science

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

Glucagon AMP/50 ML in sterile water

Regular Insulin 7 units subcutaneously

Lantus 26 units qd

NS 20 mEq/l

K

CL @ 200ml/hr x 1 hour then 125 ml/hr

Universal Self-Care Deficits: Assessment: (Highlight all abnormal assessment findings)

Vital Signs

Admission

Reassess

Oxygenation/ Circulation

Input:

SPO2

1. 2. 3.

Accu-check

1. 2. 3. 4.

Output:

Cardiovascular Assessment:

Specialty devices:

Teaching needs:

Heart Sounds:

Circulatory Assessment:

Edema: JVD:

Pain assessment: (PQRST)- Specific area

Respiratory assessment

Special devices:

Teaching Needs:

Lung sounds:

Pulmonary assessment: (respiratory pattern)

Cough:

Respiratory treatment and rational for use:

Neurological assessment:

Assistive devices:

Teaching Needs:

Neuro assessment: Level of Consciousness

Fine motor function:

Gross motor functioning:

Sleep patterns: (During admission)

GI Assessment:

LBM: (description)

Teaching needs:

GI assessment: (observe – auscultate – palpate)

Alteration in eating or elimination patterns:

Nutrition Metabolic Assessment:

% of diet taken:

Alternative nutritional methods:

GU assessment:

Teaching needs:

Last void:

Due to void:

Alternative urinary elimination method: (if Foley when inserted)

Bladder scan

Assessment of urinary patterns:

Urine assessment (color odor concentration etc.)

LMP

Integumentary Assessment:

Teaching needs:

Color/ Mucous membranes

Hydration:

Wound Care:

Condition of skin:

Nutritional Assessment

Teaching needs:

Eating patterns:

Insulin administration:

Treatment of hypoglycemia:

Alternative feeding patterns:

IV Therapies:

IV fluids infusing

IV Site 1: Assessment

Date of insertion: Change (site or dressing)

IV removal:

Reason for removal:

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)

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.

Interventions

Patient response

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.