WAYNE COUNTY COMMUNITY COLLEGE DISTRICT NURSING PROGRAM NURSING CARE PLAN General Information: Postop pt undergone a cholecystectomy Patient intials: R.M. Confidential Marital Status: SINGLE Student’s Name: Hanadi Abdou Age: 61 Birthdate: 12/3/1950 Religion: not specified (pt nonverbal) Clinical Instructor: Mary Servey Admittance date: 3/12/12 Interest: not specified (pt nonverbal) Date: 3/21/12 Class: Med Surg Diagnoses: Impaired skin integrity Diet: NPO Allergies: None
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NURSING CARE PLANS Impaired Physical Mobility Assessment | Nursing Diagnosis | Scientific explanation | Objectives | Nursing Interventions | Rationale | Expected Outcome | S > θO > Patient manifest:- weak and pale appearance - difficulty in standing and sitting - slowed movement - limited range of motion | Impaired Physical Mobilityr/t neuromuscular impairment aeb slowed movement | Limitation in independent‚ purposeful physical movement of the body or of one more extremities.Due
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respiratory and physical exercises 7) Patient will be able to state the importance of weight management and demonstrate exercises to increase success in lowering BMI in 6 weeks 8) Patient will incorporate his family and/or support systems into his care to obtain and meet health goals Nursing interventions 1) Teach the patient how to breathe effectively with slow‚ deep‚ abdominal breathing and incorporate pursed lip breathing to ensure there is sufficient oxygen being perfused to the body. Rationale:
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Natalie Sullivan 6/4/2013 Nursing Care Plans Care Plan: Post Partum Patient’s initials: SR Date of Care: 5/6/2013 Assessment Data: * G1P1 * C/S on 5/5/2013 at 1832 * Incision at suprapubic region * Staples mid right side to end of left side of incision * Steri strips on right side of incision r/t to removal of 5 staples because staples were loose * Pt complaining of pain in lower abdomen * Pt complaining of “uncomfortableness” at incision
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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 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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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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Nursing care plan (Colonoscopy) S.E is a 59 year old African-American male admitted to the critical care unit because of his left lower quadrant (LLQ) abdominal pain. S.E had a colonoscopy 2 days ago. He has a family history of hypertension (HTN) and a medical history of HTN and anemia. He is alert and oriented ×3 (time‚ place‚ and person). S.E has no known drug allergy and he is NPO except for medicine. Problem: LLQ abdominal pain Acute pain | Assessment | Planning/Nursing Goals |
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treatment regimens‚ unfamiliar and often complex problems. Because of the patient’s education is considered a skill reimbursed by Medicare & other commercial insurance carriers. It is important for the nurse to include knowledge deficit in the plan of care. The deficit in knowledge may relate to clients lack of information about their disease process‚ medication or resources Kozier‚ 2007; Perry and Potter‚ 2002 | After couple of nursing interventions‚ the patient will gain enough knowledge
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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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