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 __________________________________________________________________________________________________________________________________________________________________________________________________________________
Clients 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 __________________________________________________________________________________________________________________________________________________________________________________________________________________
Clients 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 __________________________________________________________________________________________________________________________________________________________________________________________________________________
Clients 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 __________________________________________________________________________________________________________________________________________________________________________________________________________________
Clients 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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