Medical Management and Collaborative Plan

NURS 3000 Medical Management and Collaborative Plan

Instructions/Descriptions

NURS 3000 Medical Management and Collaborative Plan

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History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).

What Brought the Pt To the Hospital? What Events Lead Up to This? What Happened When They Got to The Hospital- Until Now When You Are Providing Care? (Use Separate Attached Word Doc When Needed)

Medical History: (SEE RUBRIC REQUIREMENTS)

PAST DIAGNOSED MEDICAL PROBLEMS

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Surgical History: (SEE RUBRIC REQUIREMENTS)

PAST DIAGNOSED SURGICAL PROBLEMS

Social History:

SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE

Chief Complaint

Admitting Diagnosis & Admission Date

Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective assessment)

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH)

❋Economic Stability (MAY DELETE THESE ‘TIPS” TO USE SPACE)

❋ Education

❋Social and Community Context

❋ Health and Health Care

❋ Neighborhood and Built Environment

Concept Map (TEMPLATE)

Student Name:

Instructor:

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DATE Care Provided and UNIT:

Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)

Lab Tests

Normal Ranges

Admission Lab Values

Current Lab Values

Explain Abnormal Labs R/T Your Pt

INCLUDE: Appropriate Diagnostic Tests/ Procedures- DATEs and RESULTS

(Can add See attached Word Doc)

ANTICIPATED TRANSFER/ DISCHARGE PLANNING:

DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE

EQUIPMENT (MAY DELETE THESE ‘TIPS” TO USE SPACE)

MEDS

TREATMENT

REFERRALS NEEDED

Medical Management and Collaborative Plan

(from MD, PT, OT notes…. etc.) *Consider past 24 – 48 hours

Patient Education (In Pt.) for Transfer/ Discharge Planning

ASSESS LEARNING STYLE:

LEARNING PREFERENCE: WRITTEN, VIDEO, etc.

LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL

ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.

Medications & Allergies (2)

Medication Name

Dose

Route

Freq.

Indications (PRN meds must include MD ordered Indication)

Mechanism of Action

Side Effects/

Adverse Reactions

Nursing Considerations

RN Considerations

Concept Map (TEMPLATE)

Student Name:

Instructor:

DATE Care Provided and UNIT:

Respiratory (7)

Cardiovascular (6)

Vital Signs (4)

Neurological (5)

ASSESSMENT/

REVIEW OF SYTEMS

Musculoskeletal

(8)

GI

Hydration/Nutrition (9)

GU (10)

Rest/ Exercise (11)

Integumentary (12)

Misc.

Psychosocial (14)

Endocrine (13)

Concept Map (TEMPLATE)

Student Name:

Instructor:

DATE of Care Provided and UNIT:

Priority Nursing Diagnosis #1

Priority Nursing Diagnosis #2

PLAN OF CARE

Evaluation #1

Intervention #1

At Risk Dx.-

Outcome/Goal #1

Outcome/Goal #1

At Risk Interventions

At Risk Outcomes/

Goal

Evaluation #2

At Risk Evaluation Plan

Interventions # 2

(VM/GP/KL-V5)

NURS 3000 Medical Management and Collaborative Plan

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