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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Natalie Sullivan 6/4/2013 Nursing Care Plans Care Plan: Post Partum Patient’s initials: SR Date of Care: 5/6/2013 Assessment Data: * G1P1 * C/S on 5/5/2013 at 1832 * Incision at suprapubic region * Staples mid right side to end of left side of incision * Steri strips on right side of incision r/t to removal of 5 staples because staples were loose * Pt complaining of pain in lower abdomen * Pt complaining of “uncomfortableness” at incision
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Nursing Care Plan Assessment equals Data Collection + Analysis | Nursing Diagnosis – Actual/Potential | Nursing Goal(SMART) | Nursing Interventions/ActionsInclude Rationale/Reference | Evaluation | Female Age : 85Code status: Full Code initially but changed to DNR on 14/Jan-2012Primary diagnosis: PancytopeniaReason for Hospital Admission: Fall at home. Allergy: PenicillinMedical History: Pacemaker‚ Hypertension‚ Fall at home‚ Bradycardia‚ Hyperlipidemia.Neurological: Alert‚ Oriented x 4.Diet
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Hospice Care Plan Walden University Hospice Care Plan Mrs. Thomas has a history of breast cancer and is status post bilateral mastectomies with subsequent radiation and chemotherapy treatments. She has recently been diagnosed with lung metastasis and further treatment is not recommended by her physician and due to a poor prognosis he is recommending palliative care. Mrs. Thomas has been spending most of her days in her bed crying. She has had very little contact with her sons and
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individualise patient care. In the 1970s this became more structured when the nursing process was introduced by the general nursing council (GNC)‚ (Lloyd‚ Hancock & Campbell‚ 2007) .By doing this their intentions were to try and understand the patient in order to give them the best care possible (Cronin & Anderson‚ 2003). Through the nursing process philosophy care plans were written for patients. It was understood that this relationship would ensure the patient received the best care possible to suit
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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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NURSING CARE PLANS Impaired Physical Mobility Assessment | Nursing Diagnosis | Scientific explanation | Objectives | Nursing Interventions | Rationale | Expected Outcome | S > θO > Patient manifest:- weak and pale appearance - difficulty in standing and sitting - slowed movement - limited range of motion | Impaired Physical Mobilityr/t neuromuscular impairment aeb slowed movement | Limitation in independent‚ purposeful physical movement of the body or of one more extremities.Due
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respiratory and physical exercises 7) Patient will be able to state the importance of weight management and demonstrate exercises to increase success in lowering BMI in 6 weeks 8) Patient will incorporate his family and/or support systems into his care to obtain and meet health goals Nursing interventions 1) Teach the patient how to breathe effectively with slow‚ deep‚ abdominal breathing and incorporate pursed lip breathing to ensure there is sufficient oxygen being perfused to the body. Rationale:
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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 |
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