... Post incision and drainage Cues | Diagnosis | Inference | Plan of care | Nursing Interventions | Rationale | Evaluation | Subjective:“ sakit sugat ko dito ma” as verbalized by the patientObjective: * Localized erythema and edema * (+) pruritus on the site of the incision. * (+) Facial grimace * (+)Irritability * (+) Guarding behavior * (+) Crying * (+) VS normal T= 36.8 ‘ c PR= 77 RR= 25 * Pain assessment>Location: Right post auricular area>Interval: frequent | Acute pain related to tissue trauma secondary to incision and drainage as manifested by * Localized erythema and edema * Pruritus on the site of the incision * Facial grimace * Irritability * Crying * Guarding behavior * Frequent interval of pain | Nociceptive stimuli(wound/inflammation)↓Nerve fibers (nociceptor) ↓ ↓A-delta fiber C-fiber (fast) (slow) ↓ ↓ Spinal cord & Dorsal horn pain modulating circuit (primary touch fiber) Neospino- Paleospino- thalamic thalamic tract (sharp, tract (dull,bright pain) aching pain) Substantia Gelatinosa (synapse) Thalamus (center of awareness of pain) Cerebral Cortex (center of interpretation) Responses | After 6 hours of nursing interventions, the pain will be...
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...November 17, 2012 ASSESSMENT | DIAGNOSIS | SCIENTIFIC EXPLANATION | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:“hindi na siya makaramdam masyado sa kanan na bahagi ng katawan niya,” as verbalized by the SOindi naObjective: * response to stimuli: * pressure (-) * tickling (-) * pain (-) * on right side of the body * patient responds to normal tone and volume of voice but does not respond to whisper on both ears * trigeminal nerve assessment (sensory) * patient was unable to feel wisp of cotton when touched on face * decreased attention span * motor incoordination | Disturbed sensory perception related to altered sensory reception, transmission or integration secondary to injury on the temporal and parietal lobe(left hemisphere) | Chronic hypertensionorArteriovenous malformations↓Rupture of diseased blood vessel↓Formation of hematoma↓Increased pressure within the brain↓Disturbance of normal brain anatomy↓Affectation of the somatosensory area in the temporal and parietal lobe of the brain↓Disturbed sensory perception | Short Term:Within the course of therapeutic regimen, the client will be able to demonstrate techniques to compensate for altered sensory perception as evidenced by: * Turning head to see people or things * Following persons or objects by moving eyes * Scanning the room for persons or objectsLong term:With continuous therapeutic regimen, the client should be able to: * Compensate for the sensory impairments * Improve...
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...Nursing Theory Plan of Care Fintan O’Connell NUR/513 May 23, 2012 Francine McDonald Care Plan for Ronald Issler |Nursing Process |Data and Relevant Information | |1. Breathe normally |Complains of shortness of breath, oxygen saturation 88% on room air, | | |heart rate 58, chest x-ray with bilateral lower lobe infiltrates, | | |history of DVT. | |2. Eat and drink adequately |Height 6 ft., weight 147 pounds. BMI 19.7 (lower range of normal). | | |History of congestive heart failure, takes diuretic. Hemoglobin and | | |hematocrit levels low (HGB 10.4 gm/dl, HCT 29.6%) | |3. Elimination of body wastes |History of congestive heart failure (as noted above), elevated | | |creatinine level of 2.0 mg/dl | |4. Move and maintain posture |Increasing weakness...
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...Running head: NURSING CARE PLAN II Nursing Care Plan II Maria Milazzo Cochise College Nursing 123 April 16, 2010 Maxine Parmley RN, MSN Nursing Care Plan II Setting and Demographics My scheduled clinical rotation at Life Care Center began on April 8th. Mrs. X, a long-term resident, was the patient I had chosen. I had conducted several patient interviews and she appeared to be an interesting patient. After passing out the morning medicines to the resident’s, I made my way down the hall to Mrs. X’s room. When I arrived to Mrs. X’s room she was quietly sleeping in her bed with a book titled the “Autobiography of Hilary Clinton” on her stomach. I knocked on the door and proceeded to greet her and introduce myself, she sat up, smiled, and said she loved visitors. I explained my school assignment to Mrs. X , and requested permission, and perform a physical assessment she stated, “ it was quite alright.” She is a hispanic ninety one year old woman, approximately five feet five inches tall, and weighs 98 pounds; she has been a resident of Life care for eight months. Her current diagnoses included a closed ulnar fracture with rehabilitation, atrial fibrillation, and coronary artery disease. Her secondary diagnoses are hypothyroidism, depressive disorder, hypertension, esophageal reflux, generalized pain, and chest pain. Functional Health Patterns Health Perception-Health Management: Subjective: Patient stated her general health has been declining recently, with three...
