Student Name:  Clinical Dates:   Pt Initials:  Admitting Problem: Overview of the situatio

Student Name:  Clinical Dates:   Pt Initials:  Admitting Problem: Overview of the situation (Client Story):  What is happening? How does client feel about the situation? What is client’s greatest concern at this time?       Client History: Surgical interventions or significant invasive procedures during this admission (Include POD or PPD number):   List all of the client’s medications and class.  Tell what the patient is taking them for: Scheduled Meds/Class Reason client is taking med PRN Meds/Class Reason client is taking med              Some important labs should be reviewed for all clients.  List them here, give the data and normal values. Indicate which are abnormal with a capital H (if high)  or capital L (if low).    Add rows if other labs are pertinent (i.e. BNP and urine culture).   Leave blanks where you don’t have results (for example when you only have a test for one day). Lab Test Normal Range Data from prepX/X/XX Day 1 DataX/X/XX  Day 2 DataX/X/XXRBC        WBC        Hgb        Hct        Platelets        PT        PTT        INR        Na+        K+        Ca+        Phos+        Mag+        BUN        Creat.        GFR                   Primary  & Secondary Medical Diagnosis The primary diagnosis may be different than the admitting problem.  Select at least 2 secondary diagnosis which are of most concern to the current situation   Exemplary grade will typically require you cover at least 3 secondary diagnosis.    Pathology/Definition of Primary Medical Diagnosis Read about the condition and describe what is going on in your own words. Include   references but minimize use of direct quotes.  For diagnosis other than the primary one, add a bullet and discuss if and how this condition impacts the current situation.    What is the current and past history of this illness?  Use bullets and include:When diagnosedPast treatment Client compliance with treatment  What nursing care is required during this stay?Use bullets and include:Necessary nursing assessmentsAppropriate nursing interventions Appropriate patient teaching Primary Diagnosis        2.          3.          4.           Consider the above diagnoses.  List the top three physical systems that require nursing care in order of priority and explain why you prioritize them as you do.   If the client’s psychosocial concerns are of high importance – you may replace a system with the term “psychosocial”. Systems include:   Neurological, CV, Pulmonary, GI, GU, Reproductive, Integumentary, Musculoskeletal, Immune and Endocrine  1.       2.  3.  Now complete the following section for your priority physical system and complete a psychosocial assessment.  Your 3 POCs should look at different systems. If your primary system is the same as one that you covered on another POC, discuss this with your instructor. You will likely be asked to do your POC on the secondary system.   If the psychosocial concerns are of top nursing concern, you should designate that and complete your POC on it. Primary Physical System:  Assessment Data:  Include pertinent labs and meds. All lab values should be followed with the normal values for the lab in parenthesis. Consult the system’s data collection grid for guidance on what to include.  Report in factual manner.  Data is factual and may be  subjective (what was said or written) and objective (observations, vitals, labs etc.). Tell where you got the information i.e. “Daughter reported…”  “Patient said…” “Doctor’s note stated …” Do not tell what the data means in this area. Interpretation:  Tell what the normal and abnormal assessment data means. This is the area in which you are to show your critical thinking ability.Discuss what is going on and explain it thoroughly. Your data should lead to (build a case for) the nursing diagnosis you give. Data from prep:          Day 1 Data:           Interpretation of data:          Nursing Diagnosis:Make sure this flows from the interpretation above.  Psychosocial  Assessment Data:  Consult the system’s data collection grid for guidance on what to include.    Do not just report what you read in the chart. You need to make inquiries to ensure this data is complete.Report in factual manner.  Data is factual and may be  subjective (what was said or written) and objective (observations, vitals, labs etc.). Tell where you got the information i.e. “Daughter reported…”  “Patient said…” “Doctor’s note stated …” Do not tell what the data means in this area.  Interpretation: This is the area in which you are to show your critical thinking ability. Discuss what is going on and explain it thoroughly. Your data should lead to (build a case for) the nursing diagnosis you give. Data from prep:          Day 1 Data:     Day 2 Data:       Interpretation of data:          Nursing Diagnosis:Make sure this flows from the interpretation above.  Primary Nursing Diagnosis (Carry over exactly as written in first section above. If your primary concern is psychosocial,  you may carry over that diagnosis.) Broad Goal (Relates to above diagnosis):  Client outcomes Should help you achieve the goal Should be in SMART formatShould be worded as something the client will accomplish It is often helpful to consider the aeb signs and symptoms in the diagnosis and address them here.  Individualized interventions that are beyond the standards of care.  Start with an action verbNo interventions can be assessmentsAt least two should be independent (something the nurse can do on their own)Ensure each will help to achieve the associated outcome. Scientific rationale for each intervention with citation(s). Use bullets to show the 3 parts:First: define/describe the intervention. This may just be telling what you will do in simple terms. Second:  Provide evidence that his intervention will help to achieve the outcome (show it is evidence-based). A citation is required. Third, describe why it is specifically helpful to helping this client -tell why it is necessary.  Outcome evaluation & Recommendation/Revision Use bullets to show the 3 parts:Specifically state if the outcome was met, partially met, or not met Give supporting evidence that shows it was met, partially met or not met.Nurses need to adjust the plan of care.  If met, give a recommendation for the next outcome.  If not met, state how you would revise the outcomes or interventions.1. 1a.  1b.   1a.  1b.  1.2.  2a.  2b.  2a.  2b.   2.    ReferencesHealth ScienceScienceNursingNURSING NURSE1300Share

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