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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NURSING CARE PLAN GUIDE ASSESSMENT OF UNIVERSAL SELF CARE REQUISITES DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient. |ASSESSMENT |PLANNING |EVALUATION | |Universal
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ASSESMENT | GOAL OF CARE | PLAN OF ACTIONS | RATIONALE | IMPLEMENTATION | DOCUMENTATION | Subjective:“Daghan man na siya samad ug hubag sa iyang lawas”(She has many wounds and bruises on her body) as verbalized by the mother.Objective:-Presence of lesions and abrasions on the patient’s body.-greenish violet discolorated patches-soaked dressingNursing Diagnosis:Risk for impaired skin integrity related to superficial factors. | At the end of 8 hours nursing interventions‚ the client will be able
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NURSING CARE PLAN CARMENCITA ABAQUIN’S SELF-PREPARATION THEORY ASSESSMENT NURSING DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION Subjective: Connection to self Express desire for enhanced acceptance; coping courage; forgiveness of self; hope;joy;love; meaning/purpose in life; satisfying philosophy of life; surrender Express lack of serenity Meditation Connection with Others Request interactions with significant others/spiritual leaders Requests forgiveness of others
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This therapeutic care plan will utilized the “I can treat and prescribe framework” to ensure that appropriate patient treatments are selected using a step by step approach‚ including assessment integration‚ drug and/or disease related problems‚ therapeutic goals‚ therapeutic alternatives and indications‚ plan of care and evaluation (OPHCNPP‚ 2012). By going through each step of this framework‚ and including or excluding treatment options based on individual patient factors and strong clinical evidence
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School of Nursing Care Plan Student’s Name: Joie Ferreiro________________________________ Date: 9/5/14 Client’s Initials: R.S. Admission Date: 7/30/14 Age: 96 Sex: f___ Race: __w____ Religion: Jewish Allergies: Phenobarbital Diet: NPO Activity: Bed rest Admitting Medical Diagnosis (es): Sacral decubitus ulcer‚ polymicrobic sacral osteomyelitis Past Medical History (including past surgical history): Illnesses include: 1) Renal insufficiency 2) Anemia 3) hyperthyroidism
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Nursing Care Plan Assessment equals Data Collection + Analysis | Nursing Diagnosis – Actual/Potential | Nursing Goal(SMART) | Nursing Interventions/ActionsInclude Rationale/Reference | Evaluation | Female Age : 85Code status: Full Code initially but changed to DNR on 14/Jan-2012Primary diagnosis: PancytopeniaReason for Hospital Admission: Fall at home. Allergy: PenicillinMedical History: Pacemaker‚ Hypertension‚ Fall at home‚ Bradycardia‚ Hyperlipidemia.Neurological: Alert‚ Oriented x 4.Diet
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A Concept Analysis if Patient Centered Care Christina Babbs Chamberlain College of Nursing Theoretical Basis Advanced Nursing NR 501 Cecelia Lipscomb-Hammond November 15‚ 2014 A Concept Analysis if Patient Centered Care Concept analysis is a process of researching‚ gaining knowledge of concepts for the purpose of clarification or further development. Concept analysis should be conducted when concepts require clarification or further development to define them for a nurse scholar’s purposes‚ whether
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CASE STUDY IN NCM-103 (CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION‚ FLUID AND ELECTROLYTE BALANCE‚ NUTRITION AND METABOLISM AND ENDOCRINE) Submitted to : Mr. Darren N. Constantino Submitted by : Olive Keithy Ascaño CASE STUDY 1 1. a. The possible fluid and electrolyte imbalances that the 78-year-old woman may experience are hyponatremia‚ hypokalemia and hyperkalemia because of nausea and vomiting that are common in these imbalances. b. The following interventions are
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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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