Enfermeria

INTER AMERICAN UNIVERSITY OF PUERTO RICO
METROPOLITIAN CAMPUS
CARMEN TORRES DE TIBURCIO SCHOOL OF NURSING
Student: _______________
Adult Care Practice I
Client’s Profile Initials: _____ Sex: __Age: __ Education: _________ Religion: ___________ Ethnic Origin: ________
Family Profile: ___________________ (see Case Study/ Assessment)
Summary of actual Health andTreatment:________________________.
Medications Ordered: See Pharm Study
Laboratories and Diagnostics Test: See Lab Study
CARE PLAN
|Health Pattern |Assessment Data |Diagnosis |Expected Outcomes or Indicators|Intervention |Scientific Rational |Evaluation |


| |NANDA |NOC, Code andpage |P
S |E
O |D
R |NIC, Code and page |Activities | |R
O |Date Resolved |Comments | |Metabolic










Activity-exercise














Activity-excercise |5 year oldwith recent surgica








Patient bed ridden due to condition.












Patients labs showing decreased levels that may impair balance manifesting as light headiness anddizziness. |Risk for infections (1986) pg 105








Impaired Physical Mobility (1998) pg 114











Risk for falls (2000) pg 67

Risk for injury (1978) pg. 106 |Tissueintergrity (1101) pg 544
-Skin lesions
-Tissue perfusion
-Erythima







Immobility Consequences: Physiological (0204) pg 318
-Urinary Tract Infections
-Pneumonia
--Nutritional statusFall Prevention Behavior (1909) pg 268
-Provides assistance with mobility
-Places barriers to prevent falls
-Controls agitation |
2
1
3








2
1
22
2
2 |
5
4
5








5
3
4












3
4
4 |

N/A










N/A














N/A
|Infection Protection (6550) pg. 443...