Assessment | Nursing Diagnosis | Goals & Expected outcomes | Nursing Interventions | Rationales | Methods of Evaluation | Name of client: Mrs. Tam Age: 65 Sex: Female Student ID:1155016494 Assessment date: 29/11/12 Medical Diagnosis: 1. Lower limbs edema 2. Low albumin level 3. hypokalemia and hypocalcaemia 4. Anemia Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to vomiting after eating as evidenced by food intake less than the recommended daily
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Chief Complaint #1 Use Quotes: ”Shortness of breath and chest pain for over a month now” on 2/6/13 on day of Admission Chief Complaint #1 Use Quotes: “Pain 8/10” on day of your nursing care Prior Illnesses Hypertension‚ coronary artery disease‚ obesity‚ angina Family History Father passed away from a heart attack; Mother had a stroke General Survey Sex M Race Caucasian Age 74 Height 175cm Weight 90.7 kg Facial Expression/Contour/Symmetry symmetrical‚ tired
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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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Sometimes after school sports can improve student’s grades because they work harder to stay playing the sport. In other cases the kids don’t care and they focus only on the athletic side of things and don’t care about athletics. Having after school sports can be fun and difficult. It is a constant schedule of doing school work‚ going straight to practice‚ then coming home to eat and sleep. After school sports can be a blessing or a curse. In my opinion after school sports is a blessing . Having
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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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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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Nursing is one of the most respected and rewarding occupations in the healthcare industry. An exemplary nurse exhibits qualities such as empathy‚ selflessness‚ and the ability to work well under pressure as a team and also independently. Although the nurses job description focuses on patient care‚ nurses are also the patient’s number one advocate; the doctor may diagnose and order treatments for the patient‚ but the nurse is the one whom the patient sees and establishes a connection most. Nurses
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Nursing care plan (Colonoscopy) S.E is a 59 year old African-American male admitted to the critical care unit because of his left lower quadrant (LLQ) abdominal pain. S.E had a colonoscopy 2 days ago. He has a family history of hypertension (HTN) and a medical history of HTN and anemia. He is alert and oriented ×3 (time‚ place‚ and person). S.E has no known drug allergy and he is NPO except for medicine. Problem: LLQ abdominal pain Acute pain | Assessment | Planning/Nursing Goals |
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NURSING CARE PLAN Nursing Assessment: Ms. F.E. is a 20yr. old female who was involved in a motor vehicle accident (M.V.A.)‚ and was admitted on 04.03.12 to the surgical unit with Spinal injuries‚ Polytrauma and fractured right humerus. She started complaining of severe abdominal pains‚ one week after assessment by Doctor‚ she was scheduled for emergency laparotomy with ?diagnosis Perforated Hallow Viscus. Following surgery patient was diagnosed with Fecal Peritonitis and was transferred to the
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