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 |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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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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Nursing Process Planner DATA | ANALYSIS | NURSING DIAGNOSIS | PLANNING | Group significant data according to needs‚ patient concerns. | Compare with normal standards‚ knowledge‚ and interpret the meaning of the data and knowledge. | State problem or concern according to needs with reasons and related factors. | Outcomes/ Objectives. A goal with more detailed objectives. | | Reference | | | Ms. C.M62 years oldDiagnosis:RT lung CancerSx:RLL&RML wedge‚ RLLwedge+mediastinal lymphadectomy
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NURSING DIAGNOSIS GOAL INTERVENTIONS RATIONALE EVALUATION impaired Gas Exchange R/T STG: 3/17/2014 throughout shift 1. Auscultate breath sounds 1. Abnormal breathing STG: PT O2 saturation on admission abnormal breathing AEB PT will maintain O2 saturation noting areas of decreased sounds are indicative was 87%. Measured at 1602 with a Objective: use of wall oxygen of 95 or higher AEB breathing sounds of numerous problems reading of
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Signs: Temp. 97.4‚ Pulse 106‚ Respirations 18‚ BP 118/56 Ht/Wt/BMI: Height = 167.64 cm‚ Weight = 84.878 kg‚ BMI 30.2 Skin/Wounds: (Skin turgor; presence of any skin breakdown; incisions; wounds.) Subjective: patient denies any skin breakdowns. Objective: leg skin is shiny and has several enlarged veins‚ otherwise‚ skin is pale and evenly pigmented‚ no lesions or excoriations‚ good turgor. Nails are light pink‚ adhere to nail bed with 160-degree angle. Hair is grey‚ shiny and full; amount and distribution
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DATE | CUES | NURSING DIAGNOSIS | KNOWLEDGE BACKGROUND | GOAL | NURSING INTERVENTION | RATIONALE | EVALUATION | | Subjective:“Medyo masakit ang dibdib ko pag umuubo ako.”as verbalized by the patientObjective:Productive coughYellow sputum dischargedPain scale of 10/10 | Acute pain R/T coughing | Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage ;sudden or slow onset of any intensity from
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Cues Nursing Problem Scientific Reasoning Planning Implementation Evaluation Subjective: >”Nay‚ kelan po tayo uuwi?” as verbalized by the patient >”Nag-aaya na nga syang umuwi.” as verbalized by the caretaker Objective: >Patient is silent when hospital staff is around >Patient does not have eye contact with the hospital staff Fear related to hospitalization as manifested by alteration in behavior. Hospitalization is usually perceived as a threat that is consciously
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treatment in order to maximize therapeutic effect and facilitate healing. When a patient and their family are educated about illness‚ medications‚ and other treatments‚ they are more likely to be interested in their healthcare and comply with the plan. An infection of the lungs triggers an inflammatory response‚ which results in edema in the alveoli. As a result of pulmonary edema‚ gas exchange becomes impaired leading to decreased activity tolerance. At the end of the shift‚ pt’s pulse oximetry
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N.C.P 1 Nursing Care Plan Catherine Traylor F.H. January 31‚2007 Karen Ruffin Mercer County Community College 2 Abstract F.H. is an 83 year old male‚ whom was cared for on January 31‚2007 by the writer. He was admitted to Capital Health System at the Mercer Campus with diagnoses of an
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