Growth and development,

Growth and development,

Nursing Diagnoses (Minimum of 5) Use your assessment of your client’s human needs to write your nursing diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your health assessment of your client.

Human Needs

Nursing Diagnoses

(Circle Selected Nursing Diagnoses)

Nursing Diagnoses Statements

Oxygenation

Perfusion (Cardiac)Acid Base BalanceVentilationDiffusion

Decreased Cardiac output

Tissue perfusion, altered (specify) renal, Cerebral, cardiopulmonary, gastrointestinal, peripheral Impaired Gas exchange Ineffective airways cleaning Ineffective Respiratory pattern Difficulty maintaining spontaneous ventilation, Respiratory dysfunctional response to Weaning High risk of Asphyxia High risk of Aspiration

Fluid & Electrolytes Balance

Acid Base BalanceMetabolismIntracranial Regulation

Liquids, excess volume Liquids, Volume Deficit Liquids, high risk of volume deficit Body temperature: high risk of impaired Hypothermia Hyperthermia Ineffective Thermoregulation

Elimination

Constipation Subjective Constipation Chronic Constipation Diarrhea Fecal Incontinence Urinary, impaired elimination Urinary incontinence: stress Urinary Incontinence: reflects Urinary Incontinence: emergency Urinary Incontinence: Functional Urinary Incontinence: total Urinary, retention Self-care, deficit: use the potty / toilet

Nutrition

EnergyCellular structure and functionFailure to ThriveMetabolism

Nutrition, altered: excess Nutrition, altered: by default Nutrition, potential alterations: excess Self-care, deficit: feeding Swallowing, impaired Ineffective Breastfeeding interrupted breastfeeding Effective Breastfeeding Infant Feeding ineffective pattern

Sleep

Sleep pattern disturbance

Mobility

Disuse, high risk of syndrome Physical mobility, disorder Peripheral Neurovascular, high risk of dysfunction Activity intolerance Activity, high risk of intolerance

Self-care, deficit: dressing / grooming

Sensation and Cognition

Mood and affectTissue integrity

Sen-so-perceptual alterations (specify) visual auditory, kin esthetic, gustatory, tactile, olfactory.

Tissue, impaired integrity Oral mucous membrane, altered Skin, impaired Cutaneous, high risk of deterioration of the integrity Self-care, deficit: bathing / hygiene

Rest and Comfort

PainStress and CopingFatigue

Coping: ineffective

Anxiety Fear FatigueTransfer, stress syndrome Pain Chronic Pain

Spiritual Integrity

Grief and lossCultural

Spiritual suffering HopelessnessImpotence Bereavement dysfunctional Early Mourning

Affiliation

Love and BelongingSocial Support SystemsSelf-Actualization

Verbal, disorder Social, impaired interaction Social isolation Coping: ineffective

Recreation, deficitRole, impaired performance Parenteral, alteration Parenteral, high risk of disruption Parenteral, role conflict Adaptation disorder Family, alteration processes Role of caregiver, overexertion in The role of caregiver, high risk to overuse in the Defensive coping Denial ineffective Ineffective family coping: disabling Ineffective family coping: engaged

Sexual Integrity

Reproductive HealthSexual RelationshipsSexuality

Sexual dysfunction Sexuality, altered patterns of

Safety

Infection and InflammationImmunitySubstance abuseAbusive environments

Infection, high risk of Dysreflexia Injury, high risk Poisoning, high risk of Trauma, high risk of Protection, impaired engaged Violence, high risk: self-injury, injury to other Self-mutilation, high risk of Post-traumatic response Rape, traumatic syndrome of Violation, trauma syndrome: compound reaction Violation, trauma syndrome: silent reaction

Self-Esteem

Developmental milestones across the lifespanHealth promotion/health beliefsBehaviorsTeaching and learning

Growth and development, altered

Coping familiar development potential

Coping:ineffective Knowledge, deficit (specify) Thought, alteration processes

Health, generating conducts (specify)

Treatment, tracking no (specify) Decisions, conflict in the making (specify)

Therapeutic regimen, ineffective management of (individual) Home, difficulties in maintaining Health, alteration in the maintenance of Body Image, disorder Self-esteem disorder Self-esteem, lack of: chronic Self-esteem, lack of: situational Personal, disorder

Section VIII

Medications

(5 Points)

Medication Sheet

Medication Dose

Brand/

Generic Name

Mechanism of Action/Indication for Use

Contraindication

Adverse Effects/Side Effects

Nursing Implications

Outcomes

Safe Dose

(yes or no)

Why is your client on the drug?

Section IX

Nursing Interventions

(Points 20)

CARE PLAN FOR “ 4 ” (MINIMUM) NURSING DIAGNOSES

Assessment

Findings

Nursing Diagnoses

(Actual & Potential Deficits, Wellness Diagnoses)

Outcomes

Short and Long Term

Interventions/Nursing Systems

(Dependent & Independent)

Rationale

(Why are you performing that intervention?)

Evaluation/Outcome

(What was the actua
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