Assessment | Nursing Diagnosis | Goals & Expected outcomes | Nursing Interventions | Rationales | Methods of Evaluation | Name of client: Mrs. Tam Age: 65 Sex: Female Student ID:1155016494 Assessment date: 29/11/12 Medical Diagnosis: 1. Lower limbs edema 2. Low albumin level 3. hypokalemia and hypocalcaemia 4. Anemia Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to vomiting after eating as evidenced by food intake less than the recommended daily
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This therapeutic care plan will utilized the “I can treat and prescribe framework” to ensure that appropriate patient treatments are selected using a step by step approach‚ including assessment integration‚ drug and/or disease related problems‚ therapeutic goals‚ therapeutic alternatives and indications‚ plan of care and evaluation (OPHCNPP‚ 2012). By going through each step of this framework‚ and including or excluding treatment options based on individual patient factors and strong clinical evidence
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Student Name: Date: February 25‚ 2006 Nursing Diagnosis Outcome Criteria (Goal) Evaluation of Outcome Criteria (Goal) PC: Postpartum Hemorrhage Patient will develop no complications related to excessive bleeding‚ will maintain normal vital signs of express understanding of her condition‚ its management‚ and discharge instructions‚ identify and use available support systems. R/T‚ RTRF and secondary to: Pathophysiology Supporting Nursing Diagnosis Statement (cite source) Uterine atony
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Nursing Assessment of the Postpartum Patient Date of data collection:___13 November 2014___ Patient initials _K.M.___ Age__28_ PP day _1__ (# days since delivery- 0‚ 1‚2 3‚ etc) Grav _4__ Para _3__ Term _3__ Preterm _0___ Ab_0__ LC___ Weeks gestation @ delivery (via EDC) _39.2____ Weeks gestation at delivery (from neonatal maturity rating/Ballard exam):_ 40_____ Date/time of delivery _12 Nov. / 1640_________ Labor onset - induced or spontaneous (circle one) If induced: indication (why)
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CASE STUDY IN NCM-103 (CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION‚ FLUID AND ELECTROLYTE BALANCE‚ NUTRITION AND METABOLISM AND ENDOCRINE) Submitted to : Mr. Darren N. Constantino Submitted by : Olive Keithy Ascaño CASE STUDY 1 1. a. The possible fluid and electrolyte imbalances that the 78-year-old woman may experience are hyponatremia‚ hypokalemia and hyperkalemia because of nausea and vomiting that are common in these imbalances. b. The following interventions are
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NURSING CARE PLAN Nursing Assessment: Ms. F.E. is a 20yr. old female who was involved in a motor vehicle accident (M.V.A.)‚ and was admitted on 04.03.12 to the surgical unit with Spinal injuries‚ Polytrauma and fractured right humerus. She started complaining of severe abdominal pains‚ one week after assessment by Doctor‚ she was scheduled for emergency laparotomy with ?diagnosis Perforated Hallow Viscus. Following surgery patient was diagnosed with Fecal Peritonitis and was transferred to the
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Physical Care: - Sleep: Be sure to maintain good sleep habits. This will include going to bed no later than 10:00pm and staying in bed a minimum of eight hours. - Nutrition: Eat a healthy diet to include 3 meals per day and at least one healthy snack. - Exercise: Take daily walks outside for a minimum of 20 minutes. Psychological Care - Family time: Make time to take family out of the house at least twice per week. Have dinner at the dinner table as a family at least 4 days a week. - House
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Infection. Objectives: Within 15 minutes of nursing intervention‚ the patient will be able to gain knowledge by : Enumerating 2/3 specific causative factors of UTI. Demonstrate behaviors and techniques to prevent urinary tract infection and manage care of urinary catheter. Shows positive attitude by verbalizing understanding of her condition. Establish rapport Assess level of awareness of the mother regarding the child’s condition. Broaden the knowledge of the mother by teaching:
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as palpated levels of spinal segmental dysfunction. Based upon these findings‚ IW is clearly demonstrating functional improvement with additional chiropractic treatment but has not achieved the expected results of chiropractic treatment‚ and further care is necessary. Chiropractic treatment is recommended at a frequency of 2 times per week for 8
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Richard J. Daley College Nursing 101 Data Collection for Care Plan Section I – Demographic Data: Patient Initials: K. J. Sex: Female MSWD: Married Age: 44 No. of children: 1 Occupation: Disabled Section II- Admission Data 1. Date admitted: 10/19/2007 2. Admitting diagnosis: Hematomesis‚ melanotic stools‚ cirrhosis‚ hepatorenal syndrome. 3. Allegries: Codiene 4. Signs and symptoms on admission: jaundice appearance‚ lethargic‚ oriented x 1‚ vomiting bright red blood‚ has had
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