Book
Protocols for the Most Common Diseases in Primary Healthcare Facilities
-Nursing Care Plans
1- Nursing care plan for a patient with oral inflammation.
2- Nursing care plan for a patient requiring health education.
3- Nursing care plan for a patient with elevated body temperature.
4- Nursing care plan for a patient with constipation.
5- Nursing care plan for a patient with diarrhea.
6- Nursing care plan for a patient with dehydration.
7- Nursing care plan for a patient with nausea and an urge to vomit.
8- Nursing care plan for a patient with anxiety.
9- Nursing care plan for a patient with pain.
10- Nursing care plan for a patient with shortness of breath.
11- Nursing care plan for a patient with sputum in the chest.
12- Nursing care plan for a patient with cough.
13- Nursing care plan for a patient with myocardial infarction.
14- Nursing care plan for a patient with chest pain.
15- Nursing care plan for a patient with general weakness due to a low blood hemoglobin level (anemia).
16- Nursing care plan for a patient with hypertension.
17- Nursing care plan for a patient with hypotension.
18- Nursing care plan for a patient in a hypoglycemic coma.
19- Nursing care plan for a patient in a hyperglycemic coma.
20- Nursing care plan for a family-planning client.
21- Nursing care plan for risk of falling.
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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1- Nursing care plan for a patient with oral inflammation. |
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Oral inflammation |
Treat the inflammation. Reduce potential complications. |
15–30 minutes |
1. Identify the primary cause, for example: Poor oral hygiene or prolonged fasting. A specific treatment, such as chemotherapy. 2. Assess the patient’s mouth using a tongue depressor, noting the color and extent of inflammation. 3. Administer an analgesic as prescribed by the physician. 4. Educate the patient to rinse the mouth every four hours and before and after meals to reduce fungal growth. 5. Educate the patient about maintaining the oral mucosa by taking fluids and soft foods. |
Refer the patient as ordered by the physician. |
Nurse’s Name /
Nursing Care Plan
Full Name:
Insurance Number /
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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2- Nursing care plan for a patient requiring health education. |
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Deficient patient knowledge regarding a specific matter, such as the condition or the prescribed diet. |
Increase the patient’s knowledge. Reduce the anxiety the patient may experience.
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5–10 minutes |
1. Prepare the environment around the patient so that it is quiet and free from stressors. 2. First gain the patient’s trust through an appropriate manner of speaking. 3. Ask the patient about prior knowledge. 4. Determine the patient’s expectations. 5. Explain the requested information in short, factual, reassuring sentences. Use language the patient can understand and avoid technical terminology. 6. Select a time for the discussion when the patient is not experiencing distress or pain. 7. During the discussion, repeatedly ask whether any information is unclear. 8. Maintain eye contact with the patient while speaking. 9. If printed materials or books support the topic discussed by the nurse, provide them to the patient. 10. Involve the family in the explanation whenever possible. |
Assess the patient’s level of understanding by asking questions. Repeat the interventions if the patient did not understand them the first time. |
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Nurse’s Name
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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3- Nursing care plan for a patient with elevated body temperature. |
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3 |
Body temperature above the normal range (over 37.5°C). |
Reduce the temperature to the normal range and maintain it below 37.5°C. |
30 minutes–2 hours |
1. Measure temperature and pulse every 30 minutes until the temperature decreases. 2. Report temperature measurements to the physician. 3. Administer the required treatment as prescribed by the physician. 4. Apply tap-water compresses over pulse points. 5. Give oral fluids if permitted by the physician. 6. When the temperature falls below 37.5°C, notify the physician and discontinue the interventions. 7. Document the results of the interventions in the nursing notes. 8. If COVID-19 is suspected, the physician should issue a medical recommendation and refer the patient to an isolation hospital. |
Discontinue the procedure when the temperature returns to the normal range. If the temperature remains elevated, repeat the same interventions when possible or refer the patient as ordered by the physician.
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Nurse’s Name
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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4- Nursing care plan for a patient with constipation. |
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4 |
Altered bowel movement causing a sensation of bowel fullness, possibly accompanied by colic and gas. |
Maintain regular bowel movements. Prevent complications. |
1–2 hours |
1. Identify the primary cause of constipation, for example: Use of medications that may cause constipation as a side effect. A change in the usual bowel routine due to hospitalization. 2. Ask the patient about the previous bowel pattern. 3. Offer fiber-rich foods such as vegetables and fruit. 4. Educate the patient about the need for mobility and exercises appropriate to the patient’s condition. 5. Encourage the patient to drink fluids. 6. Educate the patient to establish a regular time for using the toilet. 7. Apply soothing ointments or creams if anal lesions are present, as ordered by the physician. 8. Administer laxatives as prescribed by the physician. 9. Auscultate bowel sounds. 10. Refer the patient for an enema when indicated and ordered by the physician. |
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Nurse’s Name
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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5- Nursing Care Plan for a Patient with Diarrhea |
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5 |
The patient has diarrhea and fluid loss and is at risk of dehydration. |
Restore the normal bowel pattern and protect the body from dehydration. |
1–2 hours |
1. Identify the cause of diarrhea, if possible. 2. Assess the number of bowel movements, color, odor, and contents. 3. Report the appearance, contents, and frequency of the diarrhea to the physician. 4. Obtain a stool analysis as ordered by the physician. 5. Administer the treatment prescribed by the physician. 6. Explain the effect of the treatment and the expected response. 7. Avoid foods that increase diarrhea, such as milk, fruit, and vegetables, until the diarrhea stops. 8. Administer oral fluids or intravenous fluids as ordered by the physician. 9. Observe for and report signs of dehydration. 10. Measure vital signs. 11- |
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Nurse’s Name
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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6- Nursing care plan for a patient with dehydration. |
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6 |
Severe body-fluid deficit. |
Maintain body fluids within the normal range. Fluid intake should be slightly greater than fluid output. |
2–3 hours |
1. Identify the primary cause of dehydration. 2. Measure vital signs. 3. Monitor the patient’s weight. 4. Observe for signs of dehydration, including poor skin turgor, weak pulse, intense thirst, low urine output, hypotension, and dry mucous membranes. 5. Administer intravenous fluids as prescribed by the physician. 6. For children, administer oral rehydration solution as ordered by the physician. 7. Encourage the patient to drink plenty of fluids and natural juices with the physician’s approval. 8. Implement medical orders for treatment of the cause of dehydration. 9. Refer the patient when necessary, as ordered by the physician. |
Assess skin characteristics. Assess vital signs. |
Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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7- Nursing care plan for a patient with nausea and an urge to vomit. |
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7 |
Uncomfortable sensation of nausea. Food intake below the body’s requirements because of vomiting. |
Maintain nutritional intake at a level appropriate for the body’s needs. Reduce the sensation of nausea and the urge to vomit. |
10–15 minutes |
1. Report the quantity, color, frequency, and contents of vomitus to the physician. 2. Administer treatment as prescribed by the physician. 3. Explain the purpose and effect of the medication. 4. Place a kidney basin beside the patient and a towel over the patient’s shoulder, ensuring that the patient’s head is turned to the side. 5. Provide general health education about preventing vomiting and nausea. 6. If COVID-19 is suspected, the physician should issue a medical recommendation and refer the patient to an isolation hospital. |
Assess for vomiting or nausea. If the problem persists, refer the patient as ordered by the physician. |
Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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8- Nursing care plan for a patient with anxiety. |
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8 |
Patient anxiety |
Eliminate or reduce anxiety. |
20–30 minutes |
1. Identify the primary cause of anxiety. 2. Speak to the patient calmly and reassuringly. 3. Use simple, brief sentences to help the patient understand the condition, and communicate only information authorized by the physician. 4. Do not appear nervous or rushed while speaking with the patient. 5. Listen to the patient and provide adequate attention. 6. If the patient cries during the discussion, allow the patient to express emotions. 7. Advise the patient to occupy time with activities such as watching television, listening to the radio, or reading newspapers. |
Assess the patient’s level of anxiety. If the problem persists, repeat the preceding interventions. |
Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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9- Nursing care plan for a patient with pain. |
