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multidimentional care

Weekly Care plan Crohn’s disease

Identify top three nursing diagnosis in order of importance. They should be written in nursing diagnosis format using NANDA Nursing Diagnosis

“related to” and “as evidenced by.” “Risk for” nursing diagnoses do not need “as evidenced by.” Primary Nursing Diagnosis should be actual not “Risk.”

1. _________________________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________________________

Assessment

Nursing Diagnosis

Goals

Interventions

Rationale for your interventions

Outcomes

Subjective and/or objective findings that pointed you to choose nursing dx

Take your #1 on page 3 and transfer it

1 LTG and 1 STG Include dates, be specific

3 LTG and 3 STG interventions. Can be Medical, holistic, etc.

3 LTG and 3 STG interventions. Site your references in-text and include a reference page

Identify if the patient met, partially met, or did not meet goal and explain

LTG:

STG:

LTG:

STG:

Describe your priority diagnosis using the following table. Nursing diagnosis must be NANDA approved. For additional space use blank piece of paper

Pls use reference

Weekly Care Plan: Updated 121316

1

multidimentional care

Rasmussen University Name: Date:

Care Plan #

Rasmussen University

CON
CEPT MAP

Pathophysiology – Gestational Diabetes

Medical Diagnosis


Gestational Diabetes

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)

.

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 long term 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.

Summer 2021 JM 9

multidimentional care

Rasmussen University Name: Date:

Care Plan #

Rasmussen University

CON
CEPT MAP

Pathophysiology – Preterm Labor

Medical Diagnosis


Gestational Diabetes

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)

.

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 long term 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.

Summer 2021 JM 9

multidimentional care

Care Map

System Care Map

Purpose of Assignment

For this assignment, you will demonstrate knowledge of the diagnostic process using the template below. You will identify common assessment data, three priority nursing diagnoses, client-centered outcomes, and nursing interventions with rationale for a client with impaired immunity.

Course Competency

· Describe strategies for safe effective multidimensional nursing practice when providing care for clients experiencing immunologic, infectious and inflammatory disorders.

Instructions

Tom Howard, a 45-year old man with HIV from the community, has come to the clinic because he reports he had not been feeling well recently. During the intake process, Tom complains of a dry cough and chilling. The intake nurse takes his vital signs, and they are: Temp 102 degrees Fahrenheit, Pulse 102, Respirations 28 breaths per minute, Blood pressure 135/86. The clinic physician refers Tom to the local hospital for a suspected opportunistic infection.


Suspected opportunistic infections for this patient are: (choose ONE to complete this template)

· Cryptococcosis

· Cytomegalovirus

·
Histoplasmosis

·
Kaposi’s sarcoma

·
Toxoplasmosis