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

 
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