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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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 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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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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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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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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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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step in a nursig care planThe first step in a nursing care plan is the assessment ‚ is the assessment ‚ jjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjThe first step in a nursing care plan isThe first step in a nursing care plan is the assessment ‚ the assessment ‚ The first step in a nursing care plan is the assessment ‚ The firstThe first step in a nursing care plan is the assessment ‚ step in a nursing care plan is the assessment ‚ The first step in a nursing care plan is the assessment
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Health problem Family nursing problem Goal of care Objectives of care Intervention plan Nursing intervention method resources Improper drainage as a health treat Inability to recognize the improper drainage. Inability to do appropriate action due to failure to comprehend the good environment. Inability to conduct adequate drainage. Lack of knowledge about proper drainage. After my 2 months nursing intervention the condition
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Nursing Critique Since the early 1900’s nurses have been trying to improve and individualise patient care. In the 1970s this became more structured when the nursing process was introduced by the general nursing council (GNC)‚ (Lloyd‚ Hancock & Campbell‚ 2007) .By doing this their intentions were to try and understand the patient in order to give them the best care possible (Cronin & Anderson‚ 2003). Through the nursing process philosophy care plans were written for patients. It was understood
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