Nursing Care Plan Assessment equals Data Collection + Analysis | Nursing Diagnosis – Actual/Potential | Nursing Goal(SMART) | Nursing Interventions/ActionsInclude Rationale/Reference | Evaluation | Female Age : 85Code status: Full Code initially but changed to DNR on 14/Jan-2012Primary diagnosis: PancytopeniaReason for Hospital Admission: Fall at home. Allergy: PenicillinMedical History: Pacemaker‚ Hypertension‚ Fall at home‚ Bradycardia‚ Hyperlipidemia.Neurological: Alert‚ Oriented x 4.Diet
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DIFFICULTY OF BREATHING” As verbalized by the patient. OBJECTIVE: ➢ Weak and pale in appearance ➢ Difficulty of breathing ➢ Poor skin turgor ➢ Clutching of hands to chest ➢ Shortness of breath ➢ Restlessness VITAL SIGNS: ➢ BP- 130/90 mmHg ➢ T- 37.5 C ➢ PR- 98 BPM ➢ RR-25BPM ➢ PAIN SCALE- 8 | ➢ ACUTE PAIN RELATED TO MYOCARDIAL ISCHEMIA. |SHORT TERM GOAL: After 8 hours of nursing intervention: ➢ The patient will be able to verbalize relief from chest pain
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ASSOCIATE DEGREE NURSING NURSING PROCESS FORM: PART I – ASSESSMENT Student: Date of Care: 3/4/13 Client’s Initial: WB Room # 1011 Occupation: Teacher Age: 59 Sex: F Race: Black Religion: Christian Admission Date: 3/1/13 Primary Language: English Role in family: Widowed from husband Stage in Life Cycle: Generativity vs. Stagnation Surgery date(s) this admission: N/A Chief complaint: Brain Dysfunction/Traumatic‚ closed injury Admission Diagnosis:
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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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DATE | CUES | NURSING DIAGNOSIS | KNOWLEDGE BACKGROUND | GOAL | NURSING INTERVENTION | RATIONALE | EVALUATION | | Subjective:“Medyo masakit ang dibdib ko pag umuubo ako.”as verbalized by the patientObjective:Productive coughYellow sputum dischargedPain scale of 10/10 | Acute pain R/T coughing | Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage ;sudden or slow onset of any intensity from
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MODULE 1: ADMINISTRATIVE PROCESS IN NURSING Submitted by: Jennelyn M. Pondang Submitted to: Prof. Liwayway T. Vallesteros • Answer learning activities (page 14) nos. 3 and 4. • Illustrate using a table a comparison of the ff leadership style: a. Democratic‚ Authoritarian‚ and Laissez-faire b. Transformational and Transactional • Which of the above leadership styles do you think your immediate manager adhere to? Support your assumption. 3. Compare Theory X‚ Y‚ and Z.
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Nutrition Care Process Nutrition Assessment The first step in the nutrition care process is the nutrition assessment. This involves collecting information about the patient’s ailment through family and medical history questionnaires‚ medical charts‚ oral or written communication with the medical staff‚ and related research. Health care personnel are responsible for recording and analyzing food and nutrition intake‚ body composition‚ and laboratory data as it relates to the patient’s condition
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Evolving Practice of Nursing and Patient Care Delivery Models Amanda Decker Grand Canyon University NRS 440-V Trends and Issues in Health Care December 5‚ 2014 Nursing is a career that presents those in it with many opportunities. There are a variety of nurses and the field in which they choose to practice is just as varied. There are oncology nurses‚ school nurses‚ home health nurses‚ trauma nurses and nurse practitioners. They work in clinics‚ hospitals‚ schools‚ prisons‚ mental health hospitals
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and Diagnosis Components of the Nursing Process Aldecia Blackwood ITT Technical Institute ASSESSMENT AND DIAGNOSIS COMPONENTS Abstract The nursing process is an organized critical thinking system used by professional nurses to give the best optimal care to clients. “It is very similar to the steps used in scientific reasoning and problem solving.” (Ackley and Ladwig‚ 2014:2). It contains five steps; Assessment‚ Diagnosis‚ plan‚ implementation of care‚ and evaluation. Assessment is
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every 30 minutes until pain is relieved. a burning sensation before taking nitroglycerine indicates medication potency. Mr.Ali has an ICD implanted in the left lower quadrant of his abdomen. When obtaining his history‚ you find out that the patient also had CABG surgery at the time of ICD lead implant. You do not see any incision lines at the subclavicular area. What kind of leads does Mr. Ali have? Transvenous sensing with “hot can” Transvenous sensing and epicardial patches Epicardial
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