Healthcare systems elements

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Healthcare systems elements

 

 

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

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Oxytocin Healthcare systems elements

          
 

Carboprost (Methergine)

          
 

Hemabate

          
 

Misoprostol (Cytotec)

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          

 

CONCEPT MAP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Diagnosis

Problem statement: (NANDA)

 

Related to: (What is happening in the body to cause the issue?)

 

Manifested by: (Specific symptoms)

 

 

 

 

 

 

.

           

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

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.

References:

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