Nursing Assessment of the Postpartum Patient Date of data collection:___13 November 2014___ Patient initials _K.M.___ Age__28_ PP day _1__ (# days since delivery- 0‚ 1‚2 3‚ etc) Grav _4__ Para _3__ Term _3__ Preterm _0___ Ab_0__ LC___ Weeks gestation @ delivery (via EDC) _39.2____ Weeks gestation at delivery (from neonatal maturity rating/Ballard exam):_ 40_____ Date/time of delivery _12 Nov. / 1640_________ Labor onset - induced or spontaneous (circle one) If induced: indication (why)
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Natalie Sullivan 6/4/2013 Nursing Care Plans Care Plan: Post Partum Patient’s initials: SR Date of Care: 5/6/2013 Assessment Data: * G1P1 * C/S on 5/5/2013 at 1832 * Incision at suprapubic region * Staples mid right side to end of left side of incision * Steri strips on right side of incision r/t to removal of 5 staples because staples were loose * Pt complaining of pain in lower abdomen * Pt complaining of “uncomfortableness” at incision
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and Diagnosis Components of the Nursing Process Aldecia Blackwood ITT Technical Institute ASSESSMENT AND DIAGNOSIS COMPONENTS Abstract The nursing process is an organized critical thinking system used by professional nurses to give the best optimal care to clients. “It is very similar to the steps used in scientific reasoning and problem solving.” (Ackley and Ladwig‚ 2014:2). It contains five steps; Assessment‚ Diagnosis‚ plan‚ implementation of care‚ and evaluation. Assessment is
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WAYNE COUNTY COMMUNITY COLLEGE DISTRICT NURSING PROGRAM NURSING CARE PLAN General Information: Postop pt undergone a cholecystectomy Patient intials: R.M. Confidential Marital Status: SINGLE Student’s Name: Hanadi Abdou Age: 61 Birthdate: 12/3/1950 Religion: not specified (pt nonverbal) Clinical Instructor: Mary Servey Admittance date: 3/12/12 Interest: not specified (pt nonverbal) Date: 3/21/12 Class: Med Surg Diagnoses: Impaired skin integrity Diet: NPO Allergies: None
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11 core competencies in nursing 1. safe and quality nursing care 2. management of resources and environment’s 3. health education 4. legal responsibility 5. ethic/moral responsibility 6. personal and professional development 7. quality improvement 8. research 9. record management 10. communication 11. collaboration and teamwork CONCEPTS UNDERLYING CORE COMPETENCIES I. PATIENT CARE COMPETENCIES 1. Safe and Quality Nursing Care Core Competency 1: Demonstrates knowledge base on the health /illness
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The nursing process comprises the steps necessary for a nurse to provide complete and comprehensive care. It has been likened to the scientific method utilized by scientists. According to Treas & Wilkinson (2014)‚ the components--or phases--of the nursing process are assessment‚ diagnosis‚ planning‚ implementation‚ and evaluation. While not always listed as such‚ documentation is also considered a necessary phase of the nursing process. Each phase is described below: Assessment - That phase
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Stage 2: Advanced Beginner Advanced beginner has some expectations of care from past experience‚ or a mentor has pointed out the principles that guide their action. Stage 3: Competent The competent nurse has practiced for two or three years and is able to establish a plan of action. The plan is based on experience‚ is abstract‚ and analytical. Planning is deliberate and makes the nurse more efficient. However‚ the competent nurse does not have the speed and does not yet view the overall situation
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documentation‚ using nursing terminology to describe individual ’s health status and nursing action. Focus • a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan)‚ i.e. skin integrity‚ coping‚ activity tolerance‚ self care deficit • a current individual concern or behavior‚ i.e. nausea‚ chest pain‚ pre-op teaching‚ hospital admission • a sign or symptom of (possible) importance to the nursing and/or medical diagnosis
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Nursing diagnosis for patient with AIDS (in the movie Philadelphia) Imbalanced Nutrition: Less than body requirements R/T inability to ingest nutrients (Gulanick & Myers‚ 2007) AEB vomiting three times per day after each meal‚ 35lb weight loss in past 60 days‚ height of patient is 5’8” weight of 110lbs (Demme‚ 1993). Impaired Skin Integrity – AIDS‚ R/T immune deficiency; AIDS related dermatitis (Gulanick & Myers‚ 2007) AEB Approximately 10‚ 3 x 2 cm reddened lesions to face and torso‚ lesions
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Answers to questions in S/NVQ Level 2 Health & Social Care Easy Steps Unit 21 Communicate with and complete records for individuals In the workplace: Jake likes to joke (page 7) 1 2 3 No‚ there will be many occasions when an individual does not want to laugh and joke‚ especially if they feel sad or angry. Jake should respond in a way that recognises the way they are feeling at that time. Jake might have to be more serious in formal meetings or when talking to individuals about
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