Physical assessment: Document what you see in your case study, if it does not apply or is not stated indicate as ‘n/a’.
Nursing diagnosis: Students are to write up 4 nursing diagnoses (2 actual and 1 risk-for) using the NSC Care Plan Template. At least 1 diagnosis must be physiological. The other diagnoses may be physiological or psychosocial. Nursing diagnosis must be relevant to the assigned patient. (NANDA approved dx related to, as evidenced by)
See link for NANDA approved nursing diagnosis.
Goals: Each nursing diagnosis should have one short-term and one long-term goal, appropriate nursing interventions, and evaluation. Must be directly related to the nursing diagnosis.
Intervention: Includes interventions or nursing actions that directly relate to the patient’s goals. Further details noted in relation to the execution of nursing care interventions (action and frequency). The number of interventions is appropriate to help the patient or family meet their goal (minimum of 3 interventions per goal stated).
Intervention Rationale: Evidence-based rationale per interventions listed.
Labs: Document lab values along with normal ranges for each value and interpret the value.
Medication: Students are to write up 3 medications used in the virtual learning experience on the appropriate NSC Medication Sheet.
