Karisa M. Young April 28‚ 2005 Nursing 374L Nursing Care Plan Twin ‘B’ was born on Monday February 14‚ 2005 at 35 weeks gestation. The mother was scheduled for a cesarean section at 38 weeks gestation‚ but presented in the hospital early with signs of labor. A cesarean delivery was performed. Twin ‘B’ APGAR scores at 1 minute and 5 minutes were 9 and the newborn weighted 4lbs 3 oz. Upon completion of the assessment‚ the newborn’s temperature decreased to 96.1 degree Celsius (axillary). Diagnosis
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Joanne’s GP requested that she has some community care The G.P Joanne first went to her GP because she felt a pain in her right breast‚ she had a feel of the breast and came across a lump‚ The GP examined the breast and referred her to the specialist breast clinic When the wound has healed‚ Joanne can begin radiotherapy 5x week for 4 weeks. This will be done to ensure that all the cancer cells have died. This treatment will be done by a therapeutic radiographer Pharmacy for her repeat
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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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Family Care Plan Thomas Chamness University of Phoenix Nursing 467 Karen Jones November 20‚ 2010 Family Care Plan My family consists of a single mother‚ age 27. Her child is a 3-year-old male. The characteristics of the mother are unique; she had to deal with losing both of her parents at a young age. Her father committed suicide when she was nine and her mother was murdered in the line of duty while working as a state trooper. The mother also has no siblings. At the present time
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ASSESSMENT & CARE PLAN CLIENT CASE STUDY #2 Student: Fall 2010 Client Initials: VC Age: 82 Gender: Female Date Admitted to Nursing Home: 12/14/07 Assessment Date: 12/3/10 1. HEALTH HISTORY Brief description of health history and reason in nursing home: VC has a history of malignant neoplasm of her large intestine which lead to her colostomy status. She also has a history of fracture and fall. She was admitted to the nursing facility secondary to her alzheimer’s diagnosis
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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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Nursing Theory Plan of Care Theoretical Foundations of Practice NUR/513 March 05‚ 2012 Nursing Theory Plan of Care Ida Orlando literally wrote the book on the function of nursing. Her theory of the deliberative nursing process outlines a dynamic nurse-patient relationship in which the nurse uses his or her senses of perception together with deliberate actions to create an individualized care plan for each patient. Results of current research on the application of her theory follow
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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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Student Name: Date: February 25‚ 2006 Nursing Diagnosis Outcome Criteria (Goal) Evaluation of Outcome Criteria (Goal) PC: Postpartum Hemorrhage Patient will develop no complications related to excessive bleeding‚ will maintain normal vital signs of express understanding of her condition‚ its management‚ and discharge instructions‚ identify and use available support systems. R/T‚ RTRF and secondary to: Pathophysiology Supporting Nursing Diagnosis Statement (cite source) Uterine atony
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patient care. This assignment will compare four cases describing my journey through the development of health assessment skills using the medical model of assessment‚ ‘history‚ examination and diagnosis ‘and joining it with the nursing assessment to give a holistic approach. The process of formulating a diagnosis will be explored‚ together with how advancing practice has enabled me to use collaborative working and expert decision making to improve the care of stroke
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