Rasmussen University Name: Date:
Care Plan #
Rasmussen University
CONCEPT MAP
Pathophysiology – (to the cellular level) Preterm Labor
Medical Diagnosis
Preterm Labor
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)
Complications
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
.
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.
PLAN OF CARE:Use your top two priorities
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NANDA NURSING DIAGNOSIS use NANDA definition |
Expected outcomes of care (Goals) |
Interventions |
Patient response |
Goal evaluation |
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NRS DX: Problem Statement: R/T: (What is the cause of the symptom) Manifested by: (Specific symptoms) |
Short term goal: Create a SMART goal that relates to hospital stay/shift/day. Long term goal: Create a SMART goal that is appropriate for discharge. |
This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes) Interventions for short-term goal: 1. 2. 3. Interventions for long term goal: 1. 2. 3. |
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch) Reassess for short-term goal: 1. 2. 3. Reassess for long-term goal: 1. 2. 3. |
Was it met or not met there is no partially met. |
Summer 2021 JM9