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Name: 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

LAB

Normal

Range

Critical

Value

Value

Clinical Significance:

Nursing Assessments/Interventions Required:

HEMATOLOGY

CBC

WB

RBC

HGB

HCT

PLATLETS

DIFF:

Polys

Bands

Lymphs

Mono’s

Eosin

CHEM 7

Glucose

Chloride

Sodium

Potassium

BUN

Creatinine

CO2

URINALYSIS

Color

Clarity

Sp. Gravity

pH

Protein

Glucose

Ketones

Bilirubin

Occ. Blood

Urobilogen

WBC

RBC

Epithelia

WBC

RBC

Epith Cell

Bacteria

Hyal Cast

Gran Cast

Leukocytes

Nitrite

STOOL O+P+

Culture

Giardia

Cryptosporidium

Entamoeba histolytica

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

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 longterm 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.

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.

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.

Pilot Summer 2016 KC 9

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