By Marilynn E. Doenges APRN BC-retired, Mary Frances Moorhouse RN MSN CRRN LNC, Alice C. Murr BSN RN-retired
Beth-El collage of Nursing and healthiness Sciences, Colorado Springs, CO. Pocket-sized define aids scholars and nurses picking out interventions more often than not linked to nursing diagnoses. contains an alphabetical directory of recent and revised nursing diagnoses in the course of the most recent NANDA convention. earlier variation: c2000. Softcover. DNLM: Nursing Diagnosis--Handbooks.
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Obtain wound tracing on adm and at discharge. Apply wet to dry sterile dressing. Use paper tape. Infection Control (NIC) Follow wound precautions. Obtain sterile specimen of wound drainage on admission. Administer dicloxacillin 500 mg PO q6h, starting 10 PM. , pruritus, urticaria, rash). Patient Situation and Prototype Plan of Care PLAN OF CARE FOR PATIENT WITH DIABETES MELLITUS RATIONALE Cleans wound without harming delicate tissues. Provides information about effectiveness of therapy and identifies additional needs.
A type 2 diabetic patient (non–insulin-dependent) for 5 years, presented to his physician’s office with a nonhealing ulcer of 3 weeks’ duration on his left foot. Screening studies done in the doctor’s office revealed blood glucose of 356/fingerstick and urine Chemstix of 2%. Because of distance from medical provider and lack of local community services, he is admitted to the hospital. ADMITTTING PHYSICIANS’S ORDERS Culture/sensitivity and Gram’s stain of foot ulcer Random blood glucose on admission and fingerstick BG qid CBC, electrolytes, serum lipid profile, glycosylated Hb in AM Chest x ray and ECG in AM Diabeta 10 mg, PO bid Glucophage 500 mg, PO qd to start—will increase gradually Humulin N 10 U SC q AM and hs.
A. A. Davis Company Sample Assessment Tool Check all that apply: Alert: _________ Drowsy: _________ Lethargic: ________ Stuporous: ______________ Comatose: ______________ Cooperative: _____________ Combative: _____________ Delusions: _____________ Hallucinations: ____________ Affect (describe): __________________________________ Memory: Recent: ______________ Remote: ______________ Glasses: _______ Contacts: _______ Hearing aids: _______ Pupil: Shape: ___________ Size/reaction: R/L: ___________ Facial droop: ______________ Swallowing: ______________ Handgrasp/release, R/L: _______________________________ Posturing: _________________________________________ Deep tendon reflexes: ____________ Paralysis: ____________ Pain/Discomfort SUBJECTIVE (REPORTS) Primary focus: ______________ Location: ______________ Intensity (0-10 with 10 = most severe): ________________ Frequency: _______________ Quality: _______________ Duration: _______________ Radiation: _______________ Precipitating/aggravating factors: _______________________ How relieved: _____________________________________ Associated symptoms: ________________________________ Effect on activities: __________________________________ Relationships: ____________________________________ Additional focus: ____________________________________ OBJECTIVE (EXHIBITS) Facial grimacing: ________ Guarding affected area: ________ Posturing: ________________ Behaviors: ________________ Emotional response: _________ Narrowed focus: _________ Change in BP: ________________ Pulse: ________________ Respiration SUBJCTIVE (REPORTS) Dyspnea/related to: __________________________________ Cough/sputum: _____________________________________ History of: Bronchitis: ____________ Asthma: ____________ Tuberculosis: _____________ Emphysema: ____________ Recurrent pneumonia: ______________________________ Exposure to noxious fumes: _________________________ Smoker: ________ pk/day: ________ No.