 years old
Gender: Female
Height: 64 inches (5 feet 4 inches)
Weight: 150 lbs
Race: Caucasian
Ethnicity: Non-Hispanic
Religion: Catholic
Marital Status: Married
Notes:
–
Mary Johnson, a 65-year-old Caucasian female, presents with symptoms of depression,
including persistent sadness, fatigue, and a significant decrease in interest in daily
activities. Her medical history includes hypertension and osteoarthritis, for which she
takes Lisinopril and acetaminophen. Mary reports difficulties with sleep, a decreased
appetite, and a recent weight loss of 5 pounds. Her HEENT assessment reveals no
abnormalities, and her physical examination shows she is independent in most ADLs but
requires minimal to moderate assistance for specific tasks such as bathing and using a
cane for walking. She has a decreased appetite and is at low risk for aspiration, but she
struggles with maintaining her weight. Her speech is clear and fluent, and she
demonstrates signs of apathy and sadness without significant anxiety. Mary’s mood and
behavior reflect her depressive symptoms, and she is encouraged to engage in social and
religious activities for emotional support. A care plan is in place focusing on nutritional
support, mental health therapy, and pain management, with regular follow-up visits to
monitor her progress and adjust interventions as needed.
Care Plan for Patient Problem
Problem Status: Active
Problem Type: Mental Health
Problem Category: Geriatric Depression
Disease Process or Etiology Contributing to Patient’s Problem:
Mary Johnson, a 65-year-old female, is experiencing geriatric depression. This condition is
characterized by persistent sadness, fatigue, and a significant decrease in interest in daily
activities. Contributing factors include chronic pain from osteoarthritis, recent life changes, and a
decrease in appetite leading to a recent weight loss of 5 pounds. The depressive symptoms are
compounded by a lack of social interaction and diminished engagement in previously enjoyed
activities.
Subjective and Objective Data Specific to Patient Problem:
•
•
Subjective Data: Mary reports feeling persistently sad, having lost interest in activities
she used to enjoy, experiencing difficulties with sleep, and noting a decreased appetite
with recent weight loss.
Objective Data: Mary appears sad and apathetic. Observations indicate she requires
minimal to moderate assistance for some ADLs and has experienced a weight loss of 5
pounds in the past month. Her mood and behavior reflect depressive symptoms
characteristic of geriatric depression.
Patient Goals:
1. The patient will demonstrate an improvement in mood and increased engagement in
daily activities.
Timeline: Within 4 weeks
2. The patient will achieve stable weight maintenance or a gradual increase in weight.
Timeline: Within 4 weeks
3. The patient will report improved sleep quality and a reduction in depressive
symptoms.
Timeline: Within 4 weeks
4. The patient will establish and attend a support system or mental health therapy
sessions.
Timeline: Within 2 weeks
Interventions
Independent Interventions:
Intervention
Frequency
Encourage
participation in social
Weekly
activities and senior
support groups
Monitor and document
changes in mood,
Daily
appetite, and sleep
patterns
Collaborative Interventions:
Rationale
Evaluation
Monitor Mary’s
Social support and engagement
involvement in activities
can reduce feelings of isolation
and support groups through
and improve mood in geriatric
observation and selfdepression.
reports.
Ongoing documentation helps Regularly review
track the effectiveness of
documented observations
interventions and guides
during follow-up visits to
necessary adjustments in care. assess progress.
Intervention
Frequency
Refer to a geriatric
mental health specialist
Once
for counseling or
therapy
Consult a dietitian for
nutritional counseling
Once
to address decreased
appetite and weight loss
Rationale
Evaluation
Specialized therapy can
Confirm Mary’s appointments
address geriatric
with the specialist and review
depression by providing
feedback from the therapist
tailored interventions and
regarding Mary’s progress.
coping strategies.
Nutritional counseling can
Review the dietitian’s
help manage appetite
recommendations and monitor
issues and promote
Mary’s adherence to the meal
healthy weight
plan and any changes in her
maintenance in older
weight.
adults.
Rationale
Rationale: The care plan addresses geriatric depression through both independent and
collaborative approaches. Encouraging social engagement and monitoring mood and appetite are
crucial for managing depressive symptoms and improving quality of life for elderly patients.
Collaborative efforts with mental health specialists and dietitians ensure a comprehensive
approach to addressing the multifaceted needs of geriatric depression.
Url: National Institute of Mental Health – Depression in Older Adults
Conclusion/Summary:
Mary Johnson’s care plan is designed to address her geriatric depression with a focus on
improving mood, managing weight, and enhancing sleep quality through a combination of
independent and collaborative interventions. The plan includes encouraging social activities,
monitoring symptoms, and working with a mental health specialist and dietitian to provide a
holistic approach to her care. Regular follow-ups will be conducted to evaluate progress and
adjust the care plan as needed to meet Mary’s goals and improve her overall well-being.
New Patient Teaching
Initial Teaching
Teaching Topic: Understanding Geriatric Depression and Coping Strategies
Learning Outcome(s):
1. The patient will be able to identify symptoms of depression and understand their
impact on daily life.
2. The patient will learn techniques for managing depressive symptoms and improving
mood.
3. The patient will understand the importance of attending therapy sessions and
utilizing support systems.
4. The patient will gain knowledge of healthy eating practices and their role in
managing depression and weight.
Learner(s):
•
Patient: Mary Johnson
Readiness to Learn:
•
•
Emotional Barrier: Mary may be feeling overwhelmed or hopeless due to her
depressive symptoms.
