HNN227 :Care Plan Assessment
- Subject Code :
HNN227
1. PROBLEM IDENTIFICATION
- a) Categorise the four (4) patient problems as either an ‘actual’ OR ‘potential’ problem providing a rationalefor your allocation.
|
|
Actual or Potential? |
Rationale |
|
1. Impaired comfort |
|
|
|
2. Risk of Fluid and electrolyte imbalance |
|
|
|
3. Impaired gas exchange |
|
|
|
4. Risk of altered tissue perfusion |
|
|
- b) Re-construct the four (4) patient problems to include the related etiology, defining characteristics &/or risk factor/s associated with each problem.
|
|
Re-constructed Patient Problem |
||||||
|
1. Actual Problem |
|
related to |
|
as evidenced by |
|
||
|
2. Actual Problem |
|
related to |
|
as evidenced by |
|
||
|
3. Potential Problem |
|
due to |
|
||||
|
4. Potential Problem |
|
due to |
|
||||
PLANNING
- Using the Primary Survey prioritisethe order of the four (4) patient problems.
|
|
Patient Problem |
|
1st Priority |
|
|
2nd Priority |
|
|
3rd Priority |
|
|
4th Priority |
|
- Developan appropriate goal of care including measurable parameters and timelines for the four (4) patient
|
|
Planning |
|
1. Impaired comfort |
|
|
2. Risk of fluid and electrolyte imbalance |
|
|
3. Impaired gas exchange |
|
|
4. Risk of altered tissue perfusion |
|
3) IMPLEMENTATION
- Identifytwo (2) nursing interventions for each of the four (4) patient
|
|
Evidence-based Nursing Intervention |
||
|
1. Impaired comfort |
1. |
|
|
|
2. |
|
||
|
2. Risk of fluid and electrolyte imbalance |
1. |
|
|
|
2. |
|
||
|
3. Impaired gas exchange |
1. |
|
|
|
2. |
|
||
|
4. Risk of altered tissue perfusion |
1. |
|
|
|
2. |
|
||
- Provide a rationale for eachof the identified nursing interventions, including an explanation of the underlining physiology and/or pathophysiology.
|
|
Evidence-based Nursing Intervention |
Rationale |
|
1. Impaired comfort |
1. |
|
|
2. |
|
|
|
Evidence-based Nursing Intervention |
Rationale |
|
2. Risk of fluid and electrolyte imbalance |
1. |
|
|
2. |
|
|
|
Evidence-based Nursing Intervention |
Rationale |
|
3. Impaired gas exchange |
1. |
|
|
2. |
|
|
|
Evidence-based Nursing Intervention |
Rationale |
|
4. Risk of altered tissue perfusion |
1. |
|
|
2. |
|
4) EVALUATION
- a)Describehow you will evaluate the effectiveness of the nursing interventions you have
|
|
Evaluation |
|
1. Impaired comfort |
|
|
2. Risk of fluid and electrolyte imbalance |
|
|
3. Impaired gas exchange |
|
|
4. Risk for altered tissue perfusion |
|
