Nursing Diagnosis 1. Acute pain R/T: inflammation and obstruction of the gallbladder AEB: patient verbalizes abdominal pain of 7/10‚ grimaces‚ rubs his stomach‚ BP 158/79‚ T990F 2. Deficient knowledge R/T: lack of knowledge about the importance of incentive spirometer AEB: patient says that he does not know how to use and needs to know more about its importance. 3. Risk for deficient fluid volume R/T: restricted intake 4. Risk for imbalanced nutrition less than body requirement R/T: impaired
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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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Care Plan Problem: Risk for bleeding r/t postpartum complications. Patient Centered Goal: Patient will not experience any abnormal/excessive bleeding by the end of clinical shift. Expected Outcomes: 1. Patient will experience lochia reducing in amount and lightening in color by the end of clinical shift. 2. Patient will observe fundus that is firm‚ midline‚ and decreasing in height by the end of clinical shift. 3. Patient will verbalize understanding of signs and symptoms
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The assessment of patients forms a major component of the nursing role. It allows the nurse to gain vital information to base the planning and implementation of prioritised care on. A systematic method of assessment is required‚ that ensures that all areas of assessment are covered and that the assessment and subsequent interventions are as effective and efficient as possible. One method that can be followed for patient assessment is the primary and secondary surveys‚ with an additional assessment
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The aim of this assignment is to critically discuss the nursing assessment individualised care and nursing interventions of the acutely ill patient. The patient discussed developed severe sepsis due to a urinary tract infection and her condition deteriorated during the recovery process in the nurse’s care. Lovick (2009) defines sepsis ‘as a known or suspected infection accompanied by evidence of two or more of the SIRS criteria’. SIRS is outlined as a ‘systemic inflammatory response’ consisting of
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NRSG258 Acute Care Nursing – S00169019 1- My chosen patient Paul is a 45-year-old man who has torn his rotator cuff during a rugby game. After consultation the surgeon informs Paul that he will require a shoulder arthroscopy with rotator cuff repair followed by rehabilitation. The rotator cuff is a group of muscles and tendons (supraspinatus‚ infraspinatus‚ teres minor and subscapularis) attached to the bones of the shoulder joint. The rotator cuff connects the humerus (upper arm) to the scapula
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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
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Assessment of the patient with acute abdominal pain Karen DeLawder Chamberlain College of Nursing NR305: Health Assessment Spring 2011 Assessment of the patient with acute abdominal pain Introduction Assessment of the patient with acute abdominal pain is an article published in the Nursing Standard Journal in the June 2006 issue‚ written by Elaine Cole‚ Antonia Lynch‚ and Helen Cugnoni. This article gives an in depth look at common diagnosis associated with abdominal pain. With each diagnosis
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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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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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