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
Premium Nursing Health care Patient
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
Premium Nursing care plan Patient Hypertension
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
Premium Dehydration Nutrition Nursing care plan
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
Premium Temperature Nursing care plan
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
Premium Lung Pneumonia Respiratory system
SAMPLE FAMILY NURSING CARE PLAN Health Problem | Family Nursing Problems | Goal of Care | Objectives of Care | INTERVENTION PLAN | | | | | Nursing Interventions | Method of Nurse-Family contact | Resources required | 1.Family size beyond what family resources can adequately provide | Inability to make decisions with respect to taking appropriate health action due to lack of knowledge as to alternative courses of action open to the family. | After nursing intervention‚ the family will provide
Free Nursing care plan Nursing
art&scienceliterature review nursing standard: clinical · research · education Spiritual care in nursing: a systematic approach Govier I (2000) Spiritual care in nursing: a systematic approach. Nursing Standard. 14‚ 17‚ 32-36. Date of acceptance: November 11 1999. Ian Govier MSc‚ BN‚ DipN‚ RGN‚ PGCE‚ RNT‚ is Charge Nurse/Ward Manager‚ Powys Ward‚ Welsh Regional Burns Unit‚ Morriston Hospital‚ Swansea NHS Trust. Summary Ian Govier suggests that patients will benefit if nurses adopt a systematic
Premium Nursing Nursing care plan
Family Health Problem | Family Nursing Problem | Goal of Care | Objective of Care | Nursing Intervention | Method of Family Contact | Resources Required | 1. Malnutrition as health deficit. | Inability to recognize the presence of malnutrition due to lack of knowledge. | After the intervention‚ the family will be able to recognize the problem. | After the nursing Intervention‚ the family will be able to plan and prepare balanced meals within the family’s budget.After the intervention‚ the family
Premium Nursing Urinary tract infection Nursing care plan
Running Head: NURSE CARE PLAN EXERCISE Nurse Care Plan Exercise School of Nursing NURSING DIAGNOSIS (ACTUAL) 75-year old female Assessment: Subj cues: Usual pattern 1 movement/day. States she goes 1-2 days w/out movement as a result used laxative. Has difficulty drinking 6-8 glasses of H2O a day. Green leafy vegetables are a challenge due to poorly-fitted dentures. Has Hyperacidity and bloating. Obj cues: There are no objective cues. NURSING DIAGNOSIS (ACTUAL)
Free Nursing care plan Nursing
Nursing Theory Plan of Care Theoretical Foundations of Practice NUR/513 March 05‚ 2012 Nursing Theory Plan of Care Ida Orlando literally wrote the book on the function of nursing. Her theory of the deliberative nursing process outlines a dynamic nurse-patient relationship in which the nurse uses his or her senses of perception together with deliberate actions to create an individualized care plan for each patient. Results of current research on the application of her theory follow
Premium Nursing Nursing care plan Nursing theory