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
Premium Wound Vaccination Vaccine
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
Free Blood pressure Hypertension
lan NURSING CARE PLAN | ASSESSTMENT | BACKGROUND KNOWLEDGE | PLANNING | INTERVENTION | RATIONALE | EVALUATION | Subjective:n/aObjective: * Preterm birth (36 weeks) * Weight: 1.75kgs. * Cool and dry skin. * Temperature: 33.6 degrees Celsius. * Poor muscle tone. * Placed under two droplights.Nursing Diagnosis: Ineffective thermoregulation related to immaturity. | Vaginal birthPretermPoor muscle developmenthypothermia | After 1 hour of nursing intervention‚ patient will maintain
Premium Temperature Nursing care plan
Nursing care plan (Colonoscopy) S.E is a 59 year old African-American male admitted to the critical care unit because of his left lower quadrant (LLQ) abdominal pain. S.E had a colonoscopy 2 days ago. He has a family history of hypertension (HTN) and a medical history of HTN and anemia. He is alert and oriented ×3 (time‚ place‚ and person). S.E has no known drug allergy and he is NPO except for medicine. Problem: LLQ abdominal pain Acute pain | Assessment | Planning/Nursing Goals |
Premium Blood Vital signs Nursing care plan
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
Premium Educational psychology Cognition Learning
Family Care Plan Thomas Chamness University of Phoenix Nursing 467 Karen Jones November 20‚ 2010 Family Care Plan My family consists of a single mother‚ age 27. Her child is a 3-year-old male. The characteristics of the mother are unique; she had to deal with losing both of her parents at a young age. Her father committed suicide when she was nine and her mother was murdered in the line of duty while working as a state trooper. The mother also has no siblings. At the present time
Free Family
many people who suffer with hearing lost‚ but unfortunately Katherine’s started at the age of thirty years old. She tells a story about attending a fun-raiser for a magazine finding herself in a conversation with a well-known Arthur she admired. While engaging in a deep conversation she began to realize she couldn’t hear a thing he was saying. She began to tell us how the effect of her trying to hear was using up a lot of her brain power and was somewhat eased by a hearing aid and cochlear implant.
Premium Brain Cognition Psychology
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
Premium Dehydration Nutrition Nursing care plan
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
Premium Antibiotic resistance
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
Premium Childbirth Blood Uterus