Nursing care plan
Content
ASSESSMENT
DATA COLLECTION
NURSING DIAGNOSIS
SCD COLLABORATIVE PROBLEM GOAL/OBJECTIVES
PLANNING
NURSING ORDERS RATIONAL FOR NURSING ORDERS 1.1 decreasing pain in early stages decreases the length one experiences pain and provides for overall well being (Kozier&Erb, 1994) Providing comfort measures is reassuring to clients and decreases anxiety and pain (Kozier&Erb, 1994)
IMPLEMENTATON
METHODS OF NRSG ASSISTANCE
EVALUATION
GOAL MET, NOT MET PARTIALLY MET
1.1 SUBJECTIVE: Dx. hypertension and angina 4 yrs. ago. Complies with medical regime for hypertension and angina Non-smoker/drinker Hip replacement 3 yrs. ago with occ. joint stiffness ³Family anxious about hospitalization SOB, chest pain, dec. energy for ADLs OBJECTIVE: Walks with limp BP 130/80 P 72 R 18 (Vital signs within normal limits) PRIORITY # #1. Alteration in comfort related to chest pain as manifested by client complaint Rationale: GOAL(S): 1. Client will experience increased comfort and relief from pain in 4 hours. 2. Client will increase activity tolerance by date of discharge (6/10/94_. 3. Client will decrease potential for injury by moving in and out of bed and ambulating without falling or injuring self. (Need to write objectives to meet goals.) 1.2 1.3 2.1
#2. Activity intolerance related to AMB as manifested by lack of energy decreased strength of cardiac contraction. Rationale: Shortness of breath ambulating. #3. Potential for injury (trauma) related to joint stiffness and limp from replacement surgery.
2.2
3.1
Assess client for pain q 4 h. Turn and change position q 2 h. Offer pain med. if ordered. Collaborate with PT and TR as to activity level per day. Assist pt. to ambulate until experience tiredness /sob. Teach pt. safety precautions by using handrails and walker.
1.2
DATA COLLECTION
NURSING DIAGNOSIS
SCD COLLABORATIVE PROBLEM GOAL/OBJECTIVES
PLANNING
NURSING ORDERS RATIONAL FOR NURSING ORDERS 1.1 decreasing pain in early stages decreases the length one experiences pain and provides for overall well being (Kozier&Erb, 1994) Providing comfort measures is reassuring to clients and decreases anxiety and pain (Kozier&Erb, 1994)
IMPLEMENTATON
METHODS OF NRSG ASSISTANCE
EVALUATION
GOAL MET, NOT MET PARTIALLY MET
1.1 SUBJECTIVE: Dx. hypertension and angina 4 yrs. ago. Complies with medical regime for hypertension and angina Non-smoker/drinker Hip replacement 3 yrs. ago with occ. joint stiffness ³Family anxious about hospitalization SOB, chest pain, dec. energy for ADLs OBJECTIVE: Walks with limp BP 130/80 P 72 R 18 (Vital signs within normal limits) PRIORITY # #1. Alteration in comfort related to chest pain as manifested by client complaint Rationale: GOAL(S): 1. Client will experience increased comfort and relief from pain in 4 hours. 2. Client will increase activity tolerance by date of discharge (6/10/94_. 3. Client will decrease potential for injury by moving in and out of bed and ambulating without falling or injuring self. (Need to write objectives to meet goals.) 1.2 1.3 2.1
#2. Activity intolerance related to AMB as manifested by lack of energy decreased strength of cardiac contraction. Rationale: Shortness of breath ambulating. #3. Potential for injury (trauma) related to joint stiffness and limp from replacement surgery.
2.2
3.1
Assess client for pain q 4 h. Turn and change position q 2 h. Offer pain med. if ordered. Collaborate with PT and TR as to activity level per day. Assist pt. to ambulate until experience tiredness /sob. Teach pt. safety precautions by using handrails and walker.
1.2
