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Care Plan #

 

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Healthcare systems elements (continued) ALLERGIES:
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.

DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication?

Medication/dose Classification Indication/ Rationale SE’s/Nursing Considerations Client Education Text Reference

 

Normal Saline 400 mL (20mL/kg)

         
 

D5½ NS IV at 62mL/hr

         
 

 

         
 

 

         
 

 

         
 

 

         

 

 

 

 

 

 

 

 

 

 

 

 

 

CON CEPT MAP

Pathophysiology – (to the cellular level)

Medical Diagnosis

Gastroenteritis

Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)

Complications

Treatment (Medical, medications, intervention and supportive)

Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Diagnosis

Problem statement: (NANDA)

 

Related to: (What is happening in the body to cause the issue?)

 

Manifested by: (Specific symptoms)

 

 

 

 

 

. Fill out LAB Chart in its entirety

LAB Normal

Range

Critical

Value

Value Clinical Significance: Nursing Assessments/Interventions Required:
HEMATOLOGY

 

         
CBC          
WB          
RBC          
HGB          
HCT          
PLATLETS          
DIFF:          
Polys          
Bands          
Lymphs          
Mono’s          
Eosin          
CHEM 7

 

         
Glucose          
Chloride          
Sodium          
Potassium          
BUN          
Creatinine          
CO2          
 

URINALYSIS

 

 

 

 

 

 

 

 

 
Color          
Clarity          
Sp. Gravity          
pH          
Protein          
Glucose          
Ketones          
Bilirubin          
Occ. Blood          
Urobilogen          
WBC          
RBC          
Epithelia          
WBC          
RBC          
Epith Cell          
Bacteria          
Hyal Cast          
Gran Cast          
Leukocytes          
Nitrite          
STOOL O+P+

Culture

         
Giardia          
Cryptosporidium          
Entamoeba histolytica          

 

 

 

 

 

 

 

 

 

REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HIS RESPONSE.

PLAN OF CARE: Use your top two priorities

NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals) Interventions Patient response Goal evaluation
NRS DX:

Problem Statement:

 

 

 

 

 

 

 

 

R/T: (What is the cause of the symptom)

 

 

 

 

 

 

 

 

Manifested by: (Specific symptoms)

 

 

 

 

 

 

 

 

 

Short term goal : Create a SMART goal that relates to hospital stay/shift/day.

 

 

 

 

 

 

 

 

 

 

 

 

Long term goal : Create a SMART goal that is appropriate for discharge.

 

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

 

Interventions for short-term goal:

1.

2.

3.

 

 

 

 

Interventions for longterm goal:

1.

2.

3.

 

 

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)

 

 

 

Reassess for short-term goal:

1.

2.

3.

 

 

 

 

 

Reassess for long-term goal:

1.

2.

3.

 

Was it met or not met there is no partially met.
NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals) Interventions Patient response Goal evaluation
NRS DX:

Problem Statement:

 

 

 

 

 

 

 

 

R/T: (What is the cause of the symptom?)

 

 

 

 

 

 

 

 

 

 

Manifested by: (specific symptoms)

 

 

 

 

 

Short term goal: Create a SMART goal that relates to hospital stay.

Long term goal: Create a SMART goal that is appropriate for discharge.

 

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

 

 

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch) Was it met or not met there is no partially met.

 

 

 

Pilot Summer 2016 KC 9

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