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 symptomsClient’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 symptomsClient’s sign and symptoms From Records – Medical H&P, Progress Notes Nsg Assmt and other parts of chart Ignatavicious Med- Surg or whatever book you are using to research above diagnoses 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

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 ASSESSMENTASSESSMENT Subjective DataObjective Data DIAGNOSESDIAGNOSES 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, ASSESSMENTASSESSMENT Subjective DataObjective Data DIAGNOSESDIAGNOSES 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___________. Any history related by patient Physical examination data plus labs Look in NANDA book for diagnosis that fits the situation Must be comprehensive, these DRIVE the care plan

PLANNINGPLANNING Desired Outcome: (Goal(s) What measurable goal will client achieve over what time frame. Client does WHAT, HOW and WHEN. InterventionsRationales EVALUATIONEVALUATION Client’s response to each intervention (If modifications necessary, what intervention would be appropriate?) Was the desired outcome achieved? (Met unmet, partially met) Why? Patient _____________________ed in ____________________ as planned. From Med-Surg or Fundamentals book OR written by nurse Be specific todiagnoses Be specific to Intervention s

PLANNINGPLANNING Desired Outcome: (Goal(s) Patient (Client) will learn 3 facts about arthritic hip disease by 10/2/2004 (48 hours) as evidenced by her describing potential treatment options to nurse. InterventionsRationales 1. Provide information re: osteoporosis and hip surgery if OK with physician. 1. Patient will be able to cope with situation once it is known. EVALUATIONEVALUATION 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: TESTNORMALCLIENTNURSING 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 Psychosocial Directly from Book