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Nursing care plan Name of client: Miss Ng Sex: F Date of assessment: 31/10/2014 Medical diagnosis: Caesarian section Diagnostic statement: Impaired comfort related to tissue trauma and reflex muscle spasms secondary to surgery as evidenced by vomiting Assessment Nursing diagnosis Goals & expected outcome Nursing interventions Rationales Method of evaluation Subjective data: 1. Patient reported of abdominal pain. 2. Elevated scoring of 8/10 of pain score Objective data: 1. Restlessness 2. Facial
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Cues | Nursing Diagnosis | Scientific Explanation | Objectives/Plan of Care | Nursing Interventions | Rationale | Evaluation | S> “ Hindi pa masyado magaling ang sugat ko” as verbalized by the patientO> S/P Appendectomy>with surgical incision at right lower abdominal area>with dry intact dressing on the surgical site | Impaired Skin Integrity related to skin/tissue trauma | Inflammation of the appendix↓Acute Appendicitis↓Appendectomy↓Dissection if right lower abdominal tissues↓Disruption
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A family can be a complex system. In order to successfully care for a family a nurse must have a good understanding of the beliefs‚ values and daily activities of the members that make up the family. Marjory Gordon’s functional health patterns model can be a great tool if used successfully to get a basic understanding of the families health. Gordon developed eleven functional health patterns that help nurses to approach people and obtain data collection and to assess the health patterns of each individual
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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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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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Nursing Diagnosis Nursing diagnosis is a medical concept that is becoming a commonly applied approach in the aspect of healthcare and medical service. This aspect mainly focuses on the presumptive and initial health and medical analysis conducted by the nursing class of healthcare serving as an overview basis and diagnosis for the following treatment and medical application. Aiding as a primary health analysis‚ nursing diagnosis actually becomes the springboard for further treatment and observation
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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
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NURSING CARE PLAN GUIDE ASSESSMENT OF UNIVERSAL SELF CARE REQUISITES DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient. |ASSESSMENT |PLANNING |EVALUATION | |Universal
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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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