individualise patient care. In the 1970s this became more structured when the nursing process was introduced by the general nursing council (GNC)‚ (Lloyd‚ Hancock & Campbell‚ 2007) .By doing this their intentions were to try and understand the patient in order to give them the best care possible (Cronin & Anderson‚ 2003). Through the nursing process philosophy care plans were written for patients. It was understood that this relationship would ensure the patient received the best care possible to suit
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Nursing care plan Name of client: Miss Ng Sex: F Date of assessment: 31/10/2014 Medical diagnosis: Caesarian section Diagnostic statement: Impaired comfort related to tissue trauma and reflex muscle spasms secondary to surgery as evidenced by vomiting Assessment Nursing diagnosis Goals & expected outcome Nursing interventions Rationales Method of evaluation Subjective data: 1. Patient reported of abdominal pain. 2. Elevated scoring of 8/10 of pain score Objective data: 1. Restlessness 2. Facial
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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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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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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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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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