Delaware Technical Community College
NUR 320 Health Assessment
STUDENT NAME: Tara Johnston
Identified problem/need: Identified goal or
(include supporting outcome:
subjective and objective
data)
The first need identified Mr. Johnston will increase 1.
during Mr. Johnstons his hours of sleep to 7
assessment was lack of hours 3 weeknights for the
sleep. Mr. Johnston stated next 30 days. Mr. Johnston
that he generally only will go to bed at 9:30pm
sleeps 4.5 to 5.5 and set his alarm for his
hours/night during the week week day time of 04:30am.
and approximately 6.5 Mr. Johnston will maintain a
hours/night on the journal to document his
weekends. sleep routine. Mr. Johnston
and the journal will be
evaluated for goal
alignment and adjustments
will be made to meet his
long-term goal of sleeping 8
hours/night 5 days a week.
RN to BSN program: Plan of Care Chart
Plan/ Interventions:
(Provide rationale/
evidence to justify the
rationale)
Mr. Johnston will exercise in the
morning. Early morning exercise
promotes longer sleep and people
who exercise first thing in the
morning experience deeper sleep
and spend 75% more time in the
most reparative stages of sleep
than those who exercise later in
the day.
2. Mr. Johnston will not engage in
screen time to include television,
computer, tablet, and/or smart
phone after 8:30pm. These types
of electronics emit a blue light from
the screen, mimicking daylight
causing stimulation, which can
make it difficult to fall asleep and
can result in Mr. Johnston waking
up feeling tired, anxious, and
depressed.
3. Mr. Johnston will avoid eating
and drinking liquids a few hours
prior to bedtime. Digestion of food
and reduction of acid reflux is best
done sitting up right. Eating and
drinking close to bedtime inhibits
digestion and can cause
indigestion and heartburn leading
to inability to fall or stay asleep.
DATE: April 24, 2017
Evaluation/ Community resources/ Ref
Outcomes
Mr. Johnston sleep Community resources to improve
patterns and feeling Mr. Johnstons sleep pattern include:
regarding sleep will be
evaluated at the end of Jennersville YMCA
30 days through 800 W Baltimore Pike
assessment and West Grove, PA 19390
review of his journal. 610-869-9622
The journal provides a Hours: M-F 0500 10:00pm
source of Sat. 0630 7:00pm
accountability that Sun. 0700 7:00pm
allows an accurate This resource provides state of the
evaluation of task art exercise equipment and early
completed throughout morning hours in which to utilize it.
the 30 days.
Snap Fitness
921 Gap Newport Pike
Adjustments will be Avondale, PA 19311
made to intervention 610-268-8100
as necessary to Open 24 hours/day
achieve long term goal This resource provides state of the
of 8 hours of sleep per art exercise equipment available, as
night 5 days a week. well as increased available with 24-
hour access.
American Sleep Medicine
200 Continental Drive
Ste 112
Newark, DE 19713
302-366-0111
This resource provides evaluation of
sleep pattern and offers

Identified problem/need:
(include supporting
subjective and objective
data)
The second need identified
during Mr. Johnstons
assessment was limited
physical activity. During Mr.
Johnstons assessment, he
stated that he would like to
improve his physical activity
level. He also stated that
he commutes 3 hours each
day for work and works
behind a desk getting very
limited activity during the
work week.
Identified goal or Plan/ Interventions:
outcome: (Provide rationale/
evidence to justify the
rationale)
Mr. Johnston will increase 1. Mr. Johnston will exercise in the
his physical activity during morning. Exercising in the
the work week by going to morning boost not only
the gym 3 times/week and metabolism, but energy levels
engaging in 30 minutes of as well. Morning exercise is
moderate exercise for the also known to improve focus
next 30 days. Mr. Johnston and mental abilities.
will maintain an exercise
journal and document 2. Mr. Johnston will take 2 -3 min
exercise completed. Mr. fitness breaks throughout the
Johnston and the exercise day to stretch or engage in a
journal will be evaluated for brisk walk. This activity is to be
goal alignment and documented in his exercise
adjustments will be made to journal. Increased physical
meet his long-term goal of activity reducing health risk of
exercising 5 times a week. disease, improves mental
health, and strengthens bones
and muscles.
3. Mr. Johnston will utilize climbing
stairs when changing floors for
meeting and building activities.
