Multiple Patient Care Assignment (25 points)
Student Name:
Course Learner Outcome Four: Demonstrate nursing judgment by selecting and prioritizing interventions, monitoring the patient’s response, and reporting changes.
Outcome competencies: The student will use and appreciate evidence-based care when conducting a focused assessment, choosing nursing interventions within a plan of care, monitoring, and reporting changes in the individualized patient’s condition across the lifespan.
Assignment: Choose two patients for this assignment and collect the requested data for both in section 3 only. Sections 1, 2, & 4 (including goals, outcomes, & interventions) are for one patient, whichever one you choose to focus on. The student will meet the competencies upon successful completion of the Kardex and clinical judgment model.
Section I:
This section should be completed on only one patient and that is the one you choose to complete the concept map on.
Patient A OR B _______
| Date of care:3/27/2024
|
Age Range:62 | Gender: Female | Clinic or site of care: Family medicine | |
| Reason for care: Routine check-up
Primary medical diagnosis: hyperlipidemia |
Medical History: laparoscopic sleeve gastrectomy
Surgical procedures as applicable: Gastrectomy |
|||
| Pathophysiology of primary diagnosis (include definition, causes, and treatments and a citation of the source): hyperlipidemia
|
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Section II:
****Include: TREATMENTS (list the treatments the patient is receiving such as dressing changes, blood glucose monitoring, NG tasks, Foley tasks, IS, SCDs, CDB, etc.) and labs that correlate to the any area of the head-to-toe assessments below for the one patient you choose to complete the concept map on.*****
| Treatment/Abnormal Labs/Diagnostic tests | When was it ordered and how often? | Why was it ordered?
(How does this correlate with the diagnosis/hospitalization?) |
Rationale
(Identify and explain the reason why the test or treatment was done) |
Normal Range for lab value |
| Example: Blood Sugars | 1/16/15
ac and hs |
Pt has a foot ulcer, is a brittle diabetic and has uncontrolled diabetes. Admitted with a blood sugar of 400 on 1/16/15. | Abnormal blood sugars can affect the healing process and circulation especially if they are above normal. Nerves and blood vessels can be damaged by excessive sugar that circulates in the blood. | From 70 to 130 mg/dl for adults |
| Wbc | 3/23/24 | 10.5 | ||
| Rbc | 3/23/24 | 4.05 | ||
| hematocrit | 12/21/23 | 39.1 | ||
| hemoglobin | 2/2/24 | 13.3 | ||
| mvc | 2/2/24 | 96.3 | ||
| mch | 2/2/24 | 33 |
Section III:
This section should be completed on both patients. It should include all the medications you administered and any PRNs they are presently taking.
Patient A:
MEDICATIONS (List medications you are responsible for) Patient A
| Generic name/Trade name
Dose Normal dose range |
Route | Lab tests related to medication | Classifications
(Therapeutic and Pharmacological) |
List 3 side effects for each medication.
|
Nursing considerations – what are you going to watch for? | Relating to which medical diagnosis/Why is this medication prescribed for this diagnosis and for this specific patient?
|
| Albuterol | inhale | |||||
| Alprazolam | tab | |||||
| diclofenac | gel | |||||
| hydrocodone | oral | |||||
| Scopolamine | oral | |||||
| Ondansetron 4mg | oral | |||||
| Zolpidem 5 mg | oral |
ALLERGIES
| Allergies/Types of reactions: oxycodone and nsaids |
Patient B:
MEDICATIONS Patient B
| Generic name/Trade name
Dose Normal dose range |
Route | Lab tests related to medication | Classifications
(Therapeutic and Pharmacological) |
List 3 side effects for each medication.
|
Nursing considerations – what are you going to watch for? | Relating to which medical diagnosis/Why is this medication prescribed for this diagnosis and for this specific patient?
|
| Albuterol prn every 4hrs | ||||||
| Codeine guaifenesin | oral | |||||
| hydrocortisone | ||||||
| Benzonatate 200mg 3/days prn | ||||||
ALLERGIES
| Allergies/Types of reactions: medium allergy to penicillin and Vaginal infection to Latex( condom) |
Section IV:
Identify one nursing problem and identify if this problem is for Patient A or Patient B. List all supporting data in the box you can identify for that patient for the problem with a focus on medications. After you have completed this portion of the assignment, in the next section complete the GOIs for that particular problem and same patient with a minimum of 3 nursing interventions. Get Improvement Plan Tool Kit Essay Help
NURSING PROBLEM: ______________________________________________________________________ Patient A or B _______
| Supporting data: |
Goals, outcomes, interventions worksheet:
| Problem # 1 Title:
Problem Definition: |
|
| Explain why this problem is a priority for this patient: | |
| General Goal: | |
| Predicted Behavioral Outcome Objective(s): The patient will on the day of care. | |
| Independent Nursing Interventions/Rationale:
1.
2.
3.
4.
|
Patient Response to Interventions
1.
2.
3.
4.
|
| Evaluation: (Identify the status of your patient at the end of your shift. Did the interventions help minimize or alleviate the problem you identified?) |
Adapted from: Schuster, P. (2006) Concept Mapping: A critical thinking approach to care planning. Philadelphia: FA Davis.
Medication Assignment Rubric: 25 points
| Section 1
Overview |
1 point
– Little to nothing complete – No details |
2 points
– Half completed – Few details |
3 points
– Everything complete but not very detailed – Some missing |
4 points
– Majority completed – Some details |
5 points
– Everything completed with details |
| Section 2
Allergies & Treatment, Labs, Diagnostic Tests |
1 Point
– Little to nothing complete – No details |
2 points
– Less than half completed with no rationale – Little detail |
3 points
– Half completed with some rationales |
4 points
– Everything complete but missing details or rationales |
5 points
– Everything completed – Full details WITH RATIONALES |
| Section 3
Medications: Patient A |
1 point
– Little to no meds or allergies listed – No relationship included
|
2 points
– Some meds listed – Missing components |
3 points
– More than half complete – Most relationships, side effects, classifications
|
4 points
– Everything complete – Missing components
|
5 points
– Everything completed – Relationship to diagnosis included |
| Section 3
Medications: Patient B |
1 point
– Little to no meds & allergies listed – No relationship included
|
2 points
– Some meds listed – Missing components (relationship, side effects, classifications)
|
3 points
– More than half complete – Most relationships, side effects, classifications
|
4 points
– Everything complete – Missing components (relationship, side effects, classifications)
|
5 points
– Everything completed – Relationship to diagnosis included |
| Section 4
Supporting Data & Behavior Outcomes |
1 point
– Little to no supporting data – Only 1 nursing intervention w/ goal for each patient |
2 points
– Less than half supporting data completed – Only 2 nursing interventions w/goal listed for each patient |
3 points
– More than half supporting data completed – Only 3 nursing interventions w/goal listed for each patient |
4 points
– Supporting data completed – Only 4 nursing interventions w/goal listed for each patient |
5 points
– Includes data supporting diagnosis – More than 4 nursing interventions w/goal listed for each patient |