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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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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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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co-ordinated care pathways. (see attached form as an example) When cleaning the wound‚ the 2 most common methods involve : a) irrigation with warmed 0.9% Normal Saline b) using a gauze soaked with 0.9 % normal saline to wipe the wound. (Remember 1 gauze = 1 wipe!) What method (a or b) would you use to cleanse wounds #1 to #5? References Crisp‚J & Taylor‚ C. (2005). Potter & Perry¡¦s Fundamentals of Nursing. (2nd ed) Elsevier: Australia. Wound care made incredibly
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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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The aim of this assignment is to critically discuss the nursing assessment individualised care and nursing interventions of the acutely ill patient. The patient discussed developed severe sepsis due to a urinary tract infection and her condition deteriorated during the recovery process in the nurse’s care. Lovick (2009) defines sepsis ‘as a known or suspected infection accompanied by evidence of two or more of the SIRS criteria’. SIRS is outlined as a ‘systemic inflammatory response’ consisting of
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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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DEGREE NURSING NURSING PROCESS FORM: PART I – ASSESSMENT Student: Date of Care: 3/4/13 Client’s Initial: WB Room # 1011 Occupation: Teacher Age: 59 Sex: F Race: Black Religion: Christian Admission Date: 3/1/13 Primary Language: English Role in family: Widowed from husband Stage in Life Cycle: Generativity vs. Stagnation Surgery date(s) this admission: N/A Chief complaint: Brain Dysfunction/Traumatic‚ closed injury Admission Diagnosis: Post Blunt
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Student Name: Dealon Rouse | Patient Initials: JB | Admission Diagnosis: Left Total Knee Arthroplasty &Excision of Left Knee Mass Related to Gouty Arthritis | Date(s) of Care: 11/10/11- 11/12/11 | Age: 46 | | Date of Admission: 11/10/11 | Gender: Male | | Marital Status: Married | Room #: 507 | Code Status: Full Code | Occupation: Electrician | Race: Hispanic | Isolation Type: | Religion: Roman Catholic | | Allergies: No Known Allergies | History of Present Illness:
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Your patient’s ECG shows depression S-T in leads V1–V2 and ST elevation in Leads II‚ III‚ and AVF. You realize that this indicates: Acute inferior infarction. Acute Anterior infarction Acute Lateral infarction Acute inferior-Posterior infarction The above ECG changes can be found if there is an occlusion of the: RCA LAD circumflex all of the above. the most complications associated with this problem is ventricular dysrhythmias. AV block. atrial flutter. hemodynamic
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