Cues | Nursing Diagnosis | Scientific Explanation | Objectives/Plan of Care | Nursing Interventions | Rationale | Evaluation | S> “ Hindi pa masyado magaling ang sugat ko” as verbalized by the patientO> S/P Appendectomy>with surgical incision at right lower abdominal area>with dry intact dressing on the surgical site | Impaired Skin Integrity related to skin/tissue trauma | Inflammation of the appendix↓Acute Appendicitis↓Appendectomy↓Dissection if right lower abdominal tissues↓Disruption
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Nursing Diagnosis: Excess fluid volume related to inactivity‚ secondary to congestive heart failure‚ as manifested by rapid weight gain‚ pitting edema in extremities‚ elevated blood pressure‚ bilateral crackle lung sounds‚ bradypnea‚ and dyspnea. Goal: Absence of fluid retention by discharge Desired Outcomes: 1. Blood pressure within regular limits by discharge 2. Absence of edema by discharge 3. Slow progression of weight gain by day 2 of admission 4. Ease of respirations
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The Complete list of NANDA Nursing Diagnosis for 2012-2014‚ with 16 new diagnoses. Below is the list of the 16 new NANDA Nursing Diagnoses 1. Risk for Ineffective Activity Planning 2. Risk for Adverse Reaction to Iodinated Contrast Media 3. Risk for Allergy Response 4. Insufficient Breast Milk 5. Ineffective Childbearing Process 6. Risk for Ineffective Child Bearing Process 7. Risk for Dry Eye 8. Deficient Community Health 9. Ineffective Impulse Control 10. Risk for Neonatal Jaundice
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International(Professional Assosiation of Nurses) Nursing Diagnosis is a clinical judgment about individual ‚ family or society responses to real or possible health problems or life process.Nursing diagnosis are developed based on the data obtained during the nursing assessment. A nursing diagnosis identifies problems that result from that disorder. An actual nursing diagnosis presents a problem response present at the time of assessment. Application To Personal Life Nursing diagnosis plays a vital role in the plan
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The goal of this nursing diagnosis is make sure patient understand the importance of cataract treatment. The nursing intervention including assess motivation and willingness of patient to learn as patients must know need or purpose for learning‚ observe existing misconceptions regarding material to be taught as assessment is important starting point in education and assess barriers to learning as social interaction patterns‚ cultural norms and environmental can influence one’s learning. Next is
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was later modified to A.S.P.I.R.E resulting in the systematic nursing diagnosis stage being brought in; By completing the initial assessment stage‚ it will help to establish the nursing diagnosis which involves making a decisive statement concerning the client’s needs (George 1995). This is often referred to as a Systematic Nursing Diagnosis; which involves identifying the patient needs from a nursing perspective. This nursing diagnosis differs greatly from that of a medical as it emphasises the holistic
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Nursing Diagnosis Potential risk for hemorrhage r/t labor and delivery Supporting Data: Objective: delivered 0741 am 3/1/07. Objective: Vaginal delivery. Objective: gravida 2 Goal & Goal Criteria Goal: Patient will show no s/s of hemorrhage in 48 h post delivery. 1. V/S will remain in wnml: T: up to 100.4 F P: 60-90 bpm R: 12-20 brpm BP :120/70 Pulse OX: 95-100% 2. Hct & hgb will remain WNML. HCT=>33% HGB= 10.5g/dl 3. Fundus will be midline & firm. 4. IV Fluids infusing
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Ackley: Nursing Diagnosis Handbook‚ 10th Edition Writing Assignment: NCP: Planning‚ Implementation & Evaluation Due to Evolve dropbox by 10/29/14@ 11:59 PM Nursing Process Case Study - Mrs. Ross (Wound Care) Case Scenario “It isn’t fair. I’ve worked so hard all my life‚ I don’t deserve this‚” thought Mrs. Ross as she looked down at her right leg where a large wound gaped open. Two weeks ago‚ she had a femoral-popliteal bypass‚ which got infected. The wound was opened up and was healing slowly
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Patient Y adjusted well on the postpartum unit with the help of the nursing interventions mentioned above. Patient Y’s pain score continued to decrease throughout her stay. She started taking medication for severe pain and by the third day she was only requiring mild medication to alleviate her pain. Patient Y’s following was discontinued the following day and she remained free from any urinary infections. In regards to reducing the risk of infection for the incision‚ the healthcare team performed
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Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to‚ the updated plan is passed on to the nursing staff at shift change and during nursing rounds. * Care plans help teach documentation. The care plan should specifically outline which observations to make‚ what nursing actions to carry out‚ and what instructions the client or family members require. * They serve as a guide for
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