NUR2488 Rasmussen SEC2 MOD9 Explanation of Medical Diagnosis Case Study

NUR2488 Rasmussen SEC2 MOD9 Explanation of Medical Diagnosis Case Study

RASMUSSEN COLLEGE

School of Nursing

FORM #3

PATHOPHYSIOLOGY

Explanation of Medical Diagnosis

Diagnosis _______________________________________________________________

Pathophysiology __________________________________________________________________________________________________________________________________________________________________________________________________________________

Textbook Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________

Client’s Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________

Recommended Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________

Teaching __________________________________________________________________________________________________________________________________________________________________________________________________________________

Prevention __________________________________________________________________________________________________________________________________________________________________________________________________________________

RASMUSSEN COLLEGE

School of Nursing

FORM #3

PATHOPHYSIOLOGY

Explanation of Medical Diagnosis

Diagnosis _______________________________________________________________

Pathophysiology __________________________________________________________________________________________________________________________________________________________________________________________________________________

Textbook Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________

Client’s Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________

Recommended Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________

Teaching __________________________________________________________________________________________________________________________________________________________________________________________________________________

Prevention __________________________________________________________________________________________________________________________________________________________________________________________________________________

Medication Sheets

A.What is the medication used for?

B.Why would a patient being taking it?

C.What are the most common side effects?

D.What vital signs could be affected?

E.What labs could be affected?

Drug name

Answer to 5 questions

A.

Vital signs:

B.

C.

Labs:

D.

E.

Drug name

Answer to 5 questions

A.

Vital signs:

B.

C.

Labs:

D.

E.

NURSING DIAGNOSES

FORM #8

PRIORITY #

NURSING

DIAGNOSIS

RELATED/TO

(R/T)

AS EVIDENCED BY (AEB)

RATIONALE FOR PRIORITIZATION

Nursing Process Report Form

FORM #9

Nursing Diagnosis (R/T and AEB):

Assessment Data

Nursing Interventions

Scientific Rationale

(including references)

  • Subjective Assessment
  • Objective Assessment

Assessment

Decrease Stressors and/or Strengthen Lines of Defense

Teaching Counseling

Measurable and Realistic Outcomes

  • Short Term
  • Long Term

Short Term Outcome:_____ Met_____ Partially Met_____ Not

Describe:

Long Term Outcome:_____ Met_____ Partially Met_____Not MetDescribe:

References

RASMUSSEN COLLEGE

School of Nursing

FORM #3

PATHOPHYSIOLOGY

Explanation of Medical Diagnosis

Diagnosis _______________________________________________________________

Pathophysiology __________________________________________________________________________________________________________________________________________________________________________________________________________________

Textbook Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________

Client’s Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________

Recommended Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________

Teaching __________________________________________________________________________________________________________________________________________________________________________________________________________________

Prevention __________________________________________________________________________________________________________________________________________________________________________________________________________________

RASMUSSEN COLLEGE

School of Nursing

FORM #3

PATHOPHYSIOLOGY

Explanation of Medical Diagnosis

Diagnosis _______________________________________________________________

Pathophysiology __________________________________________________________________________________________________________________________________________________________________________________________________________________

Textbook Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________

Client’s Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________

Recommended Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________

Teaching __________________________________________________________________________________________________________________________________________________________________________________________________________________

Prevention __________________________________________________________________________________________________________________________________________________________________________________________________________________

Medication Sheets

A.What is the medication used for?

B.Why would a patient being taking it?

C.What are the most common side effects?

D.What vital signs could be affected?

E.What labs could be affected?

Drug name

Answer to 5 questions

A.

Vital signs:

B.

C.

Labs:

D.

E.

Drug name

Answer to 5 questions

A.

Vital signs:

B.

C.

Labs:

D.

E.

NURSING DIAGNOSES

FORM #8

PRIORITY #

NURSING

DIAGNOSIS

RELATED/TO

(R/T)

AS EVIDENCED BY (AEB)

RATIONALE FOR PRIORITIZATION

Nursing Process Report Form

FORM #9

Nursing Diagnosis (R/T and AEB):

Assessment Data

Nursing Interventions

Scientific Rationale

(including references)

  • Subjective Assessment
  • Objective Assessment

Assessment

Decrease Stressors and/or Strengthen Lines of Defense

Teaching Counseling

Measurable and Realistic Outcomes

  • Short Term
  • Long Term

Short Term Outcome:_____ Met_____ Partially Met_____ Not

Describe:

Long Term Outcome:_____ Met_____ Partially Met_____Not MetDescribe:

References

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