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NURSING DIAGNOSIS NANDA diagnosis? Related factors noted? Evidence if an "actual" problem? NURSING INTERVENTIONS Note Frequency. 3 ACTION based interventions.
NURSING DIAGNOSIS NANDA diagnosis? Related factors noted? Evidence if an "actual" problem? NURSING INTERVENTIONS Note Frequency. 3 ACTION based interventions.
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NURSING DIAGNOSIS NANDA diagnosis? Related factors noted? Evidence if an "actual" problem? NURSING INTERVENTIONS Note Frequency. 3 ACTION based interventions.
Copyright:
Attribution Non-Commercial (BY-NC)
Formati disponibili
Scarica in formato DOC, PDF, TXT o leggi online su Scribd
Childbearing/Childrearing ASSESSMENTS NURSING DIAGNOSIS NURSING INTERVENTIONS EVIDENCE SUPORTING IMPLEMENTATION EVALUATION (Subjective/Objective Data NANDA diagnosis? Related Note Frequency. PRACTICE (Rationale) Explain how interventions State outcome pertinent to this nursing factors noted? Evidence if an (Cite source: Author & Page #) were met or not met (and achievement in diagnosis) “actual” problem? *3 ACTION based interventions List full reference separately. why) Behavioral terms. Note: Continue Change (specify), Discontinue POC 1) Maintain 1) After 48hrs 1) Intervention A) Goal met Subjective: Risk for infection r/t C- temperature less temperature > 99.8 met pt. continue section incision and than or equal to suggest fever r/t temperature POC. “It’s kind of red on the inadequate secondary 98.7 incision site (Ricci remained B) Goal met outside of my cut.” defenses i.e.) decreased 2) Teach the patient & Kyle, pg. 487). under 98.7. continue H&H the importance of 2) Family members or 2) Met. Patient POC. “My staples are sticking together with burning avoiding contact visitors can spread understands C) Goal met drainage.” with those who are infections through that good continue OUTCOME STATEMENTS infected or have cold or cough. hand POC. Measurable? Realistic? Time “No severe pain but still element noted? Pertinent to colds. (Ricci & Kyle, pg. hygiene and sore.” diagnosis? 3) Teach patient to 487). the threat GOAL & Objectives TCDB. 3) Encourage TCDB to infected avoid retaining people have Objective: Pt. will remain free of secretions, on her. 23 year old Female infection by 10/26 by 1-9pm infections, 3) Met. Patient BP: 116/70 clinical shift a.e.b. aspirations and carried out P:82 pneumonia (Pan, instructions Repeat C-section A) Normal VS & BP: pg.424). TCDB and Redness outside of incision less than or equal to educated Staples sticking to other 125/85. why this staples with drainage B) Absence of purulent procedure is H&H: 8.8, 26.9% drainage or done post- erythema from op. incision q 8hrs throughout hospital stay. C) Identify interventions to prevent risk for infection.