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9 |
The patient is experiencing pain. |
Eliminate or reduce the patient’s pain. |
15–30 minutes |
1. Assess the pain in terms of location, type, frequency, and severity. Help the patient describe the pain and determine whether it is associated with a particular factor, such as movement. 2. Identify factors that precipitate the pain. 3. Ask whether the patient has experienced this pain before and how it was managed. 4. Notify the physician and provide sufficient information from the pain assessment. 5. Administer the treatment prescribed by the physician. 6. Provide psychological support to the patient. 7. Provide nursing care appropriate to the type of pain, for example: Avoid moving the painful area and support it with a pillow. Apply warm compresses to the painful area. |
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Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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10- Nursing care plan for a patient with shortness of breath. |
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10 |
Shortness of breath
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Maintain a normal respiratory rate and pattern. |
10–15 minutes |
2. Administer oxygen as prescribed by the physician. 3. Administer nebulizer therapy as prescribed by the physician. 4. Monitor vital signs. 5. Observe the patient. 1. Position the patient in semi-Fowler’s position. Respiratory characteristics: rate and depth. 6. Administer appropriate treatment as directed by the physician. 7. If secretions are present, observe the quantity, color, and odor of sputum. 8. If COVID-19 is suspected, the physician should issue a medical recommendation and refer the patient to an isolation hospital. |
Measure the respiratory rate. Assess the patient’s color. Measure blood oxygen saturation as ordered by the physician.
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Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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11- Nursing care plan for a patient with sputum in the chest. |
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11 |
Sputum in the chest. |
Maintain a normal respiratory rate and pattern. |
10–15 minutes |
1. Position the patient comfortably in bed. 2. Monitor vital signs continuously. 3. Observe the patient’s color. 4. Observe the sputum—color, quantity, and odor. 5. Perform breathing exercises. 6. Administer oxygen as prescribed by the physician. 7. Administer treatment as prescribed by the physician. 8. Educate the patient to drink warm fluids. 9. Provide ongoing mouth care, skin care, and general hygiene. 10. Encourage the patient to cough to expel secretions. 11. Suction the airways. 12. If COVID-19 is suspected, the physician should issue a medical recommendation and refer the patient to an isolation hospital. |
Respiratory rate. Monitor the color, quantity, and odor of secretions. Assess the patient’s color. |
Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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12- Nursing Care Plan for a Patient with Cough |
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12 |
Presence of cough. |
Eliminate or reduce the patient’s cough. |
20–30 minutes |
1. Reassure the patient and listen attentively. 2. Perform breathing exercises. 3. Encourage the patient to cough to expel secretions. 4. Give warm fluids. Administer treatment as prescribed by the physician. 5. If COVID-19 is suspected, the physician should issue a medical recommendation and refer the patient to an isolation hospital. |
Assess the patient. If the problem persists, repeat the preceding interventions. |
Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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13- Nursing Care Plan for a Patient with Myocardial Infarction |
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13 |
Nursing Care for a Patient with Myocardial Infarction |
Provide first aid to reduce complications. |
10–15 minutes |
1. Obtain the patient’s medical history to confirm the condition and identify the location of pain, and assess and document a complete description of the pain. 2. Help the patient rest completely by providing reassurance and placing the patient in semi-Fowler’s position to reduce oxygen consumption. 3. Measure vital signs rapidly and accurately, noting skin color and the degree of sweating. 4. Obtain an electrocardiogram, preferably while the patient is in pain, and present it to the physician. 5. Insert one or two peripheral IV cannulas and obtain a blood sample for complete laboratory investigations. 6. Ask whether the patient has an aspirin allergy or has recently experienced bleeding from the nose or mouth or recently experienced symptoms of a stroke. 7. Administer medications, including analgesics, as directed by the physician. 8. Administer Dinitra as directed by the physician—one sublingual tablet. Measure blood pressure before administration to prevent hypotension. 9. Administer aspirin as ordered by the physician; the tablet should be chewed and swallowed. 10. Administer oxygen if the patient experiences shortness of breath, as prescribed by the physician. 11. Obtain another electrocardiogram and present it to the physician. 12. Continue all these interventions while arranging immediate referral to the nearest hospital, because the patient must be admitted to a coronary care unit for continued specialized care.
