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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CUES/ CLUES |DIAGNOSIS |OBJECTIVES |INTERVENTIONS |EVALUATION | |SUBJECTIVE: ➢ “I ALWAYS EXPERIENCED CHEST PAIN AND DIFFICULTY OF BREATHING” As verbalized by the patient. OBJECTIVE: ➢ Weak and pale in appearance ➢ Difficulty of breathing ➢ Poor skin turgor ➢ Clutching of hands to chest ➢ Shortness of breath ➢ Restlessness VITAL SIGNS: ➢ BP- 130/90 mmHg ➢ T- 37.5 C ➢ PR- 98 BPM ➢ RR-25BPM ➢ PAIN SCALE- 8 | ➢ ACUTE PAIN RELATED TO MYOCARDIAL ISCHEMIA. |SHORT
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ASSESSMENT (Data Collection) NURSING DIAGNOSIS (Patient Problem/Priority) PLANNING (Patient-Centered Goals) IMPLEMENTATION (Nursing Interventions) Nurse roles: Assess‚ monitor‚ use of communication techniques‚ patient education EVALUATION (Patient-Centered Goal Met?) Subjective: (what you heard the patient describe) Objective: (what you see‚ hear‚ smell‚ feel) *Use nursing diagnosis language 1 goal per physical What specifically will you do - as a nurse - to assist the patient
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NURSING DIAGNOSIS GOAL INTERVENTIONS RATIONALE EVALUATION impaired Gas Exchange R/T STG: 3/17/2014 throughout shift 1. Auscultate breath sounds 1. Abnormal breathing STG: PT O2 saturation on admission abnormal breathing AEB PT will maintain O2 saturation noting areas of decreased sounds are indicative was 87%. Measured at 1602 with a Objective: use of wall oxygen of 95 or higher AEB breathing sounds of numerous problems reading of
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A payment status of IN PROCESS means your payment is still being processed. A payment status other than PAID indicates that the Department of State has not received your payment. If you receive a notice that your case has entered termination do not attempt to pay any fees. You must contact the NVC immediately to resume processing of your petition. NVC contact information can be found at http://travel.state.gov/visa/immigrants/info/info_3177.html. Next Steps 1. When the IV fee payment status is
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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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Personal Ethics Reflection Paper Introduction Ethical theories and principles help the medical community make moral decisions in difficult situations. However‚ each person has a different set of morals they abide by‚ including the varying ethical theories and principles. In this paper‚ I will discuss what theories I agree and disagree with concerning my moral framework‚ along with explaining what principles I think are most important. Theories Aligned
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elderly lady with advanced inoperable cancer‚ subsequently on an end of life pathway receiving palliative care. The World of Health Organisation (WHO) defines palliative care as: “The active total care of patients whose disease no longer responds to curative treatment. Control of pain‚ of other symptoms‚ and of psychological‚ social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families” Towards the end she could
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with a disability. I was told to use the Gibbs Reflective Cycle (1998)‚ for this exercise. I decided to focus on Indigenous Australians living with a disability for an example of a low socio-economic class. Step 2 My first thought on this reflection task was that I the definition of health and illness that I would provide for myself compared to what I would provide for a disabled indigenous person would be the same. Defining health seemed very simple to me. I see it as being free from disease
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child does‚ and finally ventured upon my true passion. After a difficult day of finals my Freshman year‚ I drug myself down the hallway to my locker‚ as exhausted as ever. Scrolling down my Facebook timeline‚ I stumbled upon a video titled “The Foster Care System”‚ the video showed the true horrors that children have to endure every day in homes that are targeted on mooching off the system. Some foster homes provide the bare necessities for these children‚ and use the rest of that money to line their
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