DUE 2/26/22 AT 10AM
[Type here]
Rasmussen College
Be sure all outside sources are cited using current APA style.
Write from nursing perspective
In text citation
Three references
Used 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 |
Normal Range |
Critical |
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 |
|||||
Ketones |
|||||
Bilirubin |
|||||
Occ. Blood |
|||||
Urobilogen |
|||||
WBC |
|||||
Epithelia |
|||||
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 Long term goal |
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. |
|||
Interventions |
Patient response |
||||||
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. |
Pilot Summer 2016 KC 9