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Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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14- Nursing care plan for a patient with chest pain. |
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14 |
Chest pain. |
Eliminate or reduce pain. |
15–20 minutes |
1. Position the patient sitting upright. 2. Administer oxygen as prescribed by the physician. 3. Administer treatment as directed by the physician. 4. Assess the type and severity of pain. Monitor vital signs. 5. Obtain an electrocardiogram. 6. Refer the patient as ordered by the physician. |
Vital signs. Type and severity of pain. |
Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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15- Nursing care plan for a patient with general weakness due to a low blood hemoglobin level (anemia). |
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15 |
General weakness due to a low blood hemoglobin level (anemia). |
Maintain the hemoglobin level within the normal range. Reduce complications. |
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1. Observe for symptoms of anemia: Lethargy and poor concentration and comprehension. Palpitations. Pallor of the skin, nails, and lips. 2. Measure the blood hemoglobin level and obtain a complete blood count as directed by the physician. 3. Provide health education about: Important iron-rich foods, such as liver, blackstrap molasses, eggplant, and fresh vegetables. Foods containing vitamin C are preferable, including parsley, guava, oranges, and tomatoes. Reduce or avoid caffeine-containing products such as tea, coffee, cola, and chocolate. 4. Administer iron, as syrup or tablets, as ordered by the physician. 5. Provide information about the side effects of iron tablets, such as black discoloration of the stool. 6. Monitor vital signs.
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Monitor hemoglobin. Monitor symptoms of anemia. |
Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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1- Nursing care plan for a patient with hypertension. |
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16 |
Hypertension |
Control blood pressure and prevent complications. |
30–45 minutes at every visit |
1. Provide health education about: Avoid foods high in sodium and reduce fat and cholesterol intake. Avoid caffeine-containing products such as tea, coffee, cola, and chocolate. Do not smoke. Provide a simple explanation of blood pressure and its effects on the heart, kidneys, blood vessels, and brain. 2. Follow an exercise program or walk for one hour daily, according to the patient’s condition. 3. Avoid stress and emotional agitation. Administer treatment as prescribed by the physician. 4. Measure vital signs. In chronic disease, monitor blood pressure at every visit and report the result to the physician. 5. If elevated blood pressure is detected for the first time, monitor it throughout the week and report the results to the physician for appropriate action. |
Assess the patient’s vital signs. Assess the dietary regimen being followed.