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...Running Head: NEWBORN ASSESSMENT AND CARE PLAN Newborn Assessment and Care Plan Newborn Assessment On 1/29/09, at 0610, 39 week gestational age, 7lb 4.6oz, black male was born to 18 year old mother. Infant born via vaginal delivery with assistance of vacuum extraction, nuchal cord x1 noted. Mother received adequate prenatal care beginning at 8weeks. Prenatal medications included Iron supplements and prenatal vitamins. Prenatal complication included pregnancy induced hypertension. Onset of labor 0647, full dilation 1705, and delivery of infant at 1810. Apgar scores 6/8.Weight 3305gms, length 20 inches, head circumference 12 inches, chest circumference 12 ¾ inches, abdominal girth 12 inches. The infant is alert and active. Anterior fontanel is soft and flat. No oral lesions. Head caput/ molding, elongated with edema, abrasion noted from suction. Color is pink and changing all over (African American.) Skin is warm, dry, and well perfused. No rashes, vesicles, or other lesions noted. Birthmark present on forehead approximately 2cm. Bilirubin test ordered. Lanugo present. Hair pattern is scattered evenly all over, fine texture and moderate amount. Eyes symmetrical and in midline. No discharge present from eyes. Eyes move from left to right and sclera is white. Eyebrows are fine and symmetrical. Nose is patent and midline. Ears present symmetrically. Mouth midline. Gums and tongue pink and moist. Cheeks symmetrical with no lesions. Saliva present. Chin well aligned on face...
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...Nursing for Health and Wellbeing 2012 Patient Name: Jake Anderson Student Name: Linda Nguyen Student Number: 17532189 Nursing Issue: Development, risk of delayed due to poor nutrition and inefficient social interaction as evidence by Jake’s limited speech and often refuses to eat lunch. Goal/s: To promote a healthy nutritional intake and increase social interactions to prevent delayed physical and psychological development. INTERVENTION | RATIONALES FOR INTERVENTIONS | 1. Full health assessment. (Crisp & Taylor, 2010). 2. Assess ADL’s. (Holland, Jenkins, Solomon & Whittam, 2009). 3. Assess activity level. (Holland, Jenkins, Solomon & Whittam, 2009). 4. Refer to Occupational Therapist. (Crisp & Taylor, 2010). 5. Refer to dietician. (Crisp & Taylor, 2010) 6. Refer to motherless mother social group located in Blacktown. (Crisp & Taylor, 2010). 7. Provide strategies for Sally to read to Jake. (Crisp & Taylor, 2010). 8. Provide strategies for Sally to assess safety in her own home. (Crisp & Taylor, 2010). 9. Teach Sally the importance of listening attentively. (Holland, Jenkins, Solomon & Whittam, 2009). | 1. A full health assessment is required to assess the degree of malnourishment in Jake and to obtain a full and complete picture of his current health status, based on the height and weight that has been examined. This will aid in developing strategies which will assist Sally in promoting Jakes...
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...Implement and monitor nursing care for clients with acute health problems. Contribute to complex nursing care of clients. Administer and monitor medications. Administer and monitor IV meds. Assessment 2 Post-op Case Study Assessment 2 Question 1. Identify a minimum of 5 nursing actions, in order of priority you would perform related to above information. Mrs Abu has had a considerable change in her vital signs (blood pressure lowered, her pulse is rapid, her respirations increased and temperature has dropped) form the baseline taken before surgery. These findings alone would be reported to the Registered Nurse and monitored. But because of the changes in vital sings, coupled with Mrs Abu reporting light-headedness and nausea, plus her significant blood loss form the surgical wound, you would be assessing for hypovolemic shock which can be life threatening. As the nurse you would be seeking assistance immediately, assessing her airway, breathing and circulation. Applying oxygen, applying pressure at the surgical site and continuing to monitor (airway, breathing, circulation) and vital signs until help arrives. Mrs Abu should be given nil by mouth as she may return to surgery (Gulanick, Myers, Klopp, Galanes, Gandishar & Puzas 2003, p.329). Question 2. Complete the interventions and rationale in Mrs Abu's care plan related to the following diagnosis |Nursing Diagnosis |Interventions |Rationale ...
