After reviewing the information that was gathered, I have come up with these two Nursing Diagnosis: 1. Impaired Gas Exchange r/t ventilation- perfusion imbalance AEB ( havent met pt. yet) Assess: assess oxygen saturation Outcome: the patient will demonstrate improved ventilation and adequate oxygenation with oxygen saturation monitoring during PCS. Intervention: the nurse will keep the patients head of bed elevated to forty five degrees at all times. Intervention: the nurse will administer
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PAST MEDICAL/SURGICAL HISTORY: Patient has a history of a myocardial infarction (MI, or also known as a heart attack) in 2004, she had a hip pinning in 2005, and a traumatic amputation of fingers on her left hand in 1974 from a lawnmower accident. Pt lived on her own until 4-27-12 when her family found her lying on the floor in her home. Pts family brought her to live with them but pt continued to have episodes of falling and hitting her head. Pt was taken to the ER and given a Ct
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Name of Patient : R.T. Diagnosis: Congestive Heart Failure secondary to CAD, HCVD Age: 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
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Nursing Assessment & Diagnosis | Planning & patient centered goals | Nursing Interventions | Scientific Rationale | Evaluation | 1) Diagnosis: Excess fluid volume r/t decreased urinary output Assessment: B.K is an 88 year-old female presented with acute renal failure with urinary retention. Patient was admitted into Lehigh Regional on July 5th, 2013.Previous history: Diabetes, HTN, UTI, skin cancer, TIA. Subjective: Patient states, “I feel a bit fatigued in the evenings. My doctor said
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Subjective: Thready, weak, rapid pulse rate Hypotension Flat neck veins Normal or low central venous pressure. Generalized skeletal muscle weakness that is worse in extremities Diminished deep tendon reflexes Objective: The only thing that was observed when I did a patient assessment was that she was confused, had a few misperceptions about what was going on with her family and their world, however she was not alert enough to give me anything objective in nature. | #1)Risk for electrolyte imbalance
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E Nursing Care Plan Roper, Logan and Tierney Model of Nursing Originally designed for the model of care, more nurses are aware of the Roper in 1976, has been updated and added to 1981.1980 and 1983 Roper, Logan and Tierney (Tierney and Roper, 2000). This form was used in a wide range of care settings. The model identifies 12 nursing activities of daily life that are related to basic human needs. They argue a “safe environment, communicating, breathing, eating and drinking, eliminating, personal
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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
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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
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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
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Assessment tools are useful for nursing care as they can act as a guideline while trying to assess patients. Finding the right assessment tool to match the nursing care going to be given is important. All assessment tools may not match the type of care going to be given. It is important to evaluate the assessment tool not only to match the care, but also to make sure the tool is thorough and useful. The three assessment tools discussed in this essay are an admission assessment by Pamela Craig, a
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