science
Favor2022
Science1.docxName: Date:
Care Plan #
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Healthcare systems elements (continued) ALLERGIES: |
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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 |
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Oxytocin |
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Carboprost (Methergine) |
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Hemabate |
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Misoprostol (Cytotec) |
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CON CEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Postpartum Hemorrhage
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)
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Additional information:
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
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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 |
|
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. |
References:
Summer 2021 JM 9
