Documente Academic
Documente Profesional
Documente Cultură
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Course Name
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Student Name
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Instructor Name
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Date
STC 201625
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Expected Findings:
Physical Assessment:
STC 201625
Assessment
This information is
derived from your data
collection sheets (your
physical assessment
findings, HPI, subjective
data, chart reports etc.)
and is the data that
supports your chosen
nursing diagnoses.
Nursing Diagnosis
Consult Ackley to select
a nursing diagnosis that
is a high priority for the
health and well being of
your patient. Consider
your patients S&S,
medical diagnoses,
functional status, risk
factors, lab and
diagnostic data.
Plan (Goals)
Planning consists of
setting measurable and
realistic goals. (Then
choosing the
appropriate
interventions to help
meet those goals.)
Interventions (with
Rationales)
1) Assessment
2) Nursing Actions
3)Collaborative
4)Medication
5)Teaching
6)Safety
These interventions
must be personalized
and individualized to
meet your patients
needs.
Supporting Subjective
Data:
#1)
ND #1:
The patient will:
1)
Assessment
interventions: What
physical, emotional,
knowledge base
assessments need to
be done on an
ongoing basis?
related to (list
causative or
contributing factors):
Supporting Objective
Data (assessment,
diagnostic, lab data
that supports your
nursing diagnoses.):
Cultural/Psychosocial
Background:
STC 201625
as manifested by
(list the
signs/symptoms that
led you to choose
this diagnosis.):
2)
Nursing actions:
What actions do I
need to take?
Collaborative
interventions: What
interdisciplinary team
members do I need
to consult with? What
medically related
(physician ordered)
ND #1:
1)
2)
#1)
ND #1:
The patient will:
1)
Assess:
ND #2:
1)
related to
Do:
as manifested by
2)
2)
Collaborative:
Medications:
STC 201625
Safety:
ND #2:
The patient will:
1)
Assess:
ND #2:
1)
related to
Do:
as manifested by
2)
2)
Collaborative:
STC 201625
Teach:
Safety:
Reference
STC 201625