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
PN 0004C Weekly Clinical Planning Sheet Student Name: S.H Care plan #5 Patient Initials: t.l Age/Sex: 73/f Allergies: Potassium Nurse on Duty: Regin Admission Date: 06/29/2013 Admitting Physician: Dr. Cole Consulting physician: Code status: Hospice‚ dnr Activity Level: As tolerated Diet: nectar thick/puree Patient History and Diagnoses: primary
Premium Medicine Patient Nursing
Wendy‚ I think your description of the pathophysiology of asthma was right on point. Due to the release of the mediators causing an increase in blood flow and vasoconstriction‚ which is why his BP increased and experiencing tachycardia. With bronchoconstriction‚ causing him to used excessive muscle to breathing‚ leading him to have tachypnea of 42 with shallow breathing. Since the patient is experiencing exacerbating‚ it is important to act quickly and manage it by early treatment and education
Premium Patient Diabetes mellitus Nursing
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
Premium Childbirth Blood Uterus
of overtime without considering the safety of the staff and patients. I work in a psychiatric hospital where safety is one of the company priorities. The majority of the decision-making in the facility where I work is controlled by the director of nursing who speaks to the manager who communicates the charge nurses; there is little or no input from the nurses on the floor even though they spend the most time with the patients. Incident report One of the most frequent incidents that occur in my work
Premium Hospital Nurse Patient
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
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:
Premium Traumatic brain injury
Cues Nursing Problem Scientific Reasoning Planning Implementation Evaluation Subjective: >”Nay‚ kelan po tayo uuwi?” as verbalized by the patient >”Nag-aaya na nga syang umuwi.” as verbalized by the caretaker Objective: >Patient is silent when hospital staff is around >Patient does not have eye contact with the hospital staff Fear related to hospitalization as manifested by alteration in behavior. Hospitalization is usually perceived as a threat that is consciously
Premium Perception Regulatory Focus Theory Time
➢ 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 be able to verbalize relief from chest pain and difficulty of breathing ➢ The patient will be able to reduce anxiety regarding his condition. LONG TERM GOAL: After 3 days of nursing intervention: ➢ The patient will report pain being absent or controlled with medication administration. ➢ The patient will
Premium Opioid Myocardial infarction Oxygen
year old boy who has had a history of eczema and asthma since early childhood. According to Guibas et al (2012) asthma is the most common chronic respiratory disease of childhood: its prevalence has been rising in the western world for the last three decades. In Scotland‚ 368‚000 people (1 in 14) are currently receiving treatment for asthma. This includes 72‚000 children and 296‚000 adults. There are 5.4 million people living with asthma in the UK and around 1 million of these are children
Premium Asthma