Student Name: Date: February 25‚ 2006 Nursing Diagnosis Outcome Criteria (Goal) Evaluation of Outcome Criteria (Goal) PC: Postpartum Hemorrhage Patient will develop no complications related to excessive bleeding‚ will maintain normal vital signs of express understanding of her condition‚ its management‚ and discharge instructions‚ identify and use available support systems. R/T‚ RTRF and secondary to: Pathophysiology Supporting Nursing Diagnosis Statement (cite source) Uterine atony
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School of Nursing Care Plan Student’s Name: Joie Ferreiro________________________________ Date: 9/5/14 Client’s Initials: R.S. Admission Date: 7/30/14 Age: 96 Sex: f___ Race: __w____ Religion: Jewish Allergies: Phenobarbital Diet: NPO Activity: Bed rest Admitting Medical Diagnosis (es): Sacral decubitus ulcer‚ polymicrobic sacral osteomyelitis Past Medical History (including past surgical history): Illnesses include: 1) Renal insufficiency 2) Anemia 3) hyperthyroidism
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reports that chiropractic treatment positively impacts his ability to perform his activities of daily living (activities of daily living (ADLs)‚ and has resulted in increased positional tolerances during the previous approved treatment period. For example‚ he previously stated he could only tolerate standing up to 10 minutes; with chiropractic treatment‚ this is increased to 15 minutes. He wishes to continue chiropractic treatment over other treatment
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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 M Race Caucasian Age 74 Height 175cm Weight 90.7 kg
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Physical Care: - Sleep: Be sure to maintain good sleep habits. This will include going to bed no later than 10:00pm and staying in bed a minimum of eight hours. - Nutrition: Eat a healthy diet to include 3 meals per day and at least one healthy snack. - Exercise: Take daily walks outside for a minimum of 20 minutes. Psychological Care - Family time: Make time to take family out of the house at least twice per week. Have dinner at the dinner table as a family at least 4 days a week. - House
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Infection. Objectives: Within 15 minutes of nursing intervention‚ the patient will be able to gain knowledge by : Enumerating 2/3 specific causative factors of UTI. Demonstrate behaviors and techniques to prevent urinary tract infection and manage care of urinary catheter. Shows positive attitude by verbalizing understanding of her condition. Establish rapport Assess level of awareness of the mother regarding the child’s condition. Broaden the knowledge of the mother by teaching:
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Richard J. Daley College Nursing 101 Data Collection for Care Plan Section I – Demographic Data: Patient Initials: K. J. Sex: Female MSWD: Married Age: 44 No. of children: 1 Occupation: Disabled Section II- Admission Data 1. Date admitted: 10/19/2007 2. Admitting diagnosis: Hematomesis‚ melanotic stools‚ cirrhosis‚ hepatorenal syndrome. 3. Allegries: Codiene 4. Signs and symptoms on admission: jaundice appearance‚ lethargic‚ oriented x 1‚ vomiting bright red blood‚ has had
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by the end of the shift. Pt will progress from NPO to clear fluids to soft foods by the end of the week. Pt will continue to ambulate as much as possible. | PLANNING | IMPLEMENTATION | EVALUATION | InterventionsSuggested nursing approaches and care-giving skills. | Rationale for InterventionsEvidence or knowledge based reason for selecting the intervention | What you actually did – compared to what you planned to do | Whether or not the goals and objectives were met and suggestions for modification
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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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treatment in order to maximize therapeutic effect and facilitate healing. When a patient and their family are educated about illness‚ medications‚ and other treatments‚ they are more likely to be interested in their healthcare and comply with the plan. An infection of the lungs triggers an inflammatory response‚ which results in edema in the alveoli. As a result of pulmonary edema‚ gas exchange becomes impaired leading to decreased activity tolerance. At the end of the shift‚ pt’s pulse oximetry
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