COMPLETE PHYSICAL EXAM ABBREVIATIONS: Vital Signs: T (temperature) HR (pulse) RR (respiration rate) BP (systolic/diastolic) SPO2 pulse ox SYSTEM Physical Exam Documentation Detailed Abbreviation Explanation GEN: General NAD‚ AAOX4‚ WDWN (AAM‚ AAF‚ WM‚ WF) No acute distress‚ alert‚ awake‚ and oriented times 4 to name‚ place‚ time‚ purpose‚ Well developed well nourished (African American Male‚ African American Female‚ White Male‚ White Female) HEENT: Head‚ NCAT‚ MMM‚ EOMI‚ PERRLA‚ b/l TM intact & Normocephalic
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her life‚ even with the associated complications of each. The participant‚ Anna‚ was asked to complete an interview based on her pregnancy of her eldest daughter. The questions being asked focused on the labour and delivery process‚ as well as the newborn‚ infancy‚ childhood and early teen stages of the child’s development. Anna’s real life pregnancy experiences will be compared and related to several concepts from the textbook
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Case Study Maria Terri L Bray NUR 403 November 7‚ 2011 Case Study Maria List five factors of patient history that demonstrates nursing needs: | 1. The patient speaks little English and may need an interpreter at the hospital. 2. The patient has little to no emotional support from her spouse. 3. The patient has not support system. 4. The patient is new to the United States and may have fears about delivering her child in an American hospital. 5. The patient has the beginning
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NURSING DIAGNOSIS | RATIONALE | NURSING INTERVENTIONS | RATIONALE | EVALUATION | February 21‚ 20132pm-10pmImpaired skin integrity related to vehicular accident as evidenced by abrasions.Objective:-abrasions on face‚ both arms‚ and left legGoal:After 6 hours of nursing intervention‚ patient will be able to display timely healing of skin lesions without complication. | Altered epidermis or dermis.Vehicular Accident direct trauma to the skinabrasions of extremities and swelling of the skin in upper
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Nursing Diagnosis(ND): Ineffective breathing pattern Related to (R/T): The patient has decreased lung compliance. As Evidenced By (AEB): The patient having dyspnea and abnormal ABGs Desired Patient Outcomes(Goals) Nursing Interventions Rationales Evaluation STG: Patient will: Patient will exhibit signs of effective breathing pattern before end of Nursing shift. 1. Nurse will monitor patient’s prescribed oxygen therapy. 2. Nurse will titrate oxygen to keep oxygen greater than ninety
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Daniel was brought into my newborn photography studio by new parents‚ Scott and Tiffany. He was just 6 days new at the time of his session. This December baby was born on the first of the month weighing 6 pounds 13 ounces and measuring 21 inches. The couple met in marching band in college back in 2007‚ but didn’t connect until years later. In 2011‚ Scott’s brother needed 3 people to critique his book and asked him to find those people. Tiffany was one of the people that Scott chose. They’ve been
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Position Individuals in Accordance With Their Plan of Care Outcome 1 1) For this we need to know the individuals normal range of movement‚ this is by looking at things such as their past injuries such as if they have had fractured bones‚ if they have ever torn any muscles or if they have any conditions such as arthritis. This can all have an impact of how we move and position an individual. All this information should be written on the individuals care plan and how they should be moved if this is not
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Cooper Green hospital and the Community Care Plan Nicole Warren California College San Diego HCA474 [ December 13‚ 2012 ] Jason Kart Cooper Green Hospital and the Community Care Plan When it comes to health care‚ it’s very hard to afford. People get sick on a daily basis and they start to treat the emergency room as walk-in clinics. The delivering of health care to an indigent population‚ the lack of communication‚ education‚ changes with the US health care system and funding started to become
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Support care plan activities unit 56 A support plan is a ‘plan’ and is therefore subject to change. It is a guide to be followed in order to support the person effectively. Circumstances and needs change‚ and unless these changes are reported and recorded‚ the plan of support may stay the same and will not fulfil its original purpose. It is the responsibility of the person who will be providing the hands-on support to notice the small changes. All changes or signs of discomfort must be recorded
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Unit 56: Support care plan activities R/601/8015 1.1 Identify sources of information about the individual and specific care plan activities Having a holistic approach will allow us to know better our service user and so‚ support him in the best way accordingly with his needs. By actively involving the service user we may obtain most of his relevant information such as health state‚ circumstances and his religious and cultural background. Accounting with service user provider permission we may obtain
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