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
 
Oxytocin		          
 
Carboprost (Methergine)		          
 
Hemabate		          
 
Misoprostol (Cytotec)		          
 
 		          
 
 		          
 
 		          
 
 		          
 
 		          
 
 		          
 
 		          
 
 		          
 
 		          
 
 		          

 
CONCEPT 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.

 

Introduction To Nursing
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