Evaluation Activity Intolerance Related to Surgical incision as manifested by Chest Tube Thoracostomy inserted at left lung. • Subjective Data: “Di ako makaligo ng mabuti kasi ang daming nakakabit sa katawan ko” • Objective data: - limit movements and requires to have assistance in some activities to be performed - Strenuous activity was restricted by the AP - (+) dry skin - Afebrile - Dry scalp noted - On 3rd day without bath - Gown worn on 2nd day - Expresses desire for self-care Background
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CHINESE GENERAL HOSPITAL COLLEGE OF NURSING NURSING CARE PLAN Student: Munoz‚ Helen Rose Yr/Sec: III-B Area: 5A Patient’s name: M.C. Diagnosis: STEMI ASSESSMENT | DIAGNOSIS | INFERENCE | PLANNING | INTERVENTION | EVALUATION | | Objective: -Easily Fatigue-Walks slowly-Use of wheelchair-Limited Range of Motion | Activity Intolerance r/t decreased muscle strength secondary to old age | MusculoskeletalMuscle mass is a primary
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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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Nursing Care Plan Assessment equals Data Collection + Analysis | Nursing Diagnosis – Actual/Potential | Nursing Goal(SMART) | Nursing Interventions/ActionsInclude Rationale/Reference | Evaluation | Female Age : 85Code status: Full Code initially but changed to DNR on 14/Jan-2012Primary diagnosis: PancytopeniaReason for Hospital Admission: Fall at home. Allergy: PenicillinMedical History: Pacemaker‚ Hypertension‚ Fall at home‚ Bradycardia‚ Hyperlipidemia.Neurological: Alert‚ Oriented x 4.Diet
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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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Nursing Critique Since the early 1900’s nurses have been trying to improve and 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
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step in a nursig care planThe first step in a nursing care plan is the assessment ‚ is the assessment ‚ jjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjThe first step in a nursing care plan isThe first step in a nursing care plan is the assessment ‚ the assessment ‚ The first step in a nursing care plan is the assessment ‚ The firstThe first step in a nursing care plan is the assessment ‚ step in a nursing care plan is the assessment ‚ The first step in a nursing care plan is the assessment
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Health problem Family nursing problem Goal of care Objectives of care Intervention plan Nursing intervention method resources Improper drainage as a health treat Inability to recognize the improper drainage. Inability to do appropriate action due to failure to comprehend the good environment. Inability to conduct adequate drainage. Lack of knowledge about proper drainage. After my 2 months nursing intervention the condition
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Assessment | Nursing Diagnosis | Goals & Expected outcomes | Nursing Interventions | Rationales | Methods of Evaluation | Name of client: Mrs. Tam Age: 65 Sex: Female Student ID:1155016494 Assessment date: 29/11/12 Medical Diagnosis: 1. Lower limbs edema 2. Low albumin level 3. hypokalemia and hypocalcaemia 4. Anemia Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to vomiting after eating as evidenced by food intake less than the recommended daily
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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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