Clinical Setting
For your project this term you will be selecting a patient from the clinical setting to complete a concept map on. You will follow the format listed below. You will complete the information on a word document.
Choose any diagnosis of your choice and work on it.
Requirements of the project:
Patient Information (10 points)
History
Medical history
Psychosocial history
Family History
Medical diagnoses
Lab values
Know what is normal range.
Know which labs are abnormal.
Know which labs are significant for the patient.
Pathophysiology (10 points):
Name:
Definition:
Causes:
Signs/Symptoms:
Medical Treatment:
Medications (10 points)
Make a list of all medications ordered for your patient. Create a drug card for each medication using the correct format. You must select a patient that is taking at least 5 medications.
You must list why they are being prescribed, common side effects, nursing implications and teaching points.
Use the following format to create your medication list:
Trade Name: Classification:
Generic Name:
Mechanism of Action:
Rationale for ordered medication:
Normal Dosage Range:
Common Adverse Effects:
Nursing Implications/Pt.Teaching/Correct Administration Techniques:
Nursing Diagnoses (20 points) – Create 2 nursing diagnoses for your selected patient.
The Nursing Diagnosis must contain:
Problem from the NANDA-I list
Be related to etiology or cause
Provide details about the patient that proves that this is a good dx for the patient.
Expected Outcome/Goals (20 points)
Each nursing diagnosis must have a goal.
The expected outcome is a specific statement of the goal the patient is expected to achieve as a result of the nursing intervention.
It should contain specific, measurable criteria and be realistic, attainable, and have a defined time line.
Interventions (20 points)
Each Nursing Diagnosis must have 3 interventions
Each intervention must:
contain measurable data, volumes, times, specific information
be individualized and realistic to this patient
may include medications or treatments as ordered
Each intervention must have a stated rationale explaining why you are doing it or how this action will help accomplish your goal.
Teaching Plan (10 points):
Appropriate Topic: What are you teaching?
Why appropriate: Specific to this patient/family
Content: Teach the material just like you would the family/patient
Strategy: How would you teach this material? Demo, movie, pamphlets, auditory (lecture), model, posters, etc.
Evaluation: How would you evaluate the patient’s/family’s understanding of the teaching.