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Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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1- Nursing care plan for a patient with hypotension. |
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17 |
Hypotension. |
Maintain blood pressure within the normal range. Prevent complications. |
15–30 minutes At every visit |
1. Drink more water. 2. Reduce alcoholic beverages. 3. Pay attention to body position: Move slowly from lying or squatting to standing, and avoid sitting with one leg crossed over the other. If symptoms begin when standing, cross your thighs in a scissors position and squeeze them together, or place one foot on a ledge or chair and lean forward as far as possible. These movements stimulate blood flow from the legs to the heart. 4. Eat small, low-carbohydrate meals, divided into several small portions throughout the day. 5. Educate the patient to exercise regularly, such as walking for at least 30 minutes. 6. Monitor vital signs. 7. Administer treatment as prescribed by the physician. |
Assess the patient’s vital signs. Assess the dietary regimen being followed. |
Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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13- Nursing care plan for a patient in a hypoglycemic coma. |
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18 |
Coma due to hypoglycemia. |
Maintain the blood glucose level within the normal range. Prevent complications. |
15–30 minutes |
1. Educate the patient about symptoms of hypoglycemia: - Loss of consciousness - Poor concentration - Dizziness and headache - Sweating - Difficulty speaking - Palpitations - Hunger and nausea - Tremors - Fatigue and exhaustion. 2. Advise the patient to consume a sugar-containing food or drink when these symptoms occur. 3. Educate the patient to divide food intake into multiple small meals throughout the day. 4. If insulin is used, identify the type of insulin and its duration of action. 5. Review the prescribed dose and adjust it as ordered by the physician. 6. Educate the patient to follow the prescribed diet and eat immediately after insulin administration. 7. In an emergency, insert a peripheral IV cannula. Administer 25% glucose as ordered by the physician. Measure random blood glucose and report the result to the physician. |
Monitor blood glucose. Monitor vital signs. Monitor signs of hypoglycemia.
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Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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1- Nursing care plan for a patient in a hyperglycemic coma. |
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19 |
Coma due to hyperglycemia. |
Maintain the blood glucose level within the normal range. Prevent complications. |
30–45 minutes |
1. Identify the type of insulin used and its duration of action. 2. Administer insulin as ordered by the physician in an emergency. 3. Do not inject refrigerated insulin subcutaneously. 4. Educate the patient about symptoms of hyperglycemia and how to manage them. 5. Observe and record vital signs and perform a random blood glucose test. 6. Obtain urine and blood samples for tests available at the unit or center, and test the patient’s urine for acetone as directed by the physician. The patient’s breath usually has an acetone odor. 7. Administer insulin according to the test results and the physician’s orders. 8. Administer fluids if dehydration accompanies ketoacidotic coma, as prescribed by the physician. 9. Monitor the patient’s level of consciousness and observe for any deterioration. 10. Educate the patient’s family about diet, exercise, adherence to treatment, the importance of follow-up, personal hygiene and infection prevention, urine testing for glucose and acetone, and self-administration of insulin if the patient is able. 11. Refer the patient when needed, as directed by the physician. |
Assess urine color. Assess urine volume. Blood glucose.
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Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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Nursing Care Plan for a Family-Planning Client |
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20 |
Obtain a contraceptive method. |
Family planning and contraception. |
According to the contraceptive method provided. |
Provide counseling about the family-planning method.
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Nurse’s Signature
Nursing Care Plan
Patient’s Full Name: Insurance Number:
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No. |
Nursing Problem / Need |
Goal |
Time Available |
Interventions |
Evaluation |
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Nursing Care Plan for Risk of Falling |
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20 |
Risk of falling due to reduced level of consciousness, weakness, general collapse, dizziness, or weak leg muscles. Cerebral thrombosis, which may lead to serious injury. |
Protect the patient from the risk of falling. |
15–30 minutes |
Patient assessment: Use the fall-risk assessment form. Raise the bed side rails. Provide health education to the patient and family. Assess the patient’s mobility and capabilities. Assess the ability to move with nursing assistance. Ensure that floors are dry to prevent slipping. Use assistive devices, such as crutches, supports, or a wheelchair. Assess and document the movements the patient is capable of performing. Maintain a quiet environment and provide appropriate lighting whenever possible. Attempt to reduce the number of times staff need to approach the patient. Limit visits whenever possible. Reduce the patient’s fluid intake at night. Notify the physician if the problem persists. Perform a fall-risk assessment once per shift. Ensure that the room is well lit. Place all items needed by the patient within reach. Ensure that the floor surrounding the patient is dry. Place the call bell and emergency bell within the patient’s reach. |
Monitor risk factors that place the client at risk of falling.
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Nurse’s Signature
