School of Nursing Care Plan Student’s Name: Joie Ferreiro________________________________ Date: 9/5/14 Client’s Initials: R.S. Admission Date: 7/30/14 Age: 96 Sex: f___ Race: __w____ Religion: Jewish Allergies: Phenobarbital Diet: NPO Activity: Bed rest Admitting Medical Diagnosis (es): Sacral decubitus ulcer‚ polymicrobic sacral osteomyelitis Past Medical History (including past surgical history): Illnesses include: 1) Renal insufficiency 2) Anemia 3) hyperthyroidism
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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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NURSING CARE PLAN GUIDE ASSESSMENT OF UNIVERSAL SELF CARE REQUISITES DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient. |ASSESSMENT |PLANNING |EVALUATION | |Universal
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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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health care process‚ which prevents life loss in many critical cases. Although the surgery has saved life‚ it also accompanied with considerable risk of death (Weiser et al.‚ 2008). It is noticeable that a teamwork and effective communication increase the positive outcome; moreover‚ a skilled professional team reduces the rate of adverse events. In proper communication between health care providers can cause the adverse result. Many studies have shown an improvement by the member of care team regarding
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WAYNE COUNTY COMMUNITY COLLEGE DISTRICT NURSING PROGRAM NURSING CARE PLAN General Information: Postop pt undergone a cholecystectomy Patient intials: R.M. Confidential Marital Status: SINGLE Student’s Name: Hanadi Abdou Age: 61 Birthdate: 12/3/1950 Religion: not specified (pt nonverbal) Clinical Instructor: Mary Servey Admittance date: 3/12/12 Interest: not specified (pt nonverbal) Date: 3/21/12 Class: Med Surg Diagnoses: Impaired skin integrity Diet: NPO Allergies: None
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Diagnosis #1: Multiple coronary artery disease Chief Complaint #1 Use Quotes: ”Shortness of breath and chest pain for over a month now” on 2/6/13 on day of Admission Chief Complaint #1 Use Quotes: “Pain 8/10” on day of your nursing care Prior Illnesses Hypertension‚ coronary artery disease‚ obesity‚ angina Family History Father passed away from a heart attack; Mother had a stroke General Survey Sex M Race Caucasian Age 74 Height 175cm Weight 90.7 kg
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ASSESMENT | GOAL OF CARE | PLAN OF ACTIONS | RATIONALE | IMPLEMENTATION | DOCUMENTATION | Subjective:“Daghan man na siya samad ug hubag sa iyang lawas”(She has many wounds and bruises on her body) as verbalized by the mother.Objective:-Presence of lesions and abrasions on the patient’s body.-greenish violet discolorated patches-soaked dressingNursing Diagnosis:Risk for impaired skin integrity related to superficial factors. | At the end of 8 hours nursing interventions‚ the client will be able
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NURSING CARE PLAN ASSESSMENT SUBJECTIVE: “Bakit kaya madalas ako mahilo?” (Why do I always feel dizzy?) as verbalized by the patient. OBJECTIVE: ♦ Request for information. ♦ Agitated behavior ♦ Inaccurate follow through of instructions. ♦ V/S taken as follows: T: 37.2 P: 84 R: 18 BP: 180/110 DIAGNOSIS ♦ Risk for prone behavior related to lack of knowledge about the disease INFERENCE ♦ High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels
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treatment regimens‚ unfamiliar and often complex problems. Because of the patient’s education is considered a skill reimbursed by Medicare & other commercial insurance carriers. It is important for the nurse to include knowledge deficit in the plan of care. The deficit in knowledge may relate to clients lack of information about their disease process‚ medication or resources Kozier‚ 2007; Perry and Potter‚ 2002 | After couple of nursing interventions‚ the patient will gain enough knowledge
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