1 ctleglarsan ideas Humber ITAL Mini Gare Plan ~ Step 1 Analysis Heath Date: Nou 'S,20'4 Week: _|2 : E AL Diet | Activity Levet ‘Accommodation Diagnosis Prblens L baro.c Wop pe ey [Sea Fast Lee! Ruban De pression ‘Step 1 Assessment - All Modes ‘Adaptivelineffective Behaviours Physiological (all systems) +f iproblen Ventilation ; aa 3 Davies on olygen oP ial pepsi aay aan espirotions = = fecefeckve breathy Use of accessory muscles | - Balke rn Trach ; Sputum: present “He Bastian runy I+ Task for as pirahent Cardiovascular mp = ‘34-4°C ar ects: aes ci circulah iL beds = nerena | eaired Circulate eae anak ees dnanase) + ia peeuge ee, = mask for dehydra- Fmmobilelewerheey | wisk os | Fluid & Electrolytes oes. FES RASA y-Feed Uo ev Hyisseuee) ih 4 3150 mula 7 Spo me jade dow +I- Thee Fluid an eae ad se FOr cohon ouyeud ions ‘elbog| +1- ESE For denydeoh Nutrition as_of segource) CFA oO eo sotcce Garllcey + /~ mioalancedt Nutr to: _yse ne Ah seem elon fe [EO “Feed \srsource tt tore | 4 /- Elimination Bowel Purchon=|_per day yy Nears corerds le ask For Sin loreak- Bed Fast gas Filey Cagretar > ‘HS Tne 1 Disk Fav infechon,‘Student Nam Date: Week: ___ Slep 1 Assessment All Modes | Adaptivelinetiecive Behaviours Physiological (all systems) +i Problem Activity & Rest Femogired physical (rgcicea ee eae Jno OS 1 Upper anc lower exkrem he $ tle louse For Fatls/imjucy . ey Assishve devicesares Gaad= none *oind alonomals-hes yes Skin Ir rit age Ww icer On Coccyy Bok Fast neisi09 [Greed \ erosarguiAdeus) Sein tecture dey findacd ‘he Senses Sroepiebyear ounces Bor yes ond two blac +00 blood glucose = Mo concern ce mhon= Limited IMotor/Sensory abil. eee ee in zp Oble 40 respond | pain Blinking eyes — FEMenired Ver loa oma ey eiseng.eeS3 |i Communicahon Neurological Function > 1S abe Fo reseed 40 4 [emparred veroal Be Sas tag, hincing eyes Icom manicorhen Una +0 40 a Commete | _ sseSment £ LOC q 3 Imetired Verloal Kommuncahon Endocrine Function - Wise Lor imparreck Sty SO Fed nfechon ames i ; fyWeek: Student Name: ‘Siep 1 Assesament= All Wades | Adapiivelinetfective Behaviours Psychosocial Modes += Problem, Self-Concept Undble to assess pt FE Seif aware ness Role Funct SY Year old Female Wife [mater IMusctloskeletal weak ness in upper/lower ey tremibey Undo +o access PIS fealingy loot ole or peclormance ~ lof) cole ae Interdependence luedu ress ia vere |lowser eytremibes epencant on heathcare worker For all reeds HI- sei Cace defert Atherect Seif mainter lance lseif Core deRet Auerect Self Care MaintenanceHumber ITAL PN Nursing Care Plan ~ Step 2 Analysis ‘Student Name: Date: Week: All Medical Diagnosis: (Admission, Surgical, Other...) ne a eee result hing in Immobility of ail wer flower ev H emihe St meaired yerbol iemmuniea bon, “Trace oftemy Ci Ta be eee 1 + = Senet Data: eT THe Mer TURE Gut put Leon C= -Fulse Phot cemmnunicahing eee rachens-teouy Priority(s) Day 1: Ae eos hoa Client Gon Cathe tar Report Day 2: a Pertinent Data: + Bese] Morey sDeast ikon PF ast Priority(s) Day 2: Wound Care (stage Bresure utcer Sar e8e ey Nursing (Client) Problem (1): Dry Mucus Vlemloranes Immediate Stimuli: Inadequate Injake of Fluids Can utevsti ahent unalle to Contsl Froct /fiquidin mouth Nursing Diagnosis (1): pew Dru mucus membrane asfavidence ky ptyunable to Control Soot [liquid in mouth. = ~ Expected Outcome(s) Target Date(s) 1. Warntans adequate Tuk volw 2 pchieseS adequate nutnhonal Vlatus BeyoeneaceS no’ aspicahons 4. hose normal mucus memberaned 6 to Mainta:n gook Sein turgor [integrity Nursing Interventions (Minimum 5) 1. Asses plS buccal membranes, sclerae and Skin For Ladicohons of alred Lluid and electrolyle Balance Zone waser wuh tube Ceekings to mamtaine adeq ual Lurd! glecholy te Nolume 3. Diary hea Management -\denhfy Lact 2g. Medhtahant Bactera, Fube Feeding Lomuta 4Gheck gravy bap rol o pump ra oery hour fo maintain adequate Fluid inbatee Document ol pi Maken en eadote Potg balance ‘Community Resource: (related to client's needs) Biehcian wa