Nursing 300/301 Nursing Care Plan – Assessments ...



Nursing 300/301 Nursing Care Plan – Nursing Diagnoses with Supporting Evidence

|Name: |Name: |Name: |Name: |

|Nursing Diagnosis |Evidence |Nursing Diagnosis |Evidence |Nursing Diagnosis |Evidence |Nursing Diagnosis |Evidence |

|1)Acute pain related to|-suffered extensive |2) Ineffective coping |- 26 years old –single |3)Impaired Tissue |-Non compliance to the hospital|4)Decreased Mobility |- Acute pain |

|extensive frostbite on |frost bite to hands, |related to Generalized |-Change in normal routine|integrity related to |food diet (proper nutrition |related to below the |- amputations (bilateral below knee |

|back, legs, arms & |back, legs |anxiety, Panic attacks |-> out of own environment|extensive frost bite on |needed for wound healing please|knee amputation and |and Rt ( all 5 digits) & Lt (5th |

|below the knee |- underwent bilateral |and self reports of |-Lost of independence |back, hands, and feet & |see links) |size of the client |digit) |

|amputation |below the knee |feeling overwhelmed by |-Financial strains |below the knee amputation|-Large open wound on back due |(188 kg) |- bedridden |

| |amputation |the current situation. |- Non complaint to the |& rhabdomyolysis |to frost bite & rhabdomyolysis.| |necrotic tissue (buttocks & back) |

| |-underwent ileostomy | |hospital food regime | |Wound debridement on legs, arms| |- morbidly obese |

| |-self reports of pain | |(wants junk food) | |& back | |- reported decreased tissue |

| |particularly before | |- non interested in his | |-Large male 188kg affects | |perfusion |

| |dressing changes & | |own care | |tissue healing | |- isolated |

| |debridement | |- depressive talk | |--application of flagyl and | |- medications side effects |

| |-use of PRN morphine | |- 4 amputees | |normal saline for daily | |Metoprolol (dizziness, fatigue, |

| |frequently throughout | |(bilateral below the | |dressing changes | |decrease BP) |

| |the day. | |knee, 5 digits of right | |-ileostomy on abdomen. | |Piperacillin/tazobactam (lethargy, |

| |-reported to have an | |hand, 1 digit on left | | | |nausea) |

| |increase pulse rate 118 | |hand) | | | |Morphine (sedation, drowsiness, |

| |& increased blood | |- isolation | | | |confusion) |

| |pressure 145/90 | |- acute pain | | | |-PT wants an aggressive ROM due to |

| |-patient having some | |managed with Morphine | | | |bed ridden. |

| |slight problems sleeping| |- needs help with ADLs | | | |- unavailability of the beriatric |

| |at night due to pain | |-Refused spiritual care | | | |lifting equipment |

| | | |worker | | | |- In crease of stuff for care ( needs|

| | | | | | | |6 people to move in bed) |

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| |Client receiving | | | | | | |

| |nutritional advice from | | | | | | |

| |the local dietician | | | | | | |

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| |Learning to resist | | | | | | |

| |chips, pop from mother. | | | | | | |

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| |Trying to develop a meal| | | | | | |

| |plan with dietician. | | | | | | |

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|5) readiness for |Low albumin levels | | | | | | |

|enhanced nutritional | | | | | | | |

|requirements related to| | | | | | | |

|clients willingness to | | | | | | | |

|learn new nutritional | | | | | | | |

|regimen. | | | | | | | |

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* Number each Dx and place the diagnosis number beside each assessment parameter, intervention and evaluation criteria that corresponds to it

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