S,studies
Favor2022
Map.docxName: Date:
Care Plan #
College
CON CEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Gastroenteritis
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)
Nursing Diagnosis
Problem statement: (NANDA)
Related to: (What is happening in the body to cause the issue?)
Manifested by: (Specific symptoms)
. Fill out LAB Chart in its entirety
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LAB |
Normal Range |
Critical Value |
Value |
Clinical Significance: |
Nursing Assessments/Interventions Required: |
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HEMATOLOGY
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CBC |
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WB |
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RBC |
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HGB |
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HCT |
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PLATLETS |
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DIFF: |
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Polys |
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Bands |
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Lymphs |
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Mono’s |
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Eosin |
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CHEM 7
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Glucose |
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Chloride |
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Sodium |
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Potassium |
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BUN |
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Creatinine |
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CO2 |
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URINALYSIS |
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Color |
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Clarity |
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Sp. Gravity |
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pH |
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Protein |
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Glucose |
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Ketones |
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Bilirubin |
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Occ. Blood |
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Urobilogen |
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WBC |
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RBC |
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Epithelia |
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WBC |
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RBC |
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Epith Cell |
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Bacteria |
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Hyal Cast |
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Gran Cast |
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Leukocytes |
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Nitrite |
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STOOL O+P+ Culture |
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Giardia |
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Cryptosporidium |
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Entamoeba histolytica |
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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 HIS RESPONSE.
PLAN OF CARE: Use your top two priorities
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NANDA NURSING DIAGNOSIS use NANDA definition |
Expected outcomes of care (Goals) |
Interventions |
Patient response |
Goal evaluation |
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NRS DX: Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
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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.
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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.
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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.
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Was it met or not met there is no partially met. |
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NANDA NURSING DIAGNOSIS use NANDA definition |
Expected outcomes of care (Goals) |
Interventions |
Patient response |
Goal evaluation |
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NRS DX: Problem Statement:
R/T: (What is the cause of the symptom?)
Manifested by: (specific symptoms)
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Short term goal: Create a SMART goal that relates to hospital stay. Long term goal: Create a SMART goal that is appropriate for discharge.
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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)
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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. |
Pilot Summer 2016 KC 9
