...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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... 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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...Running head: Professional Development Plan Professional Development Plan Jeff S. University of Phoenix Course Number Nur/391 Mr. November 18, 20 Professional Development Introduction The field of nursing attracted me for several reasons. The first being, that a nurse is the frontline person caring for others living or dyeing. Nurses many times will discover patients who need immediate attention before physician will and it’s up to the nurse to respond accordingly within the scope of their practice to take care of that patient. That attracted me because years ago I thought of going to medical school after high school but lack of money prevented that, nursing was not introduced to me till later while attending a ACLS class at a local collage in which the instructor was a R.N., she thought I was a person whom would be good at nursing. I then searched and found out what nursing had to offer, which seemed to be along the lines of a M.D. but without the length of schooling and residency. I have been able to find a job in different areas of nursing and now working in a perioperative setting which presently meets my carrier goals. Working in an enviroment that has high technology and being self motivated, working with different disciplines and a 12 hour work days three days a week keeps me attracted. The philosophy of nursing goes beyond culture, religious beliefs, geographic location; it sometimes becomes a part of us and who we are. Though...
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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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...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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...Department Plan for Nursing Department As the Director of the Nursing Department at Riverview Hospital, I would like to present a department plan for the long term care facility that is currently being planned. This plan will discuss the staffing needs for the facility to ensure patients are receiving the best quality care, maintaining education and training of staff, and I will make my recommendations on policies that should be implemented. First and foremost the matter of staffing the facility with the mandatory amount of well qualified medical staff as required by the Federal and State governments is of utmost importance. Considering the size of our facility we shall no fewer than five direct care personnel, on duty during...
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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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...The beauty of nursing is that there are no limits to where you can go and no limits as to what you can do. The possibilities are endless. Post Graduation and Future Plans Immediately after graduating from nursing school, soon after passing the NCLEX exam and taking a mini vacation, I would like to begin my career as an active duty army nurse. I am currently in the Army Reserve; however, I am not in the ROTC program. Because I am not in the ROTC program, which may inevitably make becoming a nurse in the army more of a difficult task. If by some unfortunate chance I cannot become a nurse in the army, I would like to begin my career in critical care or the emergency department. However, my preference would be the emergency department. I think...
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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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...MY NURSING CAREER AND LIFE PLAN As written by Walter Mosely, “America now stand on a fiscal precipice and right now our money is worth less daily as our children’s potential is dwindling, our medical insurance, Social Security and ability to make choices about when and if we retire are eroding”. So I decided to become a nurse, to have health insurance, paid vacations, 401k pension plans and security of tenure. The need for a career that is not just a JOB, but a career that can make me financially stable (no more paycheck to paycheck), a career which will bring joy to both me and those I help nurture back to health. Even as a small child attending Elementary School, I had this vision of becoming a Nurse and working in as hospital assisting the sick and needy. Not just a nurse trying to make money, but also that nurse who shows caring and understanding for all patients young or old, rich or poor, and of course the one that would see beyond a patients color. Life doesn’t always take you in a single direction, so even though I have worked in numerous industries including the healthcare field, dreams got pushed aside as other interests were pursued. Today I can say that I have taken that first step; that giant leap to achieving that dream. Finally, I have registered and started classes which will lead to me graduating with an Associate of Science degree and ultimately becoming a Registered Nurse after 2 years of study and also being successful in the State Licensure...
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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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...Student: ____________________ Date: _3/25/12_____ Topic: Hourly Nursing Rounds to Improve HCAHPS Scores * Clearly state the proposed project (what do you plan to do): Implement hourly nursing rounds on the Progressive Care Unit at SPGH to improve patient satisfaction. Hourly nursing rounds have been shown in evidenced based practices to not only improve patient satisfaction but also help to reduce patient falls and reduce the occurrence of decubitus ulcers. Not only does hourly nursing rounds help the before mentioned items it also serves to reduce the call light usage by patients thereby increasing productivity for nurses (Culley, 2008). The proposed project includes education of the nursing staff on PCU to the initiation of hourly nursing rounds, including evidenced based research showing how regular rounds helps to improve patient satisfaction and safety. Described potential or real barriers and solutions (financial, political, social, etc) and methods that will or could be used to address these barriers: Some potential barriers could be reluctance by the nursing staff to participate in the hourly nursing rounds due to the feeling that they do not have enough time to complete these hourly rounds. By providing the unit with appropriate staff and helping to reduce or eliminate their fears by providing them with the research gathered can hopefully achieve this goal. Also by showing them that call light frequency will be lower when hourly rounds are...
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...Change Project Proposal To provide high-quality care, nurses must be the coordinator of the care and activities of the multidisciplinary team that is providing care for the patient. Clinical pathways and physician standing orders can be used as a guide for the team in managing stroke patients. They ensure that the appropriate diagnostic tests, therapies and care needs are being included in plan for a patient. Clinical pathways also improve coordination of acute stroke care and discharge planning, decrease hospital care costs, decrease readmission rates, reduce length of hospital stay, and improve patient outcomes by providing a guide to ensure best practice care guidelines are being followed (Summers et al, 2009). Currently, our hospital does not utilize nursing clinical guidelines for patients who suspected or actual stroke. I am proposing that our hospital implement the use of nursing clinical guidelines for the care of possible and actual stroke patients beginning in the Emergency Department and to other nursing units that provide care to stroke patients....
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