Identified Identified goal or Plan/ Evaluation/ Community

problem/need: outcome: Interventions: Outcomes resources/

(include (Provide Referrals
supporting rationale/
subjective and evidence to
objective data) justify the
rationale)
Hypertension Patient to Patient to take The evaluation Community
objective data verbalize desired prescribed will be the resources
elevated BP range for blood medication as collected date American heart
reading pressure and ordered because from the patient association has
Subjective verbalize Blood-pressure of her blood information on
Patient reports possible side control can save pressure reading hypertension
high blood effect of more lives than that she is weight
pressure denies uncontrolled any other clinical recording on a management and
any headaches hypertension. intervention daily basis and eating healthy
ringing in the (Friedan, 2015) the goal is to with classes
ears Instruct on have a normal offered. There is
limiting sodium reading daily for a local agency is
and low sodium at least a two in Delaware
diet. Rational week period. As address 200
High sodium recommended by continental drive
intake is a the ACP and suite 101
leading AAF Adults aged Newark, de.
contributor to 60 years or older
hypertension, at high
and Americans cardiovascular
consume an risk, based on
average of 3500 individualized
mg of sodium assessment, to
per day, far more achieve a target
than systolic blood
recommended. pressure of less
Reducing than 140 mm Hg
average sodium to reduce the risk
intake by a third for stroke or
could save up to cardiac events.
half a million
lives and nearly
$100 billion in
health care costs
over the next 10
years (Friedan
2015)
Educate patient
to the side effect
 of uncontrolled
hypertension
such as kidney
failure or heart
disease.
Rationale,
hypertension is
an important risk
factor for
cardiovascular
disease and
mortality.
(Friedan, 2015)

Lack of regular Patient Educate the The patient Give list of local
physical activity verbalizes the patient on the stated goal is she gyms and or
no exercise plan importance of importance of will start walking YMCA for ideas
regular daily physical exercise for 3 miles a day on exercises she
Subjective data physical exercise daily. The on a daily basis may enjoy.
patient reports rationale that in 30 days. This List of walking
occasional walks even as little as is to be achieved clubs for older
with dogs 15 minutes of by starting to adults. There is a
Objective data moderate walk one mile a Volksmarch club
monitoring of exercise a day is day for a week that have regular
daily activity extremely then increasing fun hikes in
recording beneficial, by half a mile Delaware the
exercise daily reducing all- weekly until state contact
cause mortality goal achieved. information for
rates by 14% them is First
(Simons,2015) State Webfooters
Have patient start Address: PO Box
an exercise 9348 City:
program that Wilmington
gradually State: DE Zip:
increases to 3- 4 19809
miles a day for
the most
therapeutic
results starting at
1 mile a day the
Increasing that to
2-3 miles a day
this will have
them following
current
guidelines but
 Averaging 3-4
miles a day
provides some
additional health
benefit, but the
incremental gain
is quite modest;
beyond that, the
only potential
health reward for
additional
exercise is
weight control.
For optimal
results, we
should encourage
motivated people
to incorporate 2-
3 sessions of
modest strength
training into their
weekly and
adding 3 years to
life expectancy.
(Simons, 2015)

Chronic pain in Patient Educate the Pt will record in Referral for

bilateral knees verbalizes patient on non- journal for 2 possible physical
due to acceptable level pharmacological weeks when pain therapy to assist
osteoarthritis of pain of a 2 or methods to occurs rate the with mobility
knee replacement less on a scale of control pain, level of pain and and ease pain
10 years ago 0-10 and ability such as what helped the Aqua therapy
Objective Data to engage in distraction, pain to better may also help
medical history desired activities. imagery, evaluate what is with chronic
knee replacement relaxation, the best knee pain
Dx. osteoarthritis massage, and treatment for her Referral for
in bilateral knees heat and cold pain or if dietician to
10 years ago applications. medication review food
noted limited Rationale, non- management choice and diet
range of motion pharmacological needs to be for weight loss
to knee methods of change to best Referral to
Subjective Data treatment have meet the needs of surgeon if pain
Patient reports found to be the patient starts to affect
pain aching in effect in quality of life
knee joints at relieving pain and if other pain
times (fernandes, el, al, management
2013) Educate on techniques no
the benefits of longer effective .
exercise on
strengthening
muscle either
traditional
physical therapy
or aqua therapy.
Rationale, this
has also shown
to be effective in
managing OA
pain (fernandes,
el, al, 2015)
Instruct on
medications if
needed for
management of
pain such as:
opioids
(narcotics), non-
opioids
(acetaminophen,
Cox-2 inhibitors,
and non-steroidal
anti-
inflammatory
drugs
[NSAIDs]), and
adjuvant
medications.
Instruct on
weight loss and
the decrease of
pain related to
stress of the knee
joint. Rational
that instruction
on diet for
overweight or
obese patients to
the combine with
patient education
or self-
management
intervention plus
exercise was
found to improve
both pain and
function in
patients with hip
or knee OA.
(fernandes, el,
al,2013)