Select a patient with the following diagnoses: Sepsis. The patient may have more than one medical diagnosis, paper should include all of the diagnoses that are relevant.
– Write a paper
– Describe the