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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as palpated levels of spinal segmental dysfunction. Based upon these findings‚ IW is clearly demonstrating functional improvement with additional chiropractic treatment but has not achieved the expected results of chiropractic treatment‚ and further care is necessary. Chiropractic treatment is recommended at a frequency of 2 times per week for 8
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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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DATE | CUES | NURSING DIAGNOSIS | KNOWLEDGE BACKGROUND | GOAL | NURSING INTERVENTION | RATIONALE | EVALUATION | | Subjective:“Medyo masakit ang dibdib ko pag umuubo ako.”as verbalized by the patientObjective:Productive coughYellow sputum dischargedPain scale of 10/10 | Acute pain R/T coughing | Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage ;sudden or slow onset of any intensity from
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CUES/ CLUES |DIAGNOSIS |OBJECTIVES |INTERVENTIONS |EVALUATION | |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
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ASSESSMENT (Data Collection) NURSING DIAGNOSIS (Patient Problem/Priority) PLANNING (Patient-Centered Goals) IMPLEMENTATION (Nursing Interventions) Nurse roles: Assess‚ monitor‚ use of communication techniques‚ patient education EVALUATION (Patient-Centered Goal Met?) Subjective: (what you heard the patient describe) Objective: (what you see‚ hear‚ smell‚ feel) *Use nursing diagnosis language 1 goal per physical What specifically will you do - as a nurse - to assist the patient
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