Closed Head Injury Case Study Y.W. is a 23-year-old male student from Thailand studying electrical engineering at the university. He was ejected from a moving vehicle‚ which was traveling 70 mph. His injuries included a severe closed head injury with an occipital hematoma‚ bilateral wrist fractures‚ and a right pneumothorax. During his neurologic intensive care unit (NICU) stay‚ Y.W. was intubated and placed on mechanical ventilation‚ had a feeding tube inserted and was placed on tube feedings
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INTRODUCTION Head injury is including injury of scalp‚ skull and also the brain. Approximately statistic in Malaysia from year 2009 to 2010 that more than 6‚000 people accidental death sustain with a head injury. According to Deputy Minister of transport Malaysia ‚ Datuk Abdul Rahim Bakri said most of the cause of death among the passengers and pillion riders is head injury (56.5%) ‚ brain injury (38.1%)‚ head and brain injury (34%) and head fracture (27.9%) .(nuffnang.blogspot). This scenario should
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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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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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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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Nursing care plan (Colonoscopy) S.E is a 59 year old African-American male admitted to the critical care unit because of his left lower quadrant (LLQ) abdominal pain. S.E had a colonoscopy 2 days ago. He has a family history of hypertension (HTN) and a medical history of HTN and anemia. He is alert and oriented ×3 (time‚ place‚ and person). S.E has no known drug allergy and he is NPO except for medicine. Problem: LLQ abdominal pain Acute pain | Assessment | Planning/Nursing Goals |
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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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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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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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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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