NURSING CARE PLANING

Name of patien :.............. Patient’s Healt Profile :........ .........

Age :............. Sex :..................
Occupation :.................. Religion:............
Date of Admissions :...........,...
Complaints :...................... Impression :.........................

Assessment Nurs. Diagnosis Objective Orders rationale Implementation evaluation

Subjective : Knowledge (1) The pt will be 1). Nursing 1). Provides a Nursing student will determine 1) Pt stated she
Pt states that deficit related able to verbally student will stepping- stone to pt current knowledge base understood surgical
the Dr. surgical express her determine pt pieces of having patient state current procedure.
Needed to procedure. understanding of current information that kmowledge regarding surgical However, was not
clean every surgical knowledge base may be incorrect procedure. able to express a
thing up when Extrapersonal: procedure on having patient or lacking. “ complete
ask why she Knowledge 3/08/00 state current clinical understanding of
had the deficit related kmowledge applications of 1) Monitoring patient for surgical procedure.
surgical surgical (2) The pt will regarding surgical nursing diagnosis, fatigue, Achieve 50% goal
procedure procedure verbally express procedure. Cox pg 442 one, continue with
performed on preformed is why surgical 2) Providing patient with quiet, goal and reevalute
3/04/00. developmental. procedure was 1) fatigue well-lighted, temperature- on 3/8/00
Pt states that Related to needed on 1) Monitor pt for interferes with controlle, teaching 1) Pt exhibits no signs
she is not sure environmental 3/08/00. fatigue, concentration, environment during of fatigue during
what the Dr. factors that which decreases teachings sessions . teaching session,
Did during the hinder the pt 2) Provide pt learning. “clinical nor did she express
procedure or learning with quiet, aplication of 2) Teaching only absolutely that she was tried.
what environment. ( well-lighted, nursing diagnosis, relevant information first 100% of
procedure abdominal temperature- cox pg 442” intervention met.
was pain, urgency controlle, 2) Pt verbally
performed of surgical teaching 2) Limits expressed an
 procedure) environment distraction. “ understanding of
Objective : during clinical why surgical
Pt is 81 year teachings application of procedure was
old. The time sessions . nursing performed. Pt
between the diagnosis, Cox expressed
ER visit and 2) Teach only pg 440 knowlodge what an
the surgical absolutely 2) Pt will ishcemic bowel is in
procedure relevant remember laymen terms.
was least then information initial Achieved 75% of
24hr. The pt first information goal two, continue
was in more than with goal and
tremendous subsequent reevalute on
pain. While information. 3/08/00.
the pt was Avoids 2) Pt indicated that
informed on overwhelming there was no
the procedure patient with environmental
her age, pain information. distraction. 100%
and time “clinical of intervention met
between application of
admit and nursing
surgery may diagnosis, Cox
have made it pg 440
diffculty for
the pt to
remember the
information
provide to
her. Pt is A&O
Times 3. Pt
exhibits no
signs of short-
term memory
loss.