Name: Date:
Care Plan #
| 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 |
|||||
|
Oxytocin |
|||||
|
Carboprost (Methergine) |
|||||
|
Hemabate |
|||||
|
Misoprostol (Cytotec) |
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
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)
.
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:
Summer 2021 JM 9
