Nursing Diagnosis # 1 Ineffective breathing pattern related to decreased oxygen saturation‚ poor tissue perfusion‚ obesity‚ decreased air entry to bases of both lungs‚ gout and arthritic pain‚ decreased cardiac output‚ disease process of COPD‚ and stress as evidenced by shortness of breath‚ BMI > 30 abnormal breathing patterns (rapid‚ shallow breathing)‚ abnormal skin colour (slightly purplish)‚ excessive diaphoresis‚ nasal flaring and use of accessory muscles‚ statement of joint pain‚ oxygen
Premium Nursing care plan Patient Hypertension
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
Premium Temperature Nursing care plan
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
Premium Educational psychology Cognition Learning
DEGREE NURSING NURSING PROCESS FORM: PART I – ASSESSMENT Student: Date of Care: 3/4/13 Client’s Initial: WB Room # 1011 Occupation: Teacher Age: 59 Sex: F Race: Black Religion: Christian Admission Date: 3/1/13 Primary Language: English Role in family: Widowed from husband Stage in Life Cycle: Generativity vs. Stagnation Surgery date(s) this admission: N/A Chief complaint: Brain Dysfunction/Traumatic‚ closed injury Admission Diagnosis: Post Blunt
Premium Traumatic brain injury
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
Premium Kidney Hypertension Renal failure
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
Free Blood pressure Hypertension
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
Premium Wound Vaccination Vaccine
Nursing Process Planner DATA | ANALYSIS | NURSING DIAGNOSIS | PLANNING | Group significant data according to needs‚ patient concerns. | Compare with normal standards‚ knowledge‚ and interpret the meaning of the data and knowledge. | State problem or concern according to needs with reasons and related factors. | Outcomes/ Objectives. A goal with more detailed objectives. | | Reference | | | Ms. C.M62 years oldDiagnosis:RT lung CancerSx:RLL&RML wedge‚ RLLwedge+mediastinal lymphadectomy
Premium Abdominal pain Nursing Constipation
A Cesarean Delivery A Cesarean Delivery A cesarean section is also known as a c-section‚ which is sometimes also written as c/s. This type of birth is done by a surgical incision in the abdomen and uterus to allow a baby or babies to be born safely when a vaginal birth is not the safest route. The current cesarean rate in the United States is over 30%. The surgery is relatively safe for mother and baby. Still‚ it is major surgery and carries risks. It also takes longer to recover from
Premium Childbirth Caesarean section
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
Premium Lung Pneumonia Respiratory system