| 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 |
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Normal Saline 400 mL (20mL/kg) |
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D5½ NS IV at 62mL/hr |
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CONCEPT MAP
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. Fill out LAB Chart in its entirety
| LAB | Normal
Range |
Critical
Value |
Value | Clinical Significance: | Nursing Assessments/Interventions Required: |
| HEMATOLOGY
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| CBC | |||||
| WB | |||||
| RBC | |||||
| HGB | |||||
| HCT | |||||
| PLATLETS | |||||
| DIFF: | |||||
| Polys | |||||
| Bands | |||||
| Lymphs | |||||
| Mono’s | |||||
| Eosin | |||||
| CHEM 7
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| Glucose | |||||
| Chloride | |||||
| Sodium | |||||
| Potassium | |||||
| BUN | |||||
| Creatinine | |||||
| CO2 | |||||
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URINALYSIS |
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| 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 |
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| 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)
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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.
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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.
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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.
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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.
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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)
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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. |
