Nursing Diagnosis # 1 Ineffective breathing pattern related to decreased oxygen saturation‚ poor tissue perfusion‚ obesity‚ decreased air entry to bases of both lungs‚ gout and arthritic pain‚ decreased cardiac output‚ disease process of COPD‚ and stress as evidenced by shortness of breath‚ BMI > 30 abnormal breathing patterns (rapid‚ shallow breathing)‚ abnormal skin colour (slightly purplish)‚ excessive diaphoresis‚ nasal flaring and use of accessory muscles‚ statement of joint pain‚ oxygen
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lan NURSING CARE PLAN | ASSESSTMENT | BACKGROUND KNOWLEDGE | PLANNING | INTERVENTION | RATIONALE | EVALUATION | Subjective:n/aObjective: * Preterm birth (36 weeks) * Weight: 1.75kgs. * Cool and dry skin. * Temperature: 33.6 degrees Celsius. * Poor muscle tone. * Placed under two droplights.Nursing Diagnosis: Ineffective thermoregulation related to immaturity. | Vaginal birthPretermPoor muscle developmenthypothermia | After 1 hour of nursing intervention‚ patient will maintain
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Assessment |Nursing Diagnosis |Analysis |Goals and Objectives |Interventions |Rationale |Evaluation | | Subjective: “kala ko nung una dahil sa kinain kong pinya‚ pero imposible naman iyon. Kasi hindi naman sumakin tiyan ng mga kasama ko” | Knowledge deficient related to unfamiliarity with information resources | A deficit in knowledge is commonly experienced by individuals coping with new medical diagnosis varied pharmacological and treatment regimens‚ unfamiliar and often complex problems
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CASE STUDY IN NCM-103 (CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION‚ FLUID AND ELECTROLYTE BALANCE‚ NUTRITION AND METABOLISM AND ENDOCRINE) Submitted to : Mr. Darren N. Constantino Submitted by : Olive Keithy Ascaño CASE STUDY 1 1. a. The possible fluid and electrolyte imbalances that the 78-year-old woman may experience are hyponatremia‚ hypokalemia and hyperkalemia because of nausea and vomiting that are common in these imbalances. b. The following interventions are
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NURSING CARE PLAN ASSESSMENT SUBJECTIVE: “Bakit kaya madalas ako mahilo?” (Why do I always feel dizzy?) as verbalized by the patient. OBJECTIVE: ♦ Request for information. ♦ Agitated behavior ♦ Inaccurate follow through of instructions. ♦ V/S taken as follows: T: 37.2 P: 84 R: 18 BP: 180/110 DIAGNOSIS ♦ Risk for prone behavior related to lack of knowledge about the disease INFERENCE ♦ High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels
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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 Race Caucasian Age 74 Height 175cm Weight 90.7 kg
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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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ASSESMENT | GOAL OF CARE | PLAN OF ACTIONS | RATIONALE | IMPLEMENTATION | DOCUMENTATION | Subjective:“Daghan man na siya samad ug hubag sa iyang lawas”(She has many wounds and bruises on her body) as verbalized by the mother.Objective:-Presence of lesions and abrasions on the patient’s body.-greenish violet discolorated patches-soaked dressingNursing Diagnosis:Risk for impaired skin integrity related to superficial factors. | At the end of 8 hours nursing interventions‚ the client will be able
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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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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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