Care Plan for Pain: Chronic| Student Name:|Samantha Lewis|Current Date: 4/19/12|| Patient:|SL|Age: |33|Sex:|F|Dates Care Given: 4/19/2012|| Admission Diagnosis/History: Chronic Pancreatitis| 1)PE 2) Hysterectomy 3)C Section | Nursing Diagnosis: Pain: Chronic | | ASSESSMENT| Objective Data|Subjective Data| · Increased blood pressure|· Pt holding lower left abdomen| · Increased heart rate|· Pt eyes closed| · Increased respirations|· Furrowed brow| · |· |
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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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OPERATIVE REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/05/65 AGE:46 SEX: M Date of Admission: 11/14/2012 Date of Procedure: 11/14/2012 Admitting Physician: Bernard Kester‚ MD Surgeon: Bernard Kester‚ MD Assistant: Jason Wagner‚ PAC Circulating Nurse: Jimmy Dale Jett‚ RN Preoperative Diagnosis: Acute Appendicitis Postoperative Diagnosis: Perforated Appendicitis
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Nursing Care Plan for Chest Pain NURSING DIAGNOSIS OUTCOME/GOALS INTERVENTIONS EVALUATION Acute chest pain related to ischemic cardiomyopathy as evidenced by tightness in chest. Patient will be chest pain free for duration of shift. Assess for chest pain q 4 hours during shift. Monitor vital signs q 4 hours during shift. Educate patient on importance of lifestyle modifications such as weight loss. Goal was met. Pt was chest pain free during shift. NURSING DIAGNOSIS
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OPERATIVE REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/5 Age: 46 Sex: M Date of Admission: 11/15 Date of Procedure: 11/15 Admitting Physician: Bernard Caster‚ MD Surgeon: Bernard Caster‚ MD Assistant: Jason Wagner‚ PAC Circulating Nurse: Jimmy Dale Jet‚ RN Preoperative Diagnosis: Acute Appendicitis Postoperative Diagnosis: Perforated Appendicitis Operative Procedure: Laparoscopic Appendectomy Placement of right lower quadrant drain Anesthesia:
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What is it and how can it help me? Pre-operative assessment (POA) and planning‚ carried out prior to treatment‚ ensures that the patient is fully informed about the procedure and the post operative recovery‚ is in optimum health and has made arrangements for admission‚ discharge and post operative care at home. POA and planning is an essential part of the planned care pathway which enhances the quality of care in a number of ways. * If a patient is fully informed‚ they will be less stressed
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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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After reviewing the post‚ there are many aspects that I agree and disagree about the nursing care method. I definitely agree on the first priority of nursing care should be to address the patient’s cramping and bloating. The cramping and bloating was essentially the primary concern of the patient and was the result of the constipation. Additionally‚ I agree that the SMART outcome should involve the goal of the patient having a bowel movement by the end of the nurse’s shift‚ because having a bowel
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____CP_____________________ Date _2/12/13_____ Pt Initials _MK_____ Medical Diagnosis #1: Multiple coronary artery disease Chief Complaint #1 Use Quotes: ”Shortness of breath and chest pain for over a month now” on 2/6/13 on day of Admission Chief Complaint #1 Use Quotes: “Pain 8/10” on day of your nursing care Prior Illnesses Hypertension‚ coronary artery disease‚ obesity‚ angina Family History Father passed away from a heart attack; Mother had a stroke General Survey Sex M
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anti-emetic. Discuss the monitoring (LO 1 & 4) and Nursing Care (LO 2 & 3) that Colin and his family will require over the next 24 hours. NOTE THIS QUESTION DOES NOT ASK YOU TO DISCUSS AN A-E ASSESSMENT. Things to consider when looking at the case scenarios are the EHI1 Assignment These are the learning outcomes of the module: 1 Evaluate the clinical indicators of acutely deteriorating health; 2 Critically discuss the nursing care of an acutely ill person; 3 Examine the experiences
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