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...61 years old Chief Complaint: Cough, Difficulty of Breathing Sex: Male Attending Physician: A.T. Status: Married Nursing Care Plan General Objective: Facilitate the maintenance of a supply of oxygen to all body cells. |Cues |Nursing Diagnosis |Rationale |Specific Objective |Interventions |Rationale |Evaluation | | | | | | | | | |Subjective Cues: |Ineffective Breathing |Inspiration and/or expiration |After 2 days of rendering |Independent: | |Goal partially met. | |“Daw ginahapo ko.” |Pattern related to decreased|that does not provide adequate |nursing care the patient will| | | | |“May tiyempo nga gahugot dughan |lung expansion secondary to |ventilation. |demonstrate improved |1.Monitor vital signs and |1.To establish baseline data. |After 2 days of nursing care | |ko.” |Pleural Effusion | |breathing pattern as |cardiac...
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...Nursing Theory Plan of Care Nursing Theory Plan of Care Transforming nursing research evidence into practice and policy is essential for the provision of quality care. Research utilization is defined as “the systematic process of transferring research knowledge into practice for the purpose of understanding, validating, enhancing, or changing practice” and has a potential to influence attitudes, beliefs, and behaviors of healthcare providers and recipients, alike (Matthew-Maich, Ploeg, Jack, & Dobbins, 2010). Most practical nursing disciplines create mechanisms of research utilization that, according to MacGuire (2006), can “clearly explicate the essential nature, meanings and components of nursing so that nurse clinicians can use this knowledge in a deliberate and meaningful way.” There are some difficulties with the process of transforming research findings into practice. Nurses may not know about the research finding, or they may find the changes to be disruptive and resist implementing them. They may not have the appropriate training or funding, or simply may not have the autonomy to apply the knowledge into their practice independently (MacGuire, 2006). When successfully implemented, research findings encourage nurses to make thoughtful and informed choices, to avoid automatic reactions based on old assumptions and practices, and to afford them ability to understand and critique research evidence in relation to their practice. Sometimes, a new idea could be rightfully...
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...Anoka Ramsey Community College Nursing 2482 Admitting Data Nursing Care Plan I Page 1 Room #: 1016 Patient Initials: ML Admit Date: 09/23/2010 Admitting Dx: Acute Congestive Heart Failure Age: 84 Sex: Female Marital Status: Married Surgery/Procedure: None Date of Surgery/Procedure: None POD/LOS (number): 6 Allergies: No known Drug Allergies Code Status: DNR Significant Hx: History of nerve damage to her esophagus, HTN, history of venous insufficiency, psoriasis, encounter of palliative care, Acute Renal failure, acute myocardial infarction. Post Surgical History: Hx. of cholecystectomy. Patient has been married for 64 yrs and currently resides in an apartment with her husband. Patient Story: She is an 84 yr old female who came to the ER on 9/23/10 complaining of SOB which she had been experiencing for approximately 4 days. She stated states she feels dyspnea both at rest and exertion. Feels better if she sits up. She has swelling on her legs, which she states is chronic and has been worse. Denies chest pain, but has had pain on her shoulder and back. She has a productive cough producing white phlegm. Appeared to be in CHF, admitted for evaluation. Lab tests done on 09/26/2010, CXR revealed that patient has CHF. She underwent a 2 D-ECHO which showed left ventricular cavity size at the upper limits of normal; moderately abnormal ventricular ejection fraction estimated...
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...Associate Degree Nurse versus the Baccalaureate Degree Nurses Nursing is one career that has spent decades establishing education requirements and advancements for those in the field to better the population of those licensed to improve patient care and nurse leadership. A registered nurse starts by becoming licensed after completing either a diploma nurse program, a two or three year associate degree program, or a four year baccalaureate program. Nurses may then advance farther into an advanced practice nurse by obtaining a master’s degree in nursing. When deciding on a nursing program, one must consider the difference between an associate degree nurse and a baccalaureate nurse. At the end of the program, all must sit for the same licensing examination known as the NCLEX. The NCLEX however is not valid proof that there are not differences between the degree levels as the test strictly tests for a minimum safe competency for entry into a basic nursing practice (AACN, 2012). It is believed by some that there is no difference between the clinical competencies between associate degree and baccalaureate degree nurses, however research have shown that baccalaureate degree nurses may be better prepared for different circumstances in a patient care setting. Associate degree nursing programs, also referred to as ADN programs emphasize their training on clinical skills rather than the theory component of nursing focusing less on critical thinking and leadership skills (Miller, 2007)...
