Original upload: September 2011

Re-upload: January 2016

Below is a sample care plan for a client whose medical diagnosis was Osteomalacia. I chose to
re-upload this topic as it is an uncommon diagnosis and configuring fitting NANDA diagnosis
seemed to be quite difficult for students. These care plans could be tailored to other diagnosis. I
hope this helps! Permission granted for full use.

Short/Long-term
goal: Patient
Activity intolerance maintains normal
heart rate and blood
pressure during
ROM activity, as
well as absence of
shortness of breath,
weakness, and
Related to
fatigue.
Osteomalcia

NANDA
Diagnosis

Assessments
1.Assess the
influence of activity
on wound condition
and general body
condition.
2. Pt monitor pulse
ox, b/p, and temp
during ADLs to
ensure comfort and
preserve energy

Actions
Evidence
Insufficient
physiological or
psychological
energy to endure or
complete required
or desired daily
activities

3.Minimize
cardiovascular
deconditioning by
positioning clients as
close to the upright
position as possible
several times daily.
4. Perform range-ofmotion exercises if
client is unable to
tolerate activity.
5.Allow for periods
of rest during pt care
and apply oxygen if
needed
6. Observe and
document skin
integrity several
times a day.

Patient
Teaching
Pt dysphasia.
Teach parents the
importance of proper
nutrition. (http://ww
w.ncbi.nlm.nih.gov/p
ubmed/12948303)
Describe to parents
the symptoms of
activity intolerance,
including which
symptoms to report
to the physician.

1.Activity stimulate
increased
vascularization and
the pulsation of the
reproductive
organs, but can
affect postoperative
wound conditions
and reduced energy.
2.Optimizing
conditions for pt,
rest is
indispensable.
3.Deconditioning of
the cardiovascular
system occurs
within days and
involves fluid
shifts.
4. Inactivity rapidly
contributes to
muscle shortening
and changes in
periarticular and
cartilaginous joint
structure.
5. Rest periods
decrease oxygen
consumption.
6. Activity
intolerance may
lead to pressure
ulcers.

Maintains normal skin

color and skin is warm
and dry with activity.
Pt tolerates ADLs with
appropriate increases in
heart rate, blood
pressure, and breathing
rate; maintains monitor
patterns WNL

NANDA
Diagnosis
Risk for Aspiration

Short-term goal: Pt
will not aspirate
during shift.
Long-term goal: Pt
will not aspirate for
one month.

Related to
Tracheostomy

Evidence
Visible copious
secretions

Assessment
1. Monitor
respiratory rate,
depth, and effort.
Note any signs of
aspiration.
2. Auscultate lung
sounds frequently
and before and after
feedings; note any
new onset of ABS.

Actions
1. During enteral
feedings, position pt
with HOB elevated
30 to 45 degrees;
maintain for 30 to 45
minutes after
feeding.
2. If client shows
symptoms of nausea
and vomiting,
position on side.

Short-term goal has

aspiration should be been met. This is an
detected as soon as ongoing care plan due
possible to prevent to permanency of trach.
further aspiration
and to initiate
treatment that can
be lifesaving.

1. Signs of

2. Early
intervention of
aspiration is
important to save
pts life.

1. Keeping client's
head elevated helps
keep food in
stomach and
decreases incidence
of aspiration
2. To prevent
aspiration of
emesis.

3. Note new onset of

abdominal distention
or increased rigidity 3. This can be
of abdomen.
associated with an
obstruction and
4. Have suction
lead to vomiting.
machine available at
all times to suction
prn.
4. Suctioning the pt
when needed will
prevent the buildPatient
up of secretions and
Teaching
lessen the
likelihood of
Teach family signs
aspiration
of aspiration and
precautions to
prevent aspiration.
Teach family how to
safely administer
tube feeding and
perform suctioning.

So they can apply

the same
interventions at
home.
If they perform
these tasks
efficiently it will
reduce the

likelihood of
aspiration
occurring.

Short/Long-term
goal: Patient
Activity intolerance maintains normal
heart rate and blood
pressure during
ROM activity, as
well as absence of
shortness of breath,
Related to
weakness, and
Osteomalcia
fatigue.

NANDA
Diagnosis

Assessment
1.Assess the
influence of activity
on wound condition
and general body
condition.
2. Pt monitor pulse
ox, b/p, and temp
during ADLs to
ensure comfort and
preserve energy

Actions
Evidence
Insufficient
physiological or
psychological
energy to endure or
complete required
or desired daily
activities

3.Minimize
cardiovascular
deconditioning by
positioning clients as
close to the upright
position as possible
several times daily.
4. Perform range-ofmotion exercises if
client is unable to
tolerate activity.
5.Allow for periods
of rest during pt care
and apply oxygen if
needed
6. Observe and
document skin
integrity several
times a day.

Teaching

1.Activity stimulate
increased
vascularization and
the pulsation of the
reproductive
organs, but can
affect postoperative
wound conditions
and reduced energy.
2.Optimizing
conditions for pt,
rest is
indispensable.
3.Deconditioning of
the cardiovascular
system occurs
within days and
involves fluid
shifts.
4. Inactivity rapidly
contributes to
muscle shortening
and changes in
periarticular and
cartilaginous joint
structure.
5. Rest periods
decrease oxygen
consumption.

6. Activity
Pt dysphasia.
intolerance may
Teach parents the
lead to pressure
importance of proper ulcers.
nutrition.
Describe to parents
the symptoms of
activity intolerance,
including which
symptoms to report
to the physician.

Maintains normal skin

color and skin is warm
and dry with activity.
Pt tolerates ADLs with
appropriate increases in
heart rate, blood
pressure, and breathing
rate; maintains monitor
patterns WNL