TRICOUNTY TECHNICAL COLLEGE
NURSING 101
CLINICAL PREPARATION
Pathophysiology (disease process and/or medical diagnosis)
Medical Diagnoses:
1. Hypertension
2. Diabetes, Type II
3. Osteoporosis
4. Osteoarthritis
Textbook signs and symptoms
Client’s sign and symptoms
TRICOUNTY TECHNICAL COLLEGE
NURSING 101
CLINICAL PREPARATION
Pathophysiology (disease process and/or medical diagnosis)
Medical Diagnoses:
1. Hypertension
2. Diabetes, Type II
3. Osteoporosis
4. Osteoarthritis L Hip
Textbook signs and symptoms
Ignatavicious MedSurg or whatever book
you are using to
research above
diagnoses
From Records – Medical H&P, Progress
Notes
Client’s sign and symptoms
1. None for Hypertension
2. None except blood sugar elevated on
testing
3. None
4. R Hip pain when walking further than 1
block, back pain on awakening
Nsg Assmt and other
parts of chart
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
A
S
S
E
S
S
M
E
N
T
D
I
A
G
N
O
S
E
S
Subjective Data
Objective Data
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,
A
S
S
E
S
S
M
E
N
T
D
I
A
G
N
O
S
E
S
Subjective Data
Any history
related by patient
Objective Data
Must be
comprehensive
, these DRIVE
the care plan
Physical examination
data plus labs
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___________.
Look in NANDA book for diagnosis that fits the situation
Desired Outcome: (Goal(s)
What measurable goal will client achieve over what time frame.
Client does WHAT, HOW and WHEN.
P
L
A
N
N 1.
I 2.
N 3.
G
Interventions
Rationales
1.
2.
3.
Be specific
Be
to to
specific
Intervention
diagnoses
s
From Med-Surg or
Fundamentals
book OR written
by nurse
E Client’s response to each intervention (If modifications necessary, what intervention would be appropriate?)
V
A
L
U
A
Was the desired outcome achieved? (Met unmet, partially met) Why?
T Patient _____________________ed in ____________________ as planned.
I
O
N
Desired Outcome: (Goal(s)
Patient (Client) will learn 3 facts about arthritic hip disease by 10/2/2004 (48 hours) as
P evidenced by her describing potential treatment options to nurse.
L
Interventions
Rationales
A
1. Patient will be able to cope with situation
N 1. Provide information re: osteoporosis and
once it is known.
N hip surgery if OK with physician.
I
N
G
E
V
A
L
U
A
T
I
O
N
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
Directly from Book
Psychosocial