NUR2488 Rasmussen SEC2 MOD9 Explanation of Medical Diagnosis Case Study
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
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__________________________________________________________________________________________________________________________________________________________________________________________________________________
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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