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...Psych Nursing Care Plan Anxiety r/t perceived threat to physical being as evidenced by insomnia, lack of concentration, not eating, restlessness, pulse range of 118-182, verbalized feelings of worry/phone tapped/”ER tried to kill me”/”meds tried to kill me” Patient Outcome: Patient will return to 8 hr. nocturnal sleep pattern, eat 3 meals/day, verbalize feeling less worried, maintain focus, and maintain relaxed posture by discharge on 3/12/12. Interventions: -Assess patient’s level of anxiety by EOS 3/6/12. Rationale: Patient’s anxiety level can affect ADL’s, judgment, compliance, and overall safety. Patient response: Patient’s level of anxiety is severe. Not eating, calling mother excessively, verbalized many feelings of worry, driving up and down streets, crawled into bed with mother in the middle of the night. Patient stated “am I going to be in trouble?” as she is worried the cops will be after her. -Use simple language and brief statements when instructing patient about self-care measures, anxiety medications, and orienting to unit throughout admission. Rationale: Using simple words will not overwhelm the client or increase her anxiety. Patient response: Patient verbalized she understood the rules of the unit. -Administer Vistaril 50 mg PO QID for anxiety as ordered by physician. Rationale: Vistaril is an antihistamine used to reduce anxiety, as it slows the CNS. Patient response: Patient is worried medications will kill her, further teaching is necessary. -Teach...
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...The Nursing Process The nursing process is a very important tool that nurses have in to make sure that they give adequate care to all their patients. It helps them not only evaluate each patients’ needs individually but also allows the nurse to prioritize which patient’s needs are more important to attend to first. Just like doctors have a way of diagnosing patients, nurses also use this process to give their own form of diagnosis. The significance of having the nursing process is to have a set way in which each nurse gets a care plan for the patient. Every nurse is taught the way the nursing process go is to assess, diagnose, plan both outcomes and interventions, implement, and evaluate. By doing these steps a nurse can not only find out what is wrong with the patient over all by assessing but after the diagnosis has been found she can plan different nursing interventions to help with the problem. After the nurse has come up with nursing interventions then she would start implementing them and then evaluate to see how the patient is responding. The purpose of this is to make sure that the patient is taken care of at all times, because doctors cannot always be there overseeing the progress of a patient the nurse has to implement what interventions she can to help the patient get better. Also while taking care of multiple patients at a time this nursing process helps a nurse pinpoint who in a higher priority and needs to be seen first. The nursing process is a profession no...
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...practice. All patient deserve the best educated nursing staff. According to researchers there is an interesting correlation between BSN education and lower mortality rate. Research also shows us that there are less medication errors and greater positive outcomes for the patients. The Nurses holding BSN degree have shown that they have decreased the risk of patient’s death. This topic will focus on the differences between ADN and BSN nursing care, based on the example of treatment a patient receives from both types of nurses. Associate Nurse An Associate degree nurse is a nurse with 2 to 3 years nursing training. Graduate of this program is qualified to take the NCLEX to become a registered nurse. An Associate degree nurse has many roles such as teaching the patient about their conditions, assessing the patient’s condition, care plans, doctors’ orders, treatments, and medication. Some of the responsibilities that ADN nurses have are supervisory of the LVN, LPN, CNA, and other healthcare workers. ADN nurses thrive with more independence along with more complex situations with lots of ill patients. Baccalaureate Nurse A Baccalaureate Nurse is represented as a nurse with 4 to 5 years nursing training. Graduates of this programs are qualified to take the NCLEX exam to become a registered nurse. BSN nursing includes the role of assessing, communicating, teaching, leading, critical thinking, providing care, and strong communications between nurses, doctors...
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...Nowadays people around the world experience various mental health difficulties on a daily basis. From the mild symptoms that can be easily resolved by their General Practitioners to more severe problems significantly affecting their everyday functioning and participation in daily activities. These problems may need to be dealt with the referral to a specialist service. According to Mental Health Act (2001) each person in care of Mental Health Service must have an individual care plan (MHA 2001; art 15&16). Mental Health Commission in its document related to individual Care Planning in Mental Health Service outlined that recovery of a client needs to be at the centre of all that nurses do and care plans are here like a key tools, guiding nursing work in this process (MHC 2012, p.8). Presented essay attempts to explore how nursing care and interventions support the process of patient’s recovery. In further part of it focus will be on how individual care plans reflect process of recovery and how they guide nurses towards it. Concept of ‘recovery’ in Mental Health slightly differs from adopted definition. Usually a person with severe mental health problems such as Schizophrenia or Bi-polar cannot fully recover from the illness like it takes place in most of the patients with physical illnesses. The concept of recovery in Mental Health addresses issues related to building-up self-esteem, learning to control the illness; recognizing symptoms of relapse; returning to normal...
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