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A CARE PLAN. The Basics. Diagnosis. Medical vs. Nursing: Medical = disease process name Nursing=functions to address the patient as a whole: EX: Medical Diagnosis: Myocardial Infarction Nursing Diagnosis: Acute Pain, R/T myocardial ischemia. Nursing Diagnosis:
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A CARE PLAN The Basics
Diagnosis • Medical vs. Nursing: • Medical = disease process name • Nursing=functions to address the patient as a whole: • EX: Medical Diagnosis: Myocardial Infarction • Nursing Diagnosis: Acute Pain, R/T myocardial ischemia
Nursing Diagnosis: • Acute Pain, R/T myocardial ischemia • Decreased Cardiac Output R/T negative ionotropic changes in the heart 2ndary to myocardial ischemia or injury • Impaired Gas Exchange, R/T decreased cardiac output • Anxiety/Fear R/T hospital admission and fear of death
5 components • Problem – dyspnea, pain, confusion etc • Diagnosis- (Nsg) Ineffective Airway Clearance • Interventions-treatments provided to pt. • Expected Outcomes-how will the patient react to treatments. • Rationale-why are these interventions done?
Problems • Shortness of breath • Inability to do ADL’s • Pain control
Expected Outcomes • The patient will: • have decreased pain as exhibited by pain scale • Perform ADL’s with minimal or no assistance • Decrease the work of breathing.
Rationale • You tell me the Rationale…
Interventions • Monitor pain and give analgesics q4h and prn as ordered by MD • Monitor spirometry for increases in lung capacity • Decrease assistance with ADL’s as stamina increases • Ambulate patient BID as ordered by MD
