Name: Date:
Care Plan #
CON CEPT MAP
Pathophysiology – (to the cellular level)-Client name-
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)
.
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. | Was it met or not met there is no partially met. |
Summer 2021 JM 9