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
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have little access to rich foods experience few heart attacks. Similarly‚ most people in rural Africa and South and Central America have little fear of diabetes and cardiovascular disease. Yet in North America‚ Australia‚ New Zealand‚ and the increasingly affluent countries in Europe and Asia‚ where diets are rich in fat‚ heart disease and diabetes are epidemic. The villains: low fiber and high fat‚ take their toll by damaging the body’s vital oxygen-carrying arteries and by upsetting important metabolic
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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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Introduction Gestational diabetes is defined as any degree of glucose intolerance that has its onset or is first diagnosed during pregnancy. Kuhl‚ Hornnes‚ and Andersen (1985) state that gestational diabetes occurs when the pancreas of a pregnant woman fails to increase insulin production to compensate for the natural decrease in cells’ sensitivity to insulin. The cardinal signs of diabetes are polyuria (related to decreased reabsorption at the renal tubules because of the osmotic activity of
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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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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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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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➢ PR- 98 BPM ➢ RR-25BPM ➢ PAIN SCALE- 8 | ➢ ACUTE PAIN RELATED TO MYOCARDIAL ISCHEMIA. |SHORT TERM GOAL: After 8 hours of nursing intervention: ➢ The patient will be able to verbalize relief from chest pain and difficulty of breathing ➢ The patient will be able to reduce anxiety regarding his condition. LONG TERM GOAL: After 3 days of nursing intervention: ➢ The patient will report pain being absent or controlled with medication administration. ➢ The patient will
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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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Clinical Journal and Care Plan Clinical Preparation & Journal Form Student Name:wolie Date: 10/24/2011 1. Biographical Data: DOB: 09/25/1959‚ Female‚ 61 y.o.a. Initials: M.S. Age & Sex: 61 years and female Ht/wt: Race/Ethnicity: white Culture and Religion: Christian Living Arrangements: nursing home People in Home (number and relationship): 1 roommate Reason for hospitalization: MRSA isolation‚ Post-op or left knee replacement Past Health History
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