This is another activity that
reducing health risk of disease
as well as burns more calories
than walking alone. This
provides a good means of
exercise for the lungs, heart and
muscles.
consultations to promote improve
sleep patterns/habits as well as
diagnosis any sleep disorders.
Evaluation/ Community resources/ Ref
Outcomes
Mr. Johnston level of Community resources to improve
physical activity will be Mr. Johnstons physical activity
evaluated at the end of include:
30 days through
assessment and Jennersville YMCA
review of his journal. 800 W Baltimore Pike
Assessment will West Grove, PA 19390
include a physical 610-869-9622
assessment of his Hours: M-F 0500 10:00pm
heart, lungs, and Sat. 0630 7:00pm
mental attitude. The Sun. 0700 7:00pm
journal provides a This resource provides state of the
source of art exercise equipment and early
accountability that morning hours in which to utilize it.
allows an accurate
evaluation of task Snap Fitness
completed throughout 921 Gap Newport Pike
the 30 days. Avondale, PA 19311
610-268-8100
Open 24 hours/day
Adjustments will be This resource provides state of the
made to intervention art exercise equipment available, as
as necessary to well as increased available with 24-
achieve long term goal hour access.
of engaging in
exercise for a
minimum of 1 hour 5
days a week.
Identified problem/need:
(include supporting
subjective and objective
data)
The third need identified
during Mr. Johnstons
assessment was lower back
pain. During Mr. Johnstons
assessment, he disclosed
that he injured his back
resulting in a herniated disc
between L4 and L5.
Identified goal or
outcome:
Mr. Johnston will strengthen1.
his core to reduce low back
pain. He will complete front
planks while at work 3
days/week as well as
complete 25 partial
crunches 3 days/week for
30 days. Mr. Johnston will
log core strengthen
exercises completed in his
exercise journal. Mr. 2.
Johnston and the exercise
journal will be evaluated for
goal alignment and
adjustments will be made to
meet his long-term goal of
minimal to no lower back
pain.
3.
4.
Plan/ Interventions:
(Provide rationale/
evidence to justify the
rationale)
Mr. Johnston will utilize his office
2-times/day 3 days/week to
complete front planks to
increase core strength. Plank
exercise require minimal
movement while contracting
abdominal fascia in turn
strengthen the core reducing
lower back pain.
Mr. Johnston will complete 25
partial crunches 3 days/week.
Partial crunch exercised require
minimal movement of the
muscles of the back while
engaging the abdominal muscles
and keeping the spine in proper
alignment. This exercise
increases core strength lending
support to the back muscles and
spine.
I provided Mr. Johnston with
education on necessity of
bending at the knees and not the
waist as well as noting activities
he is engaged in or has been
engaged in with increased lower
back pain. Mr. Johnston was
instructed to document these
events in his exercise journal.
I provided Mr. Johnston with
education on the importance of
core strength to support back
injuries. The abdominal muscle
provide support to the back
muscles as well as the spine
allowing one to stand up right
Evaluation/ Outcomes
Mr. Johnston level of lower
back pain will be evaluated
at the end of 30 days
through assessment and
review of his journal. The
journal provides a source of
accountability that allows an
accurate evaluation of task
completed throughout the
30 days.
Adjustments will be made to
interventions as necessary
to achieve long term goal of
living with minimal to no
lower back pain.
Community resources/ Ref
Community resources to improve
Mr. Johnstons assist with
strengthening his core and
decreasing lower back pain include:
Jennersville YMCA
800 W Baltimore Pike
West Grove, PA 19390
610-869-9622
Hours: M-F 0500 10:00pm
Sat. 0630 7:00pm
Sun. 0700 7:00pm
This resource provides state of the
art exercise equipment to engage
the core muscles with minimal
pressure on back muscles and early
morning hours in which to utilize it.
Snap Fitness
921 Gap Newport Pike
Avondale, PA 19311
610-268-8100
Open 24 hours/day
This resource provides state of the
art exercise equipment available to
engage the core muscles with
minimal pressure on back muscles,
as well as increased available with
24-hour access.
Pure Wellness
550 Stanton Christiana Rd.
Ste 302
Newark, DE 19713
302-365-5470
This resource provided a service
called Kinesio-taping that facilitates
the bodys natural healing process
while allowing support and stability
and move throughout the day. to the spine, muscles, and joints of
the body.