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Pathophysiology Ventricular Septal  Defect
 
           Medical Diagnosis
Ventricular Septal  Defect
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)

CEPT MAP
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Nursing Diagnosis
Problem statement: (NANDA)
 
Related to: (What is happening in the body to cause the issue?)
 
Manifested by: (Specific symptoms)

 
 
 
 
 
 
.
 
 
 
 
 
 
 
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 HER 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.

 

Pathophysiology
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