Acute painrelated to decreased myocardial flow as evidenced by grimacing, expression ofpain, guarding behavior. Risk Nursing Diagnosis The second type of nursing diagnosis is calledrisk nursing diagnosis.These areclinical judgmentfor a problem does not exist, but the presence of risk factors indicates...
Assessment and management of the nursing diagnosis of acute pain are the main focus of this care plan.Causes of PainHere are the common causes and related factors for patients with Acute Pain:Tissue Damage. Surgical incisions, injuries, fractures, burns. Inflammation. Conditions like appendicitis ...
4. Prepare the patient for possible blood transfusions. Patients with Crohn’s disease are at risk of developing bloody stools, intestinal bleeding, and anemia and may need a blood transfusion to support perfusion and hemodynamic stability.
Actions, Rationales, and Documentation for Selected Nursing Diagnoses Activity Intolerance Airway Clearance, Ineffective Anxiety Aspiration, Risk for Breathing Pattern, Ineffective Cardiac Output, Decreased Constipation Coping, Ineffective Individual Diarrhea Deficient Fluid Volume Fluid Volume, Excess Gas Exchange...
Practice answering NCLEX test questions on a computer. Time yourself if you need to. Score your results. Know the rationales in every test item and review the areas or topics where you are weak. OCULAR SURVEY Visit your test site the day before you take your NCLEX-RN examination. Be famili...
25. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering ...
Nursing Interventions and Rationales Assess and monitor cardiac and respiratory status; perform 12-lead EKG to rule out cardiac involvement Shifts in fluid balance and electrolytes may cause arrhythmias and difficulty breathing. Monitor fluid and electrolyte balance; I & O, fluid restrictions as necessar...
complete DATA ASSESSMENT with all pertinent data and interpretation of data completed. Based on the data‚ formulate an individualizedcareplan using (1) priority NANDA diagnosis and (2) secondary NANDA diagnoses. Each diagnosis requires at least (5) interventions‚ (5) rationales and (5) ...
muscle spasms secondary to surgery as evidenced by vomiting AssessmentNursingdiagnosis Goals & expected outcomeNursinginterventions Rationales Method of evaluation Subjective data: 1. Patient reported of abdominal pain. 2. Elevated scoring of 8/10 of pain score Objective data: 1. Restlessness 2. ...
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation ...