NURSING DIAGNOSIS (in priority order) PATIENT-CENTERED GOALS NURSING INTERVENTION RATIONALE EVALUATION Risk for hypovolemia related to excessive fluid loss secondary to caesarean section as evidenced by: Subjective Data: Patient states: “I feel lightheaded and weak.” Objective Data: Elevated pulse (97)‚ blood loss from C-section of 704 mL‚ low hemoglobin (8.1) and hematocrit levels (24.7). (Before C-section‚ her hemoglobin levels were 13.1‚ her hematocrit levels 36). Short Term Goal
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Nursing Care Plan Nursing Diagnosis 1: Risk for Deficient Fluid Volume Risk for Deficient Fluid Volume related to evaporative loss of fluids and capillary damage through the burn wound as evidenced by weakness shown and abnormalities in PTR‚ BP‚ SpO2 due to flame burn at work on the entire right leg. Nursing Assessment: Objective data: (1) Temp 35.8°C in tympanic is below normal as pt sustained a flame burn at work causing heat loss from the body with risk of hypovolemic shock and
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will demonstrate the ability to assess and develop a care plan for this patient. For this case study‚ the patient’s name will be changed to Paul and confidentiality will be kept at all times. The nursing process will be described and used to develop a nursing care plan for the above patient. The setting is an integrated hospital service made up of Older Peoples health which provides services such as assessment‚ treatment and rehabilitation care for the over 65 years old population. These services
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Care Plan for Pain: Chronic| Student Name:|Samantha Lewis|Current Date: 4/19/12|| Patient:|SL|Age: |33|Sex:|F|Dates Care Given: 4/19/2012|| Admission Diagnosis/History: Chronic Pancreatitis| 1)PE 2) Hysterectomy 3)C Section | Nursing Diagnosis: Pain: Chronic | | ASSESSMENT| Objective Data|Subjective Data| · Increased blood pressure|· Pt holding lower left abdomen| · Increased heart rate|· Pt eyes closed| · Increased respirations|· Furrowed brow| · |· |
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Critical Evaluation of a Nursing Care Plan Course: HE Diploma Clinical Veterinary Nursing Module title and number: Systematic Delivery of Veterinary Nursing Care VN2019 Date: April 2011 Tutor: Claire Bloor By Amy Robinson Contents | Page number | Models of nursing and the nursing process................................................. | 3 | The Ability Model........................................................................................ | 4 | The case: Diva...........
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Care Planning Proforma 5NH008 Patient/Client…………………………………………………………………………………… PBL Group/Site/Facilitator………………………………………………………………… Problem/Need Outcome Nursing Care Interventions Evaluation Write a problem statement identifying an actual or potential need How does this impact on the patient/user? Ensure this statement is personalised Patient problems should have been identified with the patient/carer/parent following holistic assessment Identify a short term and long term goal
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Nursing Care: Congestive Heart Failure Beverly Baum‚ Chrysten Brown and Christina Bhowanidan Herzing University Nursing Care: Congestive Heart Failure The general population is living longer than ever before. The Federal Interagency on Aging-Related Statistics (2012) states “The number of older people will increase dramatically during 2010-2030 period. The older population in 2030 is projected to be twice as large as their counterparts in 2000‚ growing from 35 million to 72 million and
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has become excoriated and tender. Objective Data (Head to Toe Assessment including Vital Signs): SOA‚ pulse oximetry reading is 88%‚ bilateral crackles in the lower lobe‚ BP102/60-T 101 F‚ P 104‚ RR 32‚ he is receiving IV fluids @ 80 ml/hour. Nursing Diagnosis: Excess fluid volume R/T CHF AEB pulmonary congestion‚ adventitious breath sounds Patient Goals/Objectives (What do you hope will be the result of your efforts? Make sure goal is patient oriented‚ measurable‚ and has a time frame). Planned
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GRADED ASSIGNMENTS Data Assessment and Care Plan Nursing Care Plan Instructions: Prepare a plan of care for your patient. The plan of care must include a complete DATA ASSESSMENT with all pertinent data and interpretation of data completed. Based on the data‚ formulate an individualized care plan using (1) priority NANDA diagnosis and (2) secondary NANDA diagnoses. Each diagnosis requires at least (5) interventions‚ (5) rationales and (5) outcomes
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Original Care plans are in black text. Changes made appear in blue directly below the lines or parts that were changed. Minor changes/additions appear in blue within black text. Multiple interventions within the same nursing diagnosis have been indicated “Same reference as above” to save space. Nursing Diagnosis Form 1 (no changes made) NURSING DIAGNOSIS: Anxiety related to lack of knowledge about diagnostic procedures and uncertain condition of fetus as evidenced by (S) patient states she has fears
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