...NURSING CARE PLAN ASSESSMENT Subjective: “Hindi ko alam ang gagawin sa sugat ko” as verbalized by the patient. Objective: • Statement of misinterpretati on. Request for information. V/S taken as follows: T: 37.3 P: 80 R: 19 BP: 120/80 DIAGNOSIS • Knowledge deficient regarding condition and self care related to information misinterpre tation. • INFERENCE Cholecystect omy is the surgical removal of the gallbladder, a small pearshaped sac that is located directly beneath the liver in the upper right side of the abdomen. The gallbladder's main function is to store bile, which is produced by the liver, and to release it as needed for digestion. The gallbladder's function is important, but it is not • PLANNING After 8 hours of nursing interventions the patient will verbalize understanding of therapeutic needs. INTERVENTION Independent: • Review disease process, surgical procedure or prognosis. • • RATIONALE Provides knowledge base on which patient can make informed choices. Promotes independence in care and reduces risk of complications. During initial 6 months after surgery, low fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats. Minimizes the risk of pancreatic involvement. Intestines require time to adjust to stimulus of continuous output of bile. Indicators of obstruction of bile flow or altered digestion, EVALUATION • After 8 hours of nursing intervention s the patient was able verbalize understandi ng of...
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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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...upper arms. P.R. is able to move his shoulders to slightly lift his arms, but has no movements in his legs or the trunk. P.R. requires total assistance for all activities of daily living, and is incontinent of both bowel and bladder function. He speaks primarily Spanish and cannot communicate in English. He is verbally abusive and becomes combative with care givers. He does not have family support in America and is having difficulty adapting to American foods. P.R. has stage III ulcers on each of his buttocks, with various bruises on his lower forearms from trying to attack the faculty personnel. Both feet are starting to turn downward, indicating plantar flexion contractures. The purpose of this paper is to demonstrate the issues that are involved in nursing care, based on Maslow’s hierarchy of needs. This includes physiological, psychological, safety, and social concerns. An example of a complete nursing care plan will be provided for each category of needs identified in P.R’s case study. Patient Care Issues General Spinal cord injuries to an individual present with multiple areas of concerns to nursing care providers. Physiological issues are first addressed when the patient arrives in the emergency room to stabilize the patient according to the airway, breathing, and circulation. Then, spinal cord injury will lead to loss of motor function, urinary/bowel incontinence, sexual dysfunction, trouble breathing, and difficulty sitting upright (O’Sullivan and Schmitz...
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... 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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...Christopher Ervin Dr. Horne English 1010 06-14-2011 Nursing Care Nursing has taking a big step now. And it’s growth shows that the number of people that get the necessary medical assistance grows too. Nursing is closely connected to ambulatory care. The main purpose of the ambulatory care is to provide ways of giving five star medical help to outpatients. To provide professionals who can give special assistance to patients in areas related to their expertise. Their functions include addressing patient complaints, family concerns and working on different programs for the medical center in addition with providing on-call medical assistance to people. Ambulatory care starts at the moment the patient calls and gets a continuation in the hospital, where the patient continues getting medical assistance but on a regular base. Ambulatory care is an integral part of the work of medical establishments, because it is an express mean of communication between the nurse and the patient who is not well at home. There are millions of people who would have died without it. The effectiveness of the ambulatory care has grown a lot for the past 10 years. Another important fact is that there also has been noticed a growth of home care in USA. We consider home care to be a system of control in the first place over patients who always need medical nursing assistance and have no supervision. Home care agencies of various types have been providing high-quality, in home services to Americans...
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...history of Bipolar Affective Disorder and previous suicide attempts, resulting to numerous psychiatric admissions. She was on lithium for approximately 18 years, which now resulted for her thyroid to become toxic and her kidneys to completely stop functioning. She has been recently diagnosed of End Stage Renal Failure (ESRF). This recent diagnosis has left her more anxious and depressed. As her family and the Community Mental Health Team (CMHT) from the POA unit had worrying concerns regarding her increasing inability to cope at home and recent suicide attempt, they have decided to refer her to Golden Living Centre (GLC) for respite. GLC is a nursing home where I did my 8-week specialist placement. The CMHT from the POA unit visits Serena on a weekly basis ensuring continuity of care. The community mental health nurse (CMHN) comes in to the nursing...
