TRICOUNTY TECHNICAL COLLEGENURSING 101

CLINICAL PREPARATION

Pathophysiology (disease process and/or medical diagnosis)

Medical Diagnoses:1. Hypertension2. Diabetes, Type II3. Osteoporosis4. Osteoarthritis

Textbook signs and symptoms Client’s sign and symptoms

TRICOUNTY TECHNICAL COLLEGENURSING 101

CLINICAL PREPARATION

Pathophysiology (disease process and/or medical diagnosis)

Medical Diagnoses:1. Hypertension2. Diabetes, Type II3. Osteoporosis4. Osteoarthritis L Hip

Textbook signs and symptoms Client’s sign and symptoms

From Records – Medical H&P, Progress Notes

Nsg Assmt and other parts of chart

Ignatavicious Med-Surg or whatever book you are using to research above diagnoses

Ignatavicious Med-Surg or whatever book you are using to research above diagnoses

1. None for Hypertension2. None except blood sugar elevated on testing3. None4. R Hip pain when walking further than 1 block, back pain on awakening

Chief Complaint: Hip pain

History of Illness: Arthritis getting worse for about 5 years; hip a problem for 6 months

Past History: Back pain off and on for 20 years

Family History: Mother had arthritis and high blood pressure; father had heart disease

Social Data: Busy 57 yo female who has been very active until lately; 2 children, husband support

Psychological Data: Sad about decreased mobility, worried about future

Adm.Medical Diagnoses: Arthritic Hip Disease

ASSESSMENT

Subjective Data Objective Data

DIAGNOSES

Nursing Diagnosis(es):1. _______P____________related to ______E_______as evidenced by ______S___________.2. ______P_____________related to ______E_______as evidenced by ______S___________.

Chief Complaint: Hip pain

History of Illness: Arthritis getting worse for about 5 years; hip a problem for 6 months

Past History: Back pain off and on for 20 years

Family History: Mother had arthritis and high blood pressure

Social Data: Busy 57 yo female who has been very active until lately; 2 children, husband support

Psychological Data: Sad about decreased mobility

Medical Diagnoses: HTN, Osteoporosis, Diabetes, Type II,

ASSESSMENT

Subjective Data Objective Data

DIAGNOSES

Nursing Diagnosis(es):1. Anxiety related to knowledge deficit re: surgery as evidenced by tearing and sadness.2. ______P_____________related to ______E_______as evidenced by ______S___________.

Any history related by patient Physical examination

data plus labs

Look in NANDA book for diagnosis that fits the situationLook in NANDA book for diagnosis that fits the situation

Must be comprehensive, these DRIVE the care plan

PLANNING

Desired Outcome: (Goal(s) What measurable goal will client achieve over what time frame.Client does WHAT, HOW and WHEN.

Interventions Rationales

1.

2.

3.

1.

2.

3.

EVALUATION

Client’s response to each intervention (If modifications necessary, what intervention would be appropriate?)

Was the desired outcome achieved? (Met unmet, partially met) Why?Patient _____________________ed in ____________________ as planned.

From Med-Surg or Fundamentals

book OR written by nurse

Be specific

to diagnose

s

Be specific to

Interventions

PLANNING

Desired Outcome: (Goal(s)Patient (Client) will learn 3 facts about arthritic hip disease by 10/2/2004 (48 hours) as evidenced by her describing potential treatment options to nurse.

Interventions Rationales

1. Provide information re: osteoporosis and

hip surgery if OK with physician. 1. Patient will be able to cope with situation once it is known.

EVALUATION

Client’s response to each intervention (If modifications necessary, what intervention would be appropriate?)1. Patient refused information offered.

Was the desired outcome achieved? (Met unmet, partially met) Why?Patient did not achieve outcome; anxiety is too high to listen to options.

Diagnostic Studies:

TEST NORMAL CLIENT NURSING IMPLICATIONS

Risk Factors for Medical Diagnoses:

List risks that lead to each diagnosis given.

Example: Smoking is a risk for COPD or ASHD

Learning Needs/Discharge Needs

May be used as nursing diagnoses also.

Nutritional/ Fluid Needs while hospitalized

Include I&O necessary and caloric intake in addition to special needs.

Growth and Development

Expected Developmental

Physiological

Psychosocial

Directly from Book