[Type here]
Rasmussen College
| Be sure all outside sources are cited using current APA style.Write from nursing perspectiveIn text citationThree referencesUsed the medical diagnosis ( Gastroenteritis) by giving their pathophysiology, causes, risk factors, signs and symptom/clinical, complication, and treatment and fill all the concept map below | |||||
| 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 | NormalRange | CriticalValue | 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