Pulse rate greater than 100 beats per minute
Blood pressure of 140/90
Respiratory rate greater than 20 breaths per minute
Frequent bowel sounds
36.3 degrees C
37.95 degrees C
40.03 degrees C
38.01 degrees C
Trial and error
Assessing, diagnosing, implementing, evaluating, planning
Diagnosing, assessing, planning, implementing, evaluating
Assessing, diagnosing, planning, implementing, evaluating
Planning, evaluating, diagnosing, assessing, implementing
Nursing care plan
Heart rate of 68 beats per minute
Client verbalized, “I feel pain when urinating.”
“The patient will feel less nauseated in 24 hours.”
“The patient will eat the right amount of food daily.”
“The patient will identify all the high-salt food from a prepared list by discharge.”
“The patient will have enough sleep.”
She writes in the chart using a no. 2 pencil.
She noted: appetite is good this afternoon.
She signs on the medication sheet after administering the medication.
She signs her charting as follow: J.R
Concern for privacy
Sister Callista Roy
Patient and relatives
Nurse and patient
Doctor and family
Nurse and doctor
Low blood pressure
Warm, dry skin
Decreased serum sodium levels
Decreased urine output
Use sterile gloves when obtaining urine.
Open the drainage bag and pour out the urine.
Disconnect the catheter from the tubing and get urine.
Aspirate urine from the tubing port using a sterile syringe.
Stop the infusion
Call the attending physician
Slow that infusion to 20 ml/hr
Place a clod towel on the site
Leave the medication at the bedside and leave the room.
After few minutes, return to that patient’s room and do not leave until the patient takes the medication.
Instruct the patient to take the medication and leave it at the bedside.
Wait for the patient to return to bed and just leave the medication at the bedside.
Place the feeding 20 inches above the pint if insertion of NGT.
Introduce the feeding slowly.
Instill 60ml of water into the NGT after feeding.
Assist the patient in fowler’s position.
Oriented to date, time and place
Clear breath sounds
Capillary refill greater than 3 seconds and buccal cyanosis
Hemoglobin of 13 g/dl
That the patient verbalized, “My headache is gone.”
That the patient’s barium enema performed 3 days ago was negative
Patient’s NGT was removed 2 hours ago
Patient’s family came for a visit this morning.
“The patient will experience decreased frequency of bowel elimination.”
“The patient will take anti-diarrheal medication.”
“The patient will give a stool specimen for laboratory examinations.”
“The patient will save urine for inspection by the nurse.
Development of a standardized NCP.
Expansion of the current taxonomy of nursing diagnosis
Making of individualized patient care
Incorporation of both nursing and medical diagnoses in patient care
Ineffective breathing pattern related to pain, as evidenced by shortness of breath.
Anxiety related to impending surgery, as evidenced by insomnia.
Risk of injury related to autoimmune dysfunction
Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.