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Provide a complete and detailed pathophysiology of the admitting diagnosis. Must
Provide a complete and detailed pathophysiology of the admitting diagnosis. Must include signs and symptoms, risk factors, and complications. Must relate the pathophysiology section back to the patient. Use academic, evidence-based references to support each criteria.
Pathophysiology of
Admitting Diagnosis
Signs & Symptoms
Risk Factors
Complications
Describe the relationship between the pathophysiology and the patient’s current condition in your own words (does not need citation)
And find 1 priority Smart goal about the CAD and 4 implementation with evidence-based citations.
PRIORITY HYPOTHESIS/PROBLEM
Using the pertinent abnormal cues, choose 1 priority hypothesis
SMART GOAL
Goal must be Specific, Measurable, Attainable, Realistic, and Timestamped.
Start goal statement with, “Patient will… by…”
Patient will by
IMPLEMENTATION
For the identified priority hypothesis/problem, provide 4 independent interventions (1 must be a teaching intervention). All interventions must have a rationale supported with evidence-based citations.
1.
Rationale:
2.
Rationale:
3.
Rationale:
4.
Rationale:
EVALUATION
Select whether your goal was met, partially met, or not met. If goal was met, explain why.
If goal was partially met or not met, must include revisions.
Goal Met
Why the goal was met:
Goal Partially Met
Revision(s):
Goal Not Met
Revision(s):
NURSING APPLICATION ASSESSMENT
Instructions: Include activities throughout the day performed in relation to the following NCLEX content categories. See content category below for examples from the NCSBN.
Management of Care
Nursing treatments provided to patient to help disease or medical problem/s
1.
Safety and Infection Control
Measures done to keep patient and you are safe, to prevent infection and worse condition
2.
Basic Care and Comfort
Nursing measures given to patient to keep clean and comfortable
3.
DEFINITIONS OF ABOVE
Management of Care: providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel.
Related content includes but is not limited to: Advance Directives. Advocacy, Assignment, Delegation and Supervision, Case Management, Client Rights, Collaboration with Interdisciplinary Team, Concepts of Management, Confidentiality/Information Security, Continuity of Care, Establishing Priorities, Ethical Practice, Informed Consent, Information Technology, Legal Rights and Responsibilities, Performance Improvement (Quality Improvement), Referrals
Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards.
Related content includes but is not limited to: Accident/Error /Injury Prevention, Emergency Response Plan, Ergonomic Principles, Managing Hazardous and Infectious Materials, Home Safety, Reporting of Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan, Standard Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of Restraints/Safety Devices
Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living.
Related content includes but is not limited to: Assistive devices, Elimination, Mobility/Immobility, Non-Pharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest
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