Identify and list a summary of relevant and significant lab values and diagnostic tests/procedures performed.
Paper , Order, or Assignment Requirements
REQUIREMENTS: THE FOLLOWING ELEMENTS MUST BE INCLUDED IN THE PAPER
Background Information Summary:
? Demographics
? History of present illness
? Relevant past medical and surgical history
? Admitting diagnosis (diagnoses)
? Course of current hospitalization to date
? Significant assessment findings during day(s) of care. Include vital signs, focused assessment,
and data from monitoring devices. (This information can be presented in a table).
Laboratory and Diagnostic Tests
Identify and list a summary of relevant and significant lab values and diagnostic tests/procedures performed. Include the rationales for performing the tests and for any abnormal results. Provide an analysis of the relationships between/among the diagnostic tests and lab results with the critically?ill individual?s current condition(s).
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?Medications
Identify and list a summary of relevant and significant medications. Indicate the trade name and generic name, the medication classification, the therapeutic use, major adverse effects, timing, dosage, route of administration, and the nursing implications. Also include the rationale(s) as to why the medication is prescribed for treatment. For example, document the rationale for how the treatment corrects the critically?ill individual?s condition or a side effect of another drug that is prescribed for treatment. *This information can be presented in a table.
Nursing Diagnoses
In order of priority, identify three (3) nursing diagnoses for the individualized plan of care for this patient. Two of the nursing diagnoses must address actual problems, and one of the nursing diagnoses must be a ?Risk for? or ?Potential Complication? (PC). For each nursing diagnosis, include three (3) nursing outcomes, three (3) nursing interventions, and three (3) collaborative interventions. *This section can be presented as a table or concept map.
Interventions ? ROUTINE NURSING MANAGEMENT
Describe independent nursing care you provided in the care of the critically?ill individual. Examples include, but are not limited to: activity level, position, ongoing monitoring, and nutrition (prescribed diet, tube feedings/TPN, formula, rate, and calculation of basal energy expenditure (BEE), patient education, wound care etc.). The rationale must be included for each intervention.
Interdisciplinary (ID) Care Collaborative Management
Identify the members of the interdisciplinary team caring for the critically?ill individual. Provide a brief description of their roles and responsibilities. Interdisciplinary team members include, but are not limited to: physician, pharmacist, lab/diagnostic tests personnel, respiratory therapy, physical therapy, occupational therapy, speech therapy, social work/case management, pastoral care, ethicist, etc.
Therapeutic Modalities
Describe the various therapeutic modalities used in the management of care for the critically?ill individual. Discuss the extent of the nurse?s responsibilities and skills required to manage the therapeutic modality in comparison to the responsibilities of the members of the interdisciplinary team. Therapeutic modalities include but are not limited to: oxygen therapy (mode, FiO2,), dialysis/CRRT (settings), ventilator therapy (mode of ventilation, settings, FiO2). The rationale must be included for each modality.
Nursing Role Reflection
Provide a brief summary of how your role interacted with the members of the interdisciplinary team. Include in your summary
? Analysis of communication style preferences among interdisciplinary team members and with the critically?ill individual and family members. What is the impact of your own communication style on others?
? System barriers and facilitators. Did the organizational framework for interdisciplinary management of care facilitate or hindered the quality of care/outcomes for the critically?ill individual? What recommendations can you make to the organizational system for enhancing
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interdisciplinary collaboration? Provide at minimum two (2) evidence?based literature sources
to support your recommendations.
? Professional Development. Based on your experience(s), write ideas for your own professional
self?development plan to enhance your potential for becoming an effective member in an interdisciplinary team.
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