Autism and Accommodations in Higher Education: Insights from the Autism Community

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Background Information Summary

Client initials:

Age:

Gender:

Primary Language

Allergies:

Code status:

Wt:

Ht:

BMI:

Admit date:

Hospital Day #

Isolation Y N

Indication

Bleeding Precautions Y N

Indication

Fall Risk Y N

Aspiration Risk Y N

Admitting diagnosis/symptoms (chief complaint upon admission):

Current medical diagnoses:

Summary of hospitalization to date: (what happened from admission to time you took care of them)

PMH/PSH:

Social history (ethnicity, occupation, marital status, family support, living situation):

Relevant Medical ORDERS

VS freq:

Diet:

Blood sugars frequency:

Activity order:

Oxygen order:

Respiratory Tx:

Dressing changes:

Other relevant orders:

Assessment and Analysis

Physical Assessment Findings

Analysis of Findings

(Explain significance related to current diagnosis and/or PMH.)

Vital signs:

I:

O:

Neurological/Sensory:

Cardiovascular:

Respiratory:

Gastrointestinal & Nutrition:

Musculoskeletal:

Genitourinary/Reproductive:

Integumentary (including incisions and drains):

IV Assessment:

Pain:

Psychosocial:

Laboratory Tests (relevant admission and current labs)

Date

Lab Test

Abnormal Lab Results

Normal Range

Rationale for performing test

Relationship between/among test results with client’s condition

Diagnostic Tests (x-rays, CT scans, endoscopies, etc.)

Date

Test

Reason for test

Results/Findings

Analysis of relationship between diagnosis test and client’s condition

Medications

Trade Name

Generic Name

Medication Classification

Therapeutic Use

Major adverse effects

Time dosage

Route of administration

Nursing Consideration

Nursing Diagnoses

List 3 pertinent nursing diagnoses for your patient and prioritize them. Two actual problems and one at-risk problem. Outcomes need to be SMART – specific, measurable, attainable, realistic and time specific. The collaborative interventions are what you do with another healthcare discipline (resp therapy, PT/OT, pharmacy, case manager, dietician, wound ostomy specialists, etc. It is not another nurse, nurse tech or notifying the MD/HCP)

Nursing Diagnosis #1:

R/T:

AEB:

Interventions (3)

Expected Outcome (3 -Measurable):

Collaborative Interventions (3)

Nursing Diagnosis #2:

R/T:

AEB:

Interventions (3)

Expected Outcome (3 - Measurable):

Collaborative Interventions (3)

Nursing Diagnosis #3:

R/T:

AEB:

Interventions (3)

Expected Outcome (3 - Measurable):

Collaborative Interventions (3)

Routine Nursing Management – what you can do independently. Each rationale needs to have evidence-based peer-journal reference cited

Interdisciplinary Care

· Collaborative Management

Member of the Team

Brief description of the role & responsibilities

· Therapeutic Modalities – The rationale must be included for each modality. The rationale must be evidence-based peer-journal referenced cited.

Nursing Reflection

Must include:

· Analysis of communication style preferences among interdisciplinary team members and with the critically‐ ill individual and family members;

· Analysis of the impact of own communication style on others

· Description of system barriers and facilitators in relation to the quality of care/outcomes for the critically‐ ill individual

· Discussion of recommendations to the organizational system for enhancing interdisciplinary collaboration, which are supported by at least two (2) evidence‐ based literature

· Description of ideas for own professional self‐ development plan to enhance own potential for becoming an effective member in an interdisciplinary team.