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Archive for November, 2009 ↓

Ineffective Airway Clearance Care Plan

Ineffective Airway Clearance (_)Actual (_) Potential Related To: [Check those that apply] (_) Atrificial airway (_) Excessive or thick secretions (_) Inability to cough effectively (_) Infection (_) Obstruction/restriction (_) Pain (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: [Check those that apply] Major: (Must be present) (_) Ineffective cough. (_) Inability to remove airway […]

Ineffective Breathing Patterns Care Plan

Ineffective Breathing Patterns (_)Actual (_) Potential Related To: [Check those that apply] (_) Allergic response (_) Anesthesia (_) Aspiration (_) COPD (_) Decreased lung compliance (_) Fatigue (_) History of smoking (_) Immobility (_) Medications (narcotics, sedatives, analgesics) (_) Neuromuscular impairment (eg. MS, Guillain-Barre) (_) Surgery or trauma (_) Pain (_) Other:_____________________________ ____________________________________ ____________________________________   […]

Ineffective Individual Coping care plan

Ineffective Individual Coping (_)Actual (_) Potential Related To: [Check those that apply] (_) Illenss:____________________________ ____________________________________ (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: [Check those that apply] Major: (Must be present) (_) Change in usual communication patterns (in acute). (_) Verbalization of inability to cope. (_) Inappropriate use of defense mechanisms. (_) Inability to meet […]

Knowledge Deficit care plan

Knowledge Deficit (_)Actual (_) Potential Related To: [Check those that apply] (_) New diagnosis:_____________________________ (_) Language differences:________________________ (_) Hospitalization (_) Diagnostic test:_____________________________ (_) Surgical procedure:__________________________ (_) Medications:_______________________________ (_) Pregnancy (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: [Check those that apply] Major: (Must be present) (_) Verbalizes a deficiency in knowledge or skill. (_) Requests […]

Noncompliance care plan

Noncompliance (_) Exercise (_) Follow-up Care (_) Medication (_) Other Related To: [Check those that apply] (_) Chronic illness (_) Fatigue (_) Depression (_) Non supportive family (_) Inadequate/incomplete instructions (_) Denial of Dx (_) Side effects of therapy/med (_) Impaired ability to perform tasks (_) Expensive therapy (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced […]

Potential for Infection

Potential for Infection (_)Actual (_) Potential Related To: [Check those that apply] (_) Alteration in skin integrity:___________________________ __________________________________________________ (_) Bone marrow depression. (_) Indwelling catheter:________________________________ (_) Nutritional deficiencies:______________________________ __________________________________________________ (_) Surgical/invasive procedures:________________________ __________________________________________________ (_) Other:__________________________________________ _________________________________________________ __________________________________________________   As evidenced by: [Check those that apply] Major: (Must be present) (_) Altered production of leukocytes. (_) […]

Powerlessness

Powerlessness (_)Actual (_) Potential Related To: [Check those that apply] (_) Inability to communicate:________________________ (_) Inability to perform ADL:________________________ (_) Inability to perform role responsibilities:_____________ ______________________________________________ (_) Progressive debilitating disease:_________________ (_) Hospital or institutional limitations:_________________ ______________________________________________ (_) Other:______________________________________ ______________________________________________ ______________________________________________   As evidenced by: [Check those that apply] Major: (Must be present) (_) Overt or […]

Rape Trauma Syndrome

Rape Trauma Syndrome (_)Actual (_) Potential Related To: [Check those that apply] Somatic Response: (_) Gastrointestinal irritability (N/V, anorexia) (_) Genitourinary discomfort (pain, puritus) (_) Skeletal muscle tension (spasm, pain) (_) Other:___________________________ ___________________________________ Sexual responses: (_) Mistrust of men (if victim is woman) (_) Change in sexual behavior Other:_____________________________ __________________________________ Psychological responses: (_) Denial (_) […]

Self Care Deficit: Bathing

Self Care Deficit: Bathing (_)Actual (_) Potential Related To: [Check those that apply] (_) Neuromuscular impairment (_) Visual disorders (_) Trauma or surgical procedure (_) External devices (_) Aging process (_) Musculoskeletal disorders (_) Immobility (_) Nonfuntioning or missing limbs (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: [Check those that apply] Major: (Must be […]

Self Care Deficit: Dressing and Grooming

Self Care Deficit: Dressing and Grooming (_)Actual (_) Potential Related To: [Check those that apply] (_) Neuromuscular impaitment:___________________________ (_) Impaired visual actuity (_) Immobility (_) Weakness (_) Decreased level of consciousness (_) Other:___________________________________________ ___________________________________________________ ___________________________________________________   As evidenced by: [Check those that apply] Major: (Must be present) (_) Impaired ability to put on or take […]

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