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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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...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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...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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...varied levels of care. The levels of health promotion in nursing will be discussed and any differences therein. Also discussed will be the evolution of nursing roles and responsibilities. Health Promotion Defined In order to begin, the three levels of health promotion will be defined. The first level- Primary Prevention, are ‘methods to avoid the occurrence of disease’ (Wikipedia 2013). Primary care is what one would seek when an acute issue has occurred; for example, the development of flu symptoms, an infection or a broken bone. Primary care is also concerned with preventive medicine such as pediatric well baby visits. Secondary Prevention is ‘a method to diagnose and treat existent disease in early stages before it causes significant morbidity’ (Wikipedia 2013). Typically a primary care provider will refer the patient to a secondary care specialist; for example, an oncologist who is a doctor that specializes in cancer. The third level- Tertiary Prevention, are ‘methods to reduce negative impact of existent disease by restoring function and reducing disease-related complications’ (Wikipedia 2013). For a patient that has ended up in the hospital setting and requires a higher level of specialty care and use of specialty equipment; for example, coronary artery bypass surgery, dialysis or severe burn treatment. Discussion Health care providers may be doctors, nurse practitioners and physician assistants, but nurses are crucial members of the health care team as they are...
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...Q.1. Describe in detail the nursing care necessary to provide for the needs of the patient with a diagnosis of hypothermia during the first 24 hours of their hospital admission. [100Marks] Q.2. List at least four clinical signs of dehydration. (20 marks) Describe the care of a patient with an indwelling catheter. (80 marks) [100 Marks] Q.3. Mrs. Mary Smith is and 80 year old widowed lady who lives alone in an inner city terraced house. She has been admitted to hospital presenting with abdominal pain and distension. The home help who visits her for one hour per day has noticed that Mrs. Smith had reduced mobility and episodes of constipation the past number of weeks. Describe the nursing care Mrs Smith will require under the following: (a) Communication (30 marks) (b) Eating and drinking (40 marks) (c) Mobility (30 marks) [100 Marks] Q.4 Describe the role of the nurse in preventing cross-infection in the ward setting. [100 Marks] Q.5 Describe the role of the nurse in the assessment of a patient with a respiratory problem. Q.1. Describe the nursing care and management of a patient with hypothermia. [100 Marks] Q.2. Describe the assessment of a patient requiring mouth care on a daily basis. [100 Marks] Q.3. (a) Define the term ‘standard precautions’. (10 Marks) (b) Describe the principles of infection control. (90 Marks) [100 Marks] Q.4. (a) List 5 factors that may affect the accuracy of a blood pressure recording. (10 Marks) ...
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...Leading and Managing Nursing Care Introduction This assignment will examine and reflect upon a critical incident that occurred whilst on placement. The incident will be analysed using relevant management concepts and an action plan formulated, which will propose a change in practice. Minghella and Benson (1995) cited by Ghyae, T and Lillyman, S (1997) identifies that ‘critical incident analysis has been espoused as a valuable method of promoting reflective practice in nursing and it can be used as a tool in developing curriculum content’ (p770). The Reflective Cycle of Gibb’s (1988) (appendix 1) will be used as a framework to conduct this assignment. My reasoning for choosing Gibb’s can be explained by [anon] (2006) ‘Gibb’s reflective cycle is fairly straight forward and encourages a clear description of the situation, analysis of feelings, evaluation of the experience, and analysis to make sense of the experience’. The assignment will also be organised into sections based on the reflective cycle. Pseudonyms will be used to maintain anonymity and confidentiality in accordance with clause five of the NMC (2004). The critical incident which I have chosen is an inappropriate assessment and application of mouth care in a pre-operative patient. ‘Oral assessment is required in planning effective care, and that the incidence of oral complications was reduced by the frequency of care’ Ginsberg (1961) cited by Mallett, J and Dougherty, L (2000 p361). I have chosen...
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...Course objective 1: Use beginning critical thinking and clinical judgement when providing safe, quality nursing care This objective was evident when working with the unit’s RN. I was able to watch him drain a patient’s chest tube. The man has two chest tubes to drain fluid that accumulates in his lungs. The nurse had me take his vitals and it was shocking for me to discover that his respiratory rate was 44 breaths per minute. This patient was certainly far more complicated than others in long term care. I was able to compare the patient’s current condition both before and after draining his chest tube. The nurse drained 1000 CC of fluid and the patient lost nearly 2.5 from this. Additionally his respiratory rate went down and his breath sounds improved. This...
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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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...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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