CON CEPT MAP Pathophysiology – (to the cellular level)-Client name-Tash Anderson

CON CEPT MAP

Pathophysiology – (to the cellular level)-Client name-Tash Anderson

Medical Diagnosis

Gestational Diabetes

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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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

NANDA NURSING DIAGNOSIS use NANDA definition	Expected outcomes of care (Goals)	Interventions	Patient response	Goal evaluation
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.