CT head shows acute infarcts involving the right frontal lobe EKG shows AFIB Chest xray shows clear lung fields Dowblowe Lab results include: BMP: Fasting glucose 184mg/dl, sodium 140, Chloride 101, potassium 3.8, CO2 19, BUN 19, Creat 0.8 CBC: Hgb 13, Hct 40, WBC 16, RBC 4.56, Platelets 300 Lipid Profile: Total cholesterol 296mg/dL, Triglycerides 246mg/dL, Low-density lipoprotein (LDL)155mg/dL, High-density lipoprotein (HDL)22mg/dL Of Nursing NURSING CARE PLAN Name: Assessment Data Relevant objective and subjective findings that wantiate Nursing Diagnosis Date: Nursing Diagnosis #1 (from ESU Nursing Database) Nursing Diagnosis Expected Outcomes Nursing Interventions Rationale with Sources Relates to smo data, 1 Short Term Goal 1 Long Term Mentifies who, what, wher, States were includes related precipitating Goal, appropriate to diagnosis when and how Independe can be expected to compliah factors, prioritized by patient centered, meble marting to or collaborative objective provide our wed Maslow’s hechy contain a time frame for whining practice includes meille de sample book, uning wil lestins (NOT limited to . DIAGNOSIS: STG 1 1 Evaluation This done from ones Including te men, dient some follow- Tinding, achievement of out SUBJECTIVE: STG: RELATED TO: 2 2 OBJECTIVE: LTG LTG: AS EVIDENCED BY: Note: Risk Dx do not have AEB data /2015 acs, reviewed 8/2016 acs Nursing Diagnosis #2 (from ESU Nursing Database) Nursing Diagnosis Assessment Data Expected Outcomes Nursing Interventions Rationale with Sources Evaluation Overall outcomes and goals 1 Relates to data, Identifies who, what, where, Rective and subjective States reason why intervention This derives from Short Term Coal, I Long Term when, and how, Independient can be expected to accomplish finding that wantite Nursing includes related precipitating Teclades ning valve factors, prioritized by Goal appropriate to diaposis Di nursing actions or collaborative objective provide word me, imi responses, follow-up Maslow’s hierarchy patient centered, mensurable, practice, includes meda, labs, dx example textbook, using article, findings, achievement of outcome or contain time frame for tining (NOT Umited to ele need for medication SUBJECTIVE: DIAGNOSIS: STG with time frame 1 1 STG 2 2 RELATED TO LTG OBJECTIVE: LTG with time frame AS EVIDENCED BY: Note: Risk Dx do not have AEB data 9/2015 acs; reviewed 8/2016 acs Assessment Data Relative finding that wantite Nursing Deals Nursing Diagnosis Real includes related precipitating fast.printed by Maslows hierary DIAGNOSIS Expected Outcomes Nursine Interventions Overall come da is who, what, where Short Term Goal 1 Long Terme when, and how, Independent Goal appear to disposi, masing action or collaborative patient centered, marble practice includes meda, labs, dx semain time frame for attaining testin NOT limited to 4 STG with time frame 1 Rationale with Sources Saytervention can be exposed to accomplish objective provide soare med example tebook, uning article de. 1 Evaluation This derived from me Includes runing evaluative mesures, follow-up finding, wievement of come weddification STG SUBJECTIVE 2 2 RELATED TO LTG OBJECTIVE LTG with time frame 3 3 AS EVIDENCED BY Note Risk Dx do not have AEB data 9/2015 acs, reviewed 8/2016 acs
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