Care Plan # Healthcare systems elements (continued) ALLERGIES:

Care Plan #

 

 

 

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