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
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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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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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|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 TERM GOAL: After 8 hours of nursing intervention: ➢ The patient will
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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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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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Review Article RA: Interleukin-6‚ its roles and significance in the pathophysiology of Rheumatoid Arthritis Introduction Rheumatoid arthritis (RA) is an inflammatory autoimmune condition principally causing synovial joint inflammation and cartilage erosion. The pathogenesis encompasses intricate cellular and humoural manifestations‚ and vascular reactions that result in the infiltration of the synovium by white blood cells‚ of which release inflammatory mediators‚ inclusive of Interleukin-6
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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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ASSOCIATE 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:
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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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