NURSING CARE PLAN Nurs 326 SFSU Student Name: Alena Makarava Instructor/Clinical Site Gerardo Caritan‚ RN‚ MSN Date: 2/26/2015 Ms. X is a 34 year old female. The patient is a G3 P2‚ with both children delivered by C-section‚ with the only complication in both being low birth weights. Ms. X has a longstanding history of hypertension‚ anxiety and depression. Additional health history includes a vitamin D deficiency‚ back surgery in 05/06 due to a herniated disc‚ and two previous cesarean
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proper care. However‚ there are an astounding number of children who are not getting the treatment they need. It is reported that out of all children who suffer from mental health issues‚ only twenty-one percent of them receive the necessary
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Postpartum Hemorrhage Jorge Garcia‚ MD December‚ 2001 Outline Case History Definition Rapid diagnosis Treatment Review risks Case History. Healthy 32 yo G2P1+0. Previous C/S 2 years back Augmented vaginal delivery with vacuum extraction‚ with episiotomy On admission uterus will contracted. Lochia normal Second day Patient complaining of continues sever pain prescribed as pressure on the rectum side which was not relieved by analgesia. Lochia was minimal‚ episiotomy
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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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Nursing Theory Plan of Care Theoretical Foundations of Practice NUR/513 March 05‚ 2012 Nursing Theory Plan of Care Ida Orlando literally wrote the book on the function of nursing. Her theory of the deliberative nursing process outlines a dynamic nurse-patient relationship in which the nurse uses his or her senses of perception together with deliberate actions to create an individualized care plan for each patient. Results of current research on the application of her theory follow
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CUES/ CLUES |DIAGNOSIS |OBJECTIVES |INTERVENTIONS |EVALUATION | |SUBJECTIVE: ➢ “I ALWAYS EXPERIENCED CHEST PAIN AND 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
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ASSESSMENT (Data Collection) NURSING DIAGNOSIS (Patient Problem/Priority) PLANNING (Patient-Centered Goals) IMPLEMENTATION (Nursing Interventions) Nurse roles: Assess‚ monitor‚ use of communication techniques‚ patient education EVALUATION (Patient-Centered Goal Met?) Subjective: (what you heard the patient describe) Objective: (what you see‚ hear‚ smell‚ feel) *Use nursing diagnosis language 1 goal per physical What specifically will you do - as a nurse - to assist the patient
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NURSING DIAGNOSIS GOAL INTERVENTIONS RATIONALE EVALUATION impaired Gas Exchange R/T STG: 3/17/2014 throughout shift 1. Auscultate breath sounds 1. Abnormal breathing STG: PT O2 saturation on admission abnormal breathing AEB PT will maintain O2 saturation noting areas of decreased sounds are indicative was 87%. Measured at 1602 with a Objective: use of wall oxygen of 95 or higher AEB breathing sounds of numerous problems reading of
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Teaching Care Plan for Nursing Identify if article has a review of literature. Yes‚ This article definitely has a review of literature‚ it is a compilation from a lot of information the author studied and applied to the specific topic she was addressing. Determine the purpose of the article. The purpose of the article is to make medical professionals aware of the signs and symptoms of depression in older adults. It was to establish a less biased approach to evaluating the mood of each client
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biological rhythms associate with postpartum mood‚ specifically the impact of sleep and biological rhythms on maternal mental health in a population of women at high and low risk for postpartum depression. Postpartum depression (PPD) is the most common maternal birth complication. Approximately 15-20% of mothers experience severe mood disturbances – meeting criteria for depression. This has a pervasive impact on developing infants. There are no biological markers for depression. Symptoms cause clinically
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