____CP_____________________ Date _2/12/13_____ Pt Initials _MK_____ Medical Diagnosis #1: Multiple coronary artery disease Chief Complaint #1 Use Quotes: ”Shortness of breath and chest pain for over a month now” on 2/6/13 on day of Admission Chief Complaint #1 Use Quotes: “Pain 8/10” on day of your nursing care Prior Illnesses Hypertension‚ coronary artery disease‚ obesity‚ angina Family History Father passed away from a heart attack; Mother had a stroke General Survey Sex
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NURSING CARE PLAN Nursing Assessment: Ms. F.E. is a 20yr. old female who was involved in a motor vehicle accident (M.V.A.)‚ and was admitted on 04.03.12 to the surgical unit with Spinal injuries‚ Polytrauma and fractured right humerus. She started complaining of severe abdominal pains‚ one week after assessment by Doctor‚ she was scheduled for emergency laparotomy with ?diagnosis Perforated Hallow Viscus. Following surgery patient was diagnosed with Fecal Peritonitis and was transferred to the
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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 Process Planner DATA | ANALYSIS | NURSING DIAGNOSIS | PLANNING | Group significant data according to needs‚ patient concerns. | Compare with normal standards‚ knowledge‚ and interpret the meaning of the data and knowledge. | State problem or concern according to needs with reasons and related factors. | Outcomes/ Objectives. A goal with more detailed objectives. | | Reference | | | Ms. C.M62 years oldDiagnosis:RT lung CancerSx:RLL&RML wedge‚ RLLwedge+mediastinal lymphadectomy
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Teaching Plan for the Patient with LeFort Colpocleisis Addressing the learning needs of patients is a major responsibility for nurses. Through teaching plans‚ nurses can help patients and their families have a safe experience and prevent possible complications. Each patient needs an individualized and comprehensive teaching plan. Nurses must anticipate goals and barriers‚ identify the subjects they will teach‚ the methods they will use to teach‚ and assess their readiness to learn. In addition‚ nurses
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|SUBJECTIVE: ➢ “I ALWAYS EXPERIENCED CHEST PAIN AND DIFFICULTY OF BREATHING” As verbalized by the patient. OBJECTIVE: ➢ Weak and pale in appearance ➢ Difficulty of breathing ➢ Poor skin turgor ➢ Clutching of hands to chest ➢ Shortness of breath ➢ Restlessness VITAL SIGNS: ➢ BP- 130/90 mmHg ➢ T- 37.5 C ➢ PR- 98 BPM ➢ RR-25BPM ➢ PAIN SCALE- 8 | ➢ ACUTE PAIN RELATED TO MYOCARDIAL ISCHEMIA. |SHORT TERM GOAL: After 8 hours of nursing intervention: ➢ The patient will
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Developing Implementation Plan According to Hill and Wee‚ 2012. Fall in the hospital among adult patients is a big problem for the health care sector‚ especially the nursing profession. Cognitive impairment‚ medically –induced immobility‚ past medical fall history‚ weak muscle and certain group of medications like psychotropic/benzodiazepines‚ are some factors that have been noted to be responsible for elderly patients vulnerability to falls. Educating the patients at risk for falls‚ lowering/stopping
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Teaching Plan for Diabetes Mellitus Teaching Plan for Diabetes Mellitus Bonny York Jacksonville University Nursing 342 October 10 2011 Teaching Plan for Diabetes Mellitus 1 The Identified Learning Need Patients with diabetes have very comprhensive learning needs. The learning needs are focused on managing their glucose levels and preventing complications of diabetes. Learning needs
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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 ‚The first step in a nursing care plan is the
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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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