CON
| 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. |
