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 Care Plan Client name: Mrs. Chan Age/ sex: 48/F Medical diagnosis: Fluid overload‚ decreased TK output and decreased Hb Assessment date: 25-11-2012 Diagnostic statement (PES): Excess fluid volume related to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral edema and patient’s weight gained from 69.8kg to 73.6kg within 4 days. Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions
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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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A payment status of IN PROCESS means your payment is still being processed. A payment status other than PAID indicates that the Department of State has not received your payment. If you receive a notice that your case has entered termination do not attempt to pay any fees. You must contact the NVC immediately to resume processing of your petition. NVC contact information can be found at http://travel.state.gov/visa/immigrants/info/info_3177.html. Next Steps 1. When the IV fee payment status is
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Cues Nursing Problem Scientific Reasoning Planning Implementation Evaluation Subjective: >”Nay‚ kelan po tayo uuwi?” as verbalized by the patient >”Nag-aaya na nga syang umuwi.” as verbalized by the caretaker Objective: >Patient is silent when hospital staff is around >Patient does not have eye contact with the hospital staff Fear related to hospitalization as manifested by alteration in behavior. Hospitalization is usually perceived as a threat that is consciously
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Student Name: Dealon Rouse | Patient Initials: JB | Admission Diagnosis: Left Total Knee Arthroplasty &Excision of Left Knee Mass Related to Gouty Arthritis | Date(s) of Care: 11/10/11- 11/12/11 | Age: 46 | | Date of Admission: 11/10/11 | Gender: Male | | Marital Status: Married | Room #: 507 | Code Status: Full Code | Occupation: Electrician | Race: Hispanic | Isolation Type: | Religion: Roman Catholic | | Allergies: No Known Allergies | History of Present Illness:
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z Managed care plans for the uninsured Aisha Jones Managed Care and Health Insurance-HEA 205 Professor: Dr. Christine Connolly January 19‚ 2013 Abstract This paper is about an article I read about how managed care plans were created for uninsured patients of New Mexico back in 1997. The University of New Mexico Health science center felt that if they created this managed care plan that it would reduce the use of the emergency room and cost of care for the patients. By utilizing preventive
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Nursing Care in Multi-Organ Disfunction Syndrome When a patient enters the Emergency Department (ED)‚ immediate and accurate assessment is mandatory to ensure prompt medical diagnosis and appropriate care. In the case of Mrs. Baker‚ a 73-year-old female who collapsed in her backyard‚ this assessment will assist in determining the reason for her collapse as well as identifying underlying medical problems that may have led to this incident. Upon her arrival at the ED‚ Mrs. Baker gives her previous
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