Student Name: Tsuei Wu

Patient Initials: Ms Ld. Smk

Diagnosis: DEEP VEIN THROMBOSIS

Definition of Diagnosis:

A blood clot in a deep vein, usually resulting from damage to the vein or blood flow
slowing down or stopping. .

Signs and Symptoms Nursing Diagnosis

• Questioning members of health care team Deficient knowledge about Deep Vein
• Verbalizing inaccurate information Thrombosis and its treatment.
• Inaccurate follow-through of instruction
• Denial of need to learn
• Incorrect task performance

Nursing Intervention Rationale

1. Provide physical comfort for the learner. 1. This allows patient to concentrate on what
is being discussed or demonstrated.

 2. Establish objectives and goals for 2. This allows learner to know what will be
learning at the beginning of the session. discussed and expected during the session.

3. Pace the instruction and keep sessions short. 3. This prevents fatigue. Learning requires
energy.

4. Allow for and support self-directed, self- 4. Adults learn when they feel they are
designed learning. personally involved in the learning process.

5. Allow adequate time for integration that is 5. Information that is in direct conflict with
in direct conflict with existing values or what is already held to be true forces a
beliefs. reevaluation of the old material and is thus
integrated more slowly.
Patient Teaching Outcome
• Provide instruction for specific topics. Patient verbalizes understanding of condition and
• Explore community resources. treatment options.
• Refer patient to support groups as needed.
• Include significant others whenever
possible.
 [Check those that apply]

(_) New diagnosis:_____________________________

(_) Language differences:________________________
(_) Hospitalization
(_) Diagnostic test:_____________________________
(_) Surgical procedure:__________________________
(_) Medications:_______________________________
(_) Pregnancy
(_) Other:_____________________________
____________________________________
____________________________________
 As evidenced by:
[Check those that apply]

Major: (_) Verbalizes a deficiency in knowledge or skill. (_) Requests information.

(Must be (_) Expresses and inaccurate perception of health status.

present) (_) Does not correctly perform a desired or prescribed health behavior.
Minor: (_) Lack of integration of treatment plans into daily activities.

(May be (_) Exhibits or expresses psychological alteration, (anxiety, depression) resulting from

present) misinformation or lack of information.

Date & Plan and Outcome Target Nursing Interventions Date

Sign. [Check those that apply] Date: [Check those that apply] Achieved:
The patient will: (_) Assess patient's readiness to
(_) Describe disease process, learn by assessing emotional
causes, factors contributing to respose to illness:
symptoms.
• Acceptance
(_) Describe procedure(s) for
disease or symptom control.
• Anger
(_) Identify needed alterations in
lifestyle. • Anxiety
(_) Other:
• Denial

• Depression

• Other:

(_) Allow person to work through

and express intense emotions
prior to teaching.
(_) Examine patient's health
beliefs:
________________________
________________________
(_) Assess patient's desire to
learn.
(_) Assess preferred learning
 mode:

• Auditory

• Group

• One to one

• Visual

• Other:

(_) Assess literacy level.

(_) Provide health teaching and
referrals: ___________________
________________________
________________________
________________________
(_) Plan and share necessity of
learning outcomes with patient -
s/o.
(_) Evaluate patient - s/o
behaviors as evidence that
learning outcomes have been
achieved:
________________________
________________________
________________________
(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
Dr Eye 有1.3G 非常大，要傳送可能要很久，請耐心等待。若
用一般的傳法可能要一星期，我現在在用特殊傳送，所以妳先
睡覺，大約二個小時後我就可以完全幫妳裝好。
看起來比想像中還要慢，目前我正把檔案送到遠端的 Server
可能要 3小時。
現在才傳了 25 MB 總共有 1250 MB 2010/2/27 01:
20