护士个案护理报告英文

演讲人：日期：护士个案护理报告英文IntroductionPatientAssessmentNursingDiagnosisandGoalsInterventionsandRationaleEvaluationofCareProvidedConclusionandReflection目录01IntroductionThepurposeofthisnursingreportistodocumentthecareprovidedtoapatientandtocommunicatethepatient'sconditionandprogresstootherhealthcareprofessionalsThebackgroundofthisreportincludesthepatient'sdiagnosis,medicalhistory,andcurrenthealthstatus,whichallinformthedevelopmentofthenursingcareplanPurposeandBackgroundThepatient'svitalsignsincludeaheartratewithinthenormalrange,bloodpressureslightlyelevated,andrespiratoryratestableThepatientisamiddleagedmalewithahistoryofhypertensionanddiabetesHepresentedwithcomplaintsofchestpainandshortnessofbreath,whichweredeterminedtobesymptomsofaheartattackPatientInformationThenursingcareplanisfocusedonmonitoringthepatient'scondition,managinghispainanddiscomfort,andpromotinghisrecoveryandrehabilitationSpecificnursinginterventionsincludeadministeringmedicine,providingeducationonself-careanddiseasemanagement,andcoordinatingcarewithotherhealthcareteammembersExpectedoutcomesofthenursingcareplanincludestabilizationofthepatient'scondition,improvementinhissymptoms,andprogresstowardsrecoveryanddischargefromthehospitalNursingCarePlanOverview02PatientAssessmentRegularmonitoringoftemperature,pulse,respirations,andbloodpressureVitalSignsRecordedtoassessnutritionalstatusandgrowthtrendsHeightandWeightCheckedforrashes,losses,dryness,andcolorchangesSkinAssessmentIncludesassessmentofeyes,ears,nose,thrust,heart,lungs,abdomens,extroversies,andneurologicalstatusHeadtoToeExaminationPhysicalAssessmentEvaluationoforientation,memory,attentionspan,andjudgmentMentalStatusAssessmentofmood,effect,andcopingmechanismsEmotionalStateIdentificationofsourcesofstressandhowtheyareaffectingthepatientStressLevelEvaluationoffamily,friends,andotherresourcesavailabletothepatientSupportSystemsPsychologicalAssessmentAssessmentofsafety,cleanliness,andequalityofthepatient'slivingconditionsHomeEnvironmentFinancialResourcesTransportationSocialSupportEvaluationofthepatient'sabilitytopayformedicalcareandmedicineAssessmentofthepatient'sabilitytogettoandfrommedicalappointmentsEvaluationofthepatient'ssocialnetworkandlevelofsupportreceivedSocialandEnvironmentalAssessment03NursingDiagnosisandGoalsThepatientexhibitssharp,fastbreakingandusesaccessorymusclestobreakthemTheremaybesignsofcyanosisand/ordecreasedoxygensaturationlevelsIneffectiveBreakingPattern:relatedtorespiratoryinsufficiencyand/orpulmonarycongestionPrimaryNumberingDiagnosis010405060302PaidSkinIntegrity:relatedtoalteredcirculationand/ormobilityThepatientmayhaveareasofskinbreakdown,suchaspressureulcersorskinteamsTheremaybesignsofcollaboration,warmth,orswingingintheaffectedareasRiskforFalls:relatedtoalteredbalanceand/ormedicalsideeffectsThepatientmaybeunsteadilyontheirfeetandhavediversitymaintainingbalanceTheremaybeahistoryoffallsornearfallsreportedbythepatientorcaregiverSecondaryNursingDiagnosis03Thepatientwilldemonstratetheabilitytouserespiratoryexercisesandtechniquestoimprovebreaking01IneffectiveBreakingPattern02ThepatientwillmaintainaneffectivebreakingpatternwithimprovedoxygensaturationlevelsGoalSettingforEachDiagnosisThepatient'sskinwillremainintactandfreefromfurtherbreakdownThepatientwillunderstandandimplementmeasurestopreventskinbreakdown,suchasfrequentpositionchangesandskincareroutesImportedSkinIntegrityGoalSettingforEachDiagnosis123RiskforFallsThepatientwillremainfreefromfallsandinjuriesrelatedtofallsduringthehospitalstayThepatientwilldemonstrateimprovedbalanceandstabilitywhenwalkingandperformingdailyactivitiesGoalSettingforEachDiagnosis04InterventionsandRationaleEnsuredpatientreceivedsubscribedmedicineontimeandincorrectmessages,monitoredforanyadversereactionsorsideeffectsMedicalAdministrationAdministeredinternalfluidsandmedicineasordered,monitoredIVsiteforsignsofinfectionorinfectionIVTherapyProvidedpayrelieftreatmentsasneeded,assessedpatient'spaylevelandreportedanychangestothehealthcareteamPainManagementPharmaceuticalInterventionsPatientEducation01Providededucationondiseaseprocess,treatmentplan,andself-caretechniquestoempowerthepatientandpromoterecoveryEmotionalSupport02Offeredemotionalsupportandcomforttothepatient,listenedtotheirconcernsandprovidedassurancePhysicalTherapy03Assistedwithphysicaltherapyexercisesandamplificationastolledbythepatient,monitoredforanydiscomfortorchangesinconditionsNonpharmacologicalinterventionsMedicationswerechosenbasedonthepatient'sdiagnosisandsymptomstoreduceinflammation,andtreatanyunderlyingconditionsIVtherapywasnecessarytoprovideimmediateandeffectivedeliveryofmedicineandfluidsPharmaceuticalInterventionsPatienteducationwascriticaltoensurethepatient'sunderstandingoftheirconditionandtreatmentplan,whichwouldaidintheirrecoveryEmotionalsupportwasprovidedtoreduceanxietyandpromoteapositiveoutlookPhysicaltherapywasessentialtoimprovemobilityandfunction,aswellaspreventanyfurthercomplicationsNonpharmacologicalinterventionsRationaleforChoiceInterventions05EvaluationofCareProvidedSupervisedvitalsignsregularlyandnotedimprovementsinbloodpressureandheartrateAssistedwithdailyactivitiessuchasbathing,dressing,andaccommodation,observingincreasedmobilityanddecreasedpaylevelsProvidedemotionalsupportandfunding,resultinginimprovedpatientmoodandcooperationwithtreatmentplanPatientProgressTowardsGoals01Implementedpaintmanagementstrategies,includingmedicaladministrationandnonpharmacologicalmethods,leadingtoreducedpaintscores02Coordinatedcarewithotherhealthcareteammembers,ensuringcontinuityoftreatmentandtimelyadjustmentstothecareplan03Educatedthepatientandfamilymembersondiseaseprocess,treatmentoptions,andself-caretechniques,enhancingtheirunderstandingandabilitytomanagetheconditionathomeEffectivenessofInterventionsIdentifiedaneedformorefrequentmonitoringofbloodglucoselevelsduetofluctuationsnotedinthepatient'sconditionRecognizedtheimportanceofinvolvingthepatientindecisionmakingrelatedtotheircare,includinggoalsettinganddischargeplanningConsideredthepossibilityofreferraltoadditionalsupportservices,suchasphysicaltherapyorhomehealthcare,tofurtherassistthepatientintheirrecoveryprocessAreasNeedingImprovementinCarePlan06ConclusionandReflectionPatient'sconditionandprogressThepatientwasadmittedwithadiagnosisofpneumoniaandshownsignsofimprovementwiththeadministeredtreatmentNursinginterventionsandtheireffectivenessFrequentmonitoringofvitalsigns,administrationofIVfluidsandantibiotics,andrespiratorytherapywereprovidedTheseinterventionscontributedtothepatient'srecoveryChallengesaccountedforandhowtheywereoverThepatientexperienceddiversebreaking,whichwasaddressedthroughpromptinterventionandadjustmentofthetreatmentplanSummaryofKeyPointsfromReportWhatIlearnedfromthiscaseTheimportanceofclosemonitoringandpromptinterventionincasesofre