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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Nursing Assessment of the Postpartum Patient Date of data collection:___13 November 2014___ Patient initials _K.M.___ Age__28_ PP day _1__ (# days since delivery- 0‚ 1‚2 3‚ etc) Grav _4__ Para _3__ Term _3__ Preterm _0___ Ab_0__ LC___ Weeks gestation @ delivery (via EDC) _39.2____ Weeks gestation at delivery (from neonatal maturity rating/Ballard exam):_ 40_____ Date/time of delivery _12 Nov. / 1640_________ Labor onset - induced or spontaneous (circle one) If induced: indication (why)
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NURSING CARE PLAN Nursing Assessment: Ms. F.E. is a 20yr. old female who was involved in a motor vehicle accident (M.V.A.)‚ and was admitted on 04.03.12 to the surgical unit with Spinal injuries‚ Polytrauma and fractured right humerus. She started complaining of severe abdominal pains‚ one week after assessment by Doctor‚ she was scheduled for emergency laparotomy with ?diagnosis Perforated Hallow Viscus. Following surgery patient was diagnosed with Fecal Peritonitis and was transferred to the
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Physical Care: - Sleep: Be sure to maintain good sleep habits. This will include going to bed no later than 10:00pm and staying in bed a minimum of eight hours. - Nutrition: Eat a healthy diet to include 3 meals per day and at least one healthy snack. - Exercise: Take daily walks outside for a minimum of 20 minutes. Psychological Care - Family time: Make time to take family out of the house at least twice per week. Have dinner at the dinner table as a family at least 4 days a week. - House
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Infection. Objectives: Within 15 minutes of nursing intervention‚ the patient will be able to gain knowledge by : Enumerating 2/3 specific causative factors of UTI. Demonstrate behaviors and techniques to prevent urinary tract infection and manage care of urinary catheter. Shows positive attitude by verbalizing understanding of her condition. Establish rapport Assess level of awareness of the mother regarding the child’s condition. Broaden the knowledge of the mother by teaching:
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as palpated levels of spinal segmental dysfunction. Based upon these findings‚ IW is clearly demonstrating functional improvement with additional chiropractic treatment but has not achieved the expected results of chiropractic treatment‚ and further care is necessary. Chiropractic treatment is recommended at a frequency of 2 times per week for 8
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Richard J. Daley College Nursing 101 Data Collection for Care Plan Section I – Demographic Data: Patient Initials: K. J. Sex: Female MSWD: Married Age: 44 No. of children: 1 Occupation: Disabled Section II- Admission Data 1. Date admitted: 10/19/2007 2. Admitting diagnosis: Hematomesis‚ melanotic stools‚ cirrhosis‚ hepatorenal syndrome. 3. Allegries: Codiene 4. Signs and symptoms on admission: jaundice appearance‚ lethargic‚ oriented x 1‚ vomiting bright red blood‚ has had
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by the end of the shift. Pt will progress from NPO to clear fluids to soft foods by the end of the week. Pt will continue to ambulate as much as possible. | PLANNING | IMPLEMENTATION | EVALUATION | InterventionsSuggested nursing approaches and care-giving skills. | Rationale for InterventionsEvidence or knowledge based reason for selecting the intervention | What you actually did – compared to what you planned to do | Whether or not the goals and objectives were met and suggestions for modification
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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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treatment in order to maximize therapeutic effect and facilitate healing. When a patient and their family are educated about illness‚ medications‚ and other treatments‚ they are more likely to be interested in their healthcare and comply with the plan. An infection of the lungs triggers an inflammatory response‚ which results in edema in the alveoli. As a result of pulmonary edema‚ gas exchange becomes impaired leading to decreased activity tolerance. At the end of the shift‚ pt’s pulse oximetry
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