Patient Assessment Data collection sheet PDF

Preview

Summary

Mock Mini Care Plan for nursing with references ...

Description

Patient Assessment/ Data Collection Sheet

Behaviors

Non- Observ Observabl able e (Objec (Subjectiv tive) e)

Cultural Factors

Nursing Diagnosis NANDA List 3 in priority order Check one you will address Activity Intolerance as evidenced by essential HTN

Nursing Interventions and Rationales (Best EvidenceBased Rationales with references) Imposed Activity Restrlction. Sedentary Lifestyle. (Vera, 2017)

Evaluation of (Impact) Patient Goals/ Outcomes

The patient will increase tolerance to ADL’s as the the activity restrictions Powerlessness decrease. The as evidenced by The patient patient can patient stating needs to feel they feel control of their reach these goals as they helpless due to situation by diabetic ulcer verbalizing how keep Dr. appointments, because they they are in have to use the control of their maintain medication wheelchair life. How they an manage the regimen and At Risk for time they have add exercise. Infection left in their life. (Registered Nurse, RN, 2015) The patient will Language: Patient Care Goals/ Teach and feel more in English Outcomes Short promote hand control of their and Long Term hygeine. (Include Teach patient to life through Race/Ethni Timeframes) verbalization of observe for city: infection, fever, things they can African Activity control in their redness, American Intolerance life. This can be swelling, pain. evaluated my Religion: Short Term: Patient BP Administer will remain with in subjective data antibiotics as Seventh normal limits until and objective appropriate. Day discharge in 3 days data. Adventist Long Term: Patient will (Vera, 2019)

Patient Patie states nt that he was smili feels fine. He ng has no when pain. He spea king. is eating He well and was is ready alert and to be dischar orien ged in a ted. Marital status: He few

be able to walk 3 times a week for 20 min in 3 months

Patient can learn effective

days.

has Single. appro Engaged. priat e affect . He was clean and pleas ant.

Powerlessness

Short Term: Patient will be able to verbalize 4 things that they can do to manage their care Long Term: Patient will verbalize satisfaction about control he has over his life in 3 months

hygeine methods and understand signs and symptoms of infection to stay free of infection.

At Risk for infection Short Term: Patient will be infection free by discharge in 3 days. Long Term: Ulcer will close completely in 3 months

References: “Nursing Care Plan and Diagnosis for Powerlessness.” Registered Nurse RN, 11 June 2015, https://www.registerednursern.com/nursing-careplan-and-diagnosis-for-powerlessness/.

Vera, Matt, and Matt Vera. “Activity Intolerance – Nursing Diagnosis & Care Plan.” Nurseslabs, 23 Sept. 2017, https://nurseslabs.com/activityintolerance/. Vera, Matt, and Matt Vera. “Diabetes Mellitus Nursing Care Plans: 13 Nursing Diagnosis - Nurseslabs - Page 3.” Nurseslabs, 3 Dec. 2019, https://nurseslabs.com/diabetes-mellitus-nursing-care-plans/3/....