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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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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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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tonsillectomy. Objective: PERLA‚ hearing intact‚ nasal patency X2‚ mucous membranes are moist and pink. Gag reflex intact. Thyroid is not enlarged. Pain Status: (Level of pain; location‚ intensity‚ characteristics‚ activities which cause/worsen pain; activities which alleviate pain) Subjective: patient complains of abdominal pain‚ nausea‚ and chest pain. C: dull O: this morning L: chest‚ back‚ stomach D: intermittent S: 8 P: walking makes it worse‚ but it’s tolerable when she is in bed A: nausea
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Nursing Care Plan As soon as the history and head-to-toe assessment were completed nursing priorities focused on alleviating pain‚ preventing infection and urinary obstruction‚ and providing information about disease process and treatments. Physical assessment data included: vital signs B/P 87/51‚ HR 110‚ T 99.7 F; weight 160lb‚ height 5’8”. MK presented to the ED with acute severe right colicky flank pain that radiated into the abdomen and lower back‚ guarding his abdomen‚ and moaning. MK rated
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Cues Nursing diagnosis Nursing objective Planning Nursing intervention Rationale Subjective Cues: “Nahihirapa n akong umihi‚‚ madalas sya pero pakonti konti lang » as verbalized by the client. Objective Cues: Distended abdomen Frequency Hesitancy T-38.3 P-105Bpm R-24 bpm BP-130/90 mmHg Impaired Urinary Elimination r/t Inflammatio n of bladder mucosa As evidence by the objective cues. __________ _ Scientific Explanation : Disturbance in urine elimination. After 8 hrs of
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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
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NURSING DIAGNOSIS GOAL INTERVENTIONS RATIONALE EVALUATION impaired Gas Exchange R/T STG: 3/17/2014 throughout shift 1. Auscultate breath sounds 1. Abnormal breathing STG: PT O2 saturation on admission abnormal breathing AEB PT will maintain O2 saturation noting areas of decreased sounds are indicative was 87%. Measured at 1602 with a Objective: use of wall oxygen of 95 or higher AEB breathing sounds of numerous problems reading of
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Establishing Acute Pain Service Many hospitals have employed an acute pain service for nearly a decade‚ but for many hospitals in the United States this still is a new idea. What we’re seeing is a new modality in treatment and the way we approach it. An acute pain service (APS) primarily manages pain after traumatic injury or surgery. The basic aspects of an APS include standardization of analgesic techniques‚ increased pain monitoring and assessment‚ and the ability to respond to inadequate or
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