Age or Developmental Barrier: Adjustments in communication methods to suit her age
and cognitive abilities.
Teaching Method(s):
•
•
•
Verbal Explanation and Discussion: To explain the nature of geriatric depression and
discuss coping strategies.
Handout: Provide a handout summarizing symptoms of depression, coping strategies,
and resources for support.
Video: Show a short educational video on managing depression in older adults and the
benefits of therapy.
Evaluation:
•
•
Teach Back: Ask Mary to explain back the key concepts of depression, coping
strategies, and the importance of therapy.
Evaluation Notes: Ensure Mary can articulate understanding of the symptoms, coping
techniques, and reasons for attending therapy.
Continued Needs:
•
Needs: Mary may need ongoing support and reinforcement of the information provided.
Regular follow-ups to ensure she is engaging with therapy and managing symptoms
effectively.
Additional Notes:
Mary’s teaching included a discussion on recognizing the signs of depression and understanding
how these symptoms can affect her daily life. She was provided with a handout detailing coping
strategies, such as engaging in social activities, practicing mindfulness, and maintaining a
routine. A video was shown to illustrate the importance of therapy and the role of support
groups. Mary was asked to reflect on the information and demonstrate her understanding of these
concepts. Continued follow-up will be essential to assess her engagement with therapy and
adherence to the provided strategies for managing depression.
URL for Additional Resources:
National Institute of Mental Health – Depression in Older Adults
Detailed Teaching Plan
Teaching
Topic
Learning
Outcome(s)
Learner(s)
Readiness to
Learn
Teaching
Method(s)
Evaluation
Continued
Needs
Additional
Notes
Understanding Geriatric Depression and Coping Strategies
1. Identify depression symptoms and their impact on daily life.
2. Learn techniques for managing depressive symptoms and improving mood.
3. Understand the importance of attending therapy and using support systems.
4. Gain knowledge of healthy eating practices for managing depression and
weight.
Patient: Mary Johnson
Emotional Barrier: Mary may feel overwhelmed.
Age or Developmental Barrier: Consideration of her age and cognitive
abilities.
Verbal Explanation and Discussion: Discuss depression symptoms and
coping strategies.
Handout: Summarize depression, coping strategies, and support resources.
Video: Educational video on managing depression and benefits of therapy.
Teach Back: Mary will explain depression symptoms, coping strategies, and
therapy importance.
Evaluation Notes: Assess Mary’s understanding and her ability to
communicate key concepts.
Needs: Ongoing support and reinforcement of information.
Follow-Up: Regular check-ins to review Mary’s engagement with therapy and
adherence to strategies.
Mary was given a handout and watched a video about depression management.
She demonstrated understanding of the information through a teach-back
method. Follow-up is necessary to ensure continued engagement and progress.
Medication Order
Medication
Sertraline
Hydrochloride
Normal Saline
(0.9% NaCl)
Dosage Route Frequency
Indication
50 mg Oral
Once daily
1000
mL
Infuse over 8 Hydration and As
hours
supportive care needed
IV
Depression
Duration Start Date
End
Date
Indefinite 07/16/2024 TBD
07/16/2024 TBD
Protocol/ Note: This protocol ensures that Sertraline is administered correctly, with clear instructions for
the patient and steps for ongoing management and follow-up. Effective medication management
requires a partnership between the healthcare provider and the patient. Regular communication and
supportive follow-up are key to successful depression treatment.
New Vital Signs Data
Vital Sign
Blood Pressure
Heart Rate
Respiratory Rate
Measurement
130/85 mmHg
78 bpm
16
breaths/minute
98%
Location Position
Notes
Left Arm Sitting Within normal range for age.
N/A
N/A
Regular and within normal limits.
N/A
N/A
Normal respiratory rate.
N/A
N/A
Adequate oxygen saturation.
None
N/A
N/A
No supplemental oxygen required.
98.6 °F
Oral
N/A
Weight
145 lb
N/A
N/A
Glucose Level
Time Since Last
Meal
105 mg/dL
N/A
N/A
8 hours
N/A
N/A
Normal body temperature.
Weight stable; within normal range
for height.
Normal fasting glucose level.
Fasting state for glucose
measurement.
SpO2
Oxygen Delivery
Method
Temperature
Interventions
1. Monitor Vital Signs: Continue to monitor blood pressure, heart rate, respiratory rate,
and SpO2 regularly to ensure stability and track any changes in Mary’s condition.
2. Hydration: Ensure adequate hydration and document intake as Mary receives IV fluids.
3. Glucose Monitoring: Check glucose levels as part of ongoing assessment and adjust diet
or medications as necessary.
Additional Notes
•
•
•
•
•
•
•
Blood Pressure: At 130/85 mmHg, Mary’s blood pressure is within an acceptable range
for her age. Regular monitoring is recommended to manage and prevent potential
complications.
Heart Rate: A heart rate of 78 bpm is normal and suggests that Mary’s cardiovascular
system is functioning well.
Respiratory Rate: The respiratory rate of 16 breaths per minute is normal, indicating
that Mary’s respiratory function is stable.
SpO2: An oxygen saturation level of 98% indicates that Mary’s oxygen levels are
adequate, and no additional oxygen therapy is necessary at this time.
Temperature: A body temperature of 98.6 °F is within the normal range, and there are
no signs of fever or hypothermia.
Weight: Mary’s weight of 145 lb is stable. Continue to monitor for any significant
changes that might indicate issues such as fluid retention or malnutrition.
Glucose Level: A glucose level of 105 mg/dL is normal for a fasting state. Continue to
monitor as part of overall health management.