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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PATIENT CENTERED NURSING CARE PLAN STUDENT NAME: _________________________ CLIENT’S AGE: ___________ SEX: MALE FEMALE DATE: _________________________________ DIAGNOSIS: __________________________________ Assessment (Subjective and Objective Data‚ Fundamental Needs) Nursing Diagnosis (NANDA) Planning Intervention Evaluation Analysis Statement… Related to… As Evidenced by… Need Specific Goal (RUMBA‚ SMART) Source
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ASSOCIATE DEGREE NURSING NURSING PROCESS FORM: PART I – ASSESSMENT Student: Date of Care: 3/4/13 Client’s Initial: WB Room # 1011 Occupation: Teacher Age: 59 Sex: F Race: Black Religion: Christian Admission Date: 3/1/13 Primary Language: English Role in family: Widowed from husband Stage in Life Cycle: Generativity vs. Stagnation Surgery date(s) this admission: N/A Chief complaint: Brain Dysfunction/Traumatic‚ closed injury Admission Diagnosis:
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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 be able to verbalize relief from chest pain
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Health Education Plan: Teaching the Patient with Hepatitic C For years‚ nursing was a task-oriented career. A nurse’s primary responsibility was to provide for the physical needs of patients experiencing illness. Nursing has evolved into a profession‚ which holistically treats and educates patients in a variety of health situations including acute illness‚ chronic disease‚ and preventative care. The competent practice of patient education has become a critical element in nursing. This paper will
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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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DISCHARGE SUMMARY Patient Name: Adela Torres Patient ID: 132463 DOB: Age: 57 Sex: Female Date of Admission: 6/22/---- Date of Discharge: 6/25/---- Admitting Physician: Liam Medina‚ MD Consultations: Sachi Kto‚ MD‚ Dermatology Procedures Performed: Intravenis Hydration Complications: None Discharge Diagnosis: 1. Methotrexate related dermatitis. 2. Rheumatoid arthritis class 3 stage 4 3. Osteoporosis
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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 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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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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