Explanation of Medical Diagnosis
Now, it’s time to turn in your semester project. Remember your project should include the following:
A Mental Health Concern – and the Patient or Community – for your project.
A brief history of the patient including diagnoses and medications – or a brief description of the community issue.
Any substance abuse, addiction or violence issues surrounding this mental health problem. Describe the attempted interventions that have been made for your patient or community, and identify what has been successful and what has not. Submit a rough draft of information gathered so far.
Describe your thoughts regarding your patient’s or community’s mental health issue. Are there any cognitive concerns? Think about interventions that may be helpful. Include sources for evidence-based practice.
List appropriate nursing interventions for your chosen patient or community. How will you evaluate effectiveness? Include an evaluation tool or rubric.
Complete your Semester Project by identifying mental health resources that can be used for your chosen patient or community. Finish with an educational tool for your patient or community.
Case Study-
RASMUSSEN COLLEGE
School of Nursing
FORM #3
PATHOPHYSIOLOGY
Explanation of Medical Diagnosis
Diagnosis _______________________________________________________________
Pathophysiology __________________________________________________________________________________________________________________________________________________________________________________________________________________
Textbook Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________
Client’s Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________
Recommended Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________
Current Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________
Teaching __________________________________________________________________________________________________________________________________________________________________________________________________________________
Prevention __________________________________________________________________________________________________________________________________________________________________________________________________________________
RASMUSSEN COLLEGE
School of Nursing
FORM #3
PATHOPHYSIOLOGY
Explanation of Medical Diagnosis
Diagnosis _______________________________________________________________
Pathophysiology __________________________________________________________________________________________________________________________________________________________________________________________________________________
Textbook Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________
Client’s Signs and Symptoms __________________________________________________________________________________________________________________________________________________________________________________________________________________
Recommended Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________
Current Treatments __________________________________________________________________________________________________________________________________________________________________________________________________________________
Teaching __________________________________________________________________________________________________________________________________________________________________________________________________________________
Prevention __________________________________________________________________________________________________________________________________________________________________________________________________________________
Medication Sheets
A. What is the medication used for?
B. Why would a patient being taking it?
C. What are the most common side effects?
D. What vital signs could be affected?
E. What labs could be affected?
Drug name
Answer to 5 questions
A.
Vital signs:
B.
C.
Labs:
D.
E.
Drug name
Answer to 5 questions
A.
Vital signs:
B.
C.
Labs:
D.
E.
NURSING DIAGNOSES
FORM#8
PRIORITY #
NURSING
DIAGNOSIS
RELATED/TO
(R/T)
AS EVIDENCED BY (AEB)
RATIONALE FOR PRIORITIZATION
Nursing Process Report Form
FORM#9
Nursing Diagnosis (R/T and AEB):
Assessment Data
Nursing Interventions
Scientific Rationale
(including references)
Subjective Assessment
Objective Assessment
Assessment
Decrease Stressors and/or Strengthen Lines of Defense
Teaching Counseling
Measurable and Realistic Outcomes
Short Term
Long Term
Short Term Outcome: _____ Met _____ Partially Met _____ Not
Describe:
Long Term Outcome: _____ Met _____ Partially Met _____Not Met Describe:
References