Nursing care plan Name of client: Miss Ng Sex: F Date of assessment: 31/10/2014 Medical diagnosis: Caesarian section Diagnostic statement: Impaired comfort related to tissue trauma and reflex muscle spasms secondary to surgery as evidenced by vomiting Assessment Nursing diagnosis Goals & expected outcome Nursing interventions Rationales Method of evaluation Subjective data: 1. Patient reported of abdominal pain. 2. Elevated scoring of 8/10 of pain score Objective data: 1. Restlessness 2. Facial
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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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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 have vital signs within normal parameters ➢ The patient will be able to verbalize
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The nurse will educate the pt and the pt’s family about the seriousness of pneumonia and how to comply with treatment in order to maximize therapeutic effect and facilitate healing. When a patient and their family are educated about illness‚ medications‚ and other treatments‚ they are more likely to be interested in their healthcare and comply with the plan. An infection of the lungs triggers an inflammatory response‚ which results in edema in the alveoli. As a result of pulmonary edema‚ gas exchange
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Care Delivery & Management Special Care In Mental Health Nursing Practice Word Count In Total: 5458 Word Count Reflective Practice Paper: 4372 Action Plan: 1086 The purpose of this assignment is to reflect upon my personal and professional development. It will consider the quality of the care I provided‚ the skills I developed in my specialist placement‚ plus my learning since the commencement of my nurse training. Personal learning and self-reflection will be identified. I shall be
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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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References: Gulanick‚ M.‚ Myers‚ J.L. (2013). Nursing care plans. Diagnose‚ interventions‚ outcomes. USA: Mosby.
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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
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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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Name: John Doe Class: NRN 101 Date: 12/12/12 Pt. initial RB Age 100 Date of Admit 01/01/01 DOB 07/01/01 Code Status full Allergies NKDA Admitting Diagnosis: Pneumonia secondary to a bacterial infection Nursing Diagnosis: Risk for ineffective tissue perfusion (arterial‚ venous‚ and peripheral) STG: Patient will have adequate perfusion AEB Spo2= 95% or greater LTG: Patient will maintain adequate tissue perfusion to vital organs AEB mucous membranes‚ capillary refill time
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