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 Assessment of the Postpartum Patient Date of data collection:___13 November 2014___ Patient initials _K.M.___ Age__28_ PP day _1__ (# days since delivery- 0‚ 1‚2 3‚ etc) Grav _4__ Para _3__ Term _3__ Preterm _0___ Ab_0__ LC___ Weeks gestation @ delivery (via EDC) _39.2____ Weeks gestation at delivery (from neonatal maturity rating/Ballard exam):_ 40_____ Date/time of delivery _12 Nov. / 1640_________ Labor onset - induced or spontaneous (circle one) If induced: indication (why)
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Independent and Collaborative Rationale (cite source for each rationale) Evaluation (of each intervention) Assess 1. Upon admission assess patient’s history and labor & delivery record for factors that might predispose the patient to postpartal hemorrhage. 2. Assess vaginal bleeding (locchia) after delivery every 15 minutes for one hour‚ then every 30 minutes for 1 hour‚ or until stable; more frequent assessments may be necessary depending upon the patient’s
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Nursing Diagnosis # 1 Ineffective breathing pattern related to decreased oxygen saturation‚ poor tissue perfusion‚ obesity‚ decreased air entry to bases of both lungs‚ gout and arthritic pain‚ decreased cardiac output‚ disease process of COPD‚ and stress as evidenced by shortness of breath‚ BMI > 30 abnormal breathing patterns (rapid‚ shallow breathing)‚ abnormal skin colour (slightly purplish)‚ excessive diaphoresis‚ nasal flaring and use of accessory muscles‚ statement of joint pain‚ oxygen
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Family Care Plan Thomas Chamness University of Phoenix Nursing 467 Karen Jones November 20‚ 2010 Family Care Plan My family consists of a single mother‚ age 27. Her child is a 3-year-old male. The characteristics of the mother are unique; she had to deal with losing both of her parents at a young age. Her father committed suicide when she was nine and her mother was murdered in the line of duty while working as a state trooper. The mother also has no siblings. At the present time
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GOAL OF CARE | PLAN OF ACTIONS | RATIONALE | IMPLEMENTATION | DOCUMENTATION | Subjective:“Daghan man na siya samad ug hubag sa iyang lawas”(She has many wounds and bruises on her body) as verbalized by the mother.Objective:-Presence of lesions and abrasions on the patient’s body.-greenish violet discolorated patches-soaked dressingNursing Diagnosis:Risk for impaired skin integrity related to superficial factors. | At the end of 8 hours nursing interventions‚ the client will be able to: 1. Display
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WAYNE COUNTY COMMUNITY COLLEGE DISTRICT NURSING PROGRAM NURSING CARE PLAN General Information: Postop pt undergone a cholecystectomy Patient intials: R.M. Confidential Marital Status: SINGLE Student’s Name: Hanadi Abdou Age: 61 Birthdate: 12/3/1950 Religion: not specified (pt nonverbal) Clinical Instructor: Mary Servey Admittance date: 3/12/12 Interest: not specified (pt nonverbal) Date: 3/21/12 Class: Med Surg Diagnoses: Impaired skin integrity Diet: NPO Allergies: None
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Geriatric Teaching Plan Bryant and Stratton College Nursing 222 Geriatrics Geriatric Teaching Plan Mr. R.D. is an eighty-year-old male. He currently resides at the Manor Care Rehabilitation/Nursing Center. Mr. D was admitted on January 5‚ 2010 for pneumonia. Mr. D has other medical history problems‚ which include leukocytosis‚ headache‚ hypertension‚ depressions‚ postural insufficiencies‚ arteriosclerotic heart disease and dementia Parkinson’s. Mr. D does not currently have any food or drug
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Hospice Care Plan Walden University Hospice Care Plan Mrs. Thomas has a history of breast cancer and is status post bilateral mastectomies with subsequent radiation and chemotherapy treatments. She has recently been diagnosed with lung metastasis and further treatment is not recommended by her physician and due to a poor prognosis he is recommending palliative care. Mrs. Thomas has been spending most of her days in her bed crying. She has had very little contact with her sons and
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LO 4.1 Confidentiality is about respecting people’s rights to a private life. In a childcare setting‚ certain information is required from parents (or carers) about themselves and their children‚ like telephone numbers‚ address and child health information. It is important that this information is kept securely and only accessed by the relevant people. This kind of information is called ‘confidential’. Sometimes parents‚ carers or children will give us information that is of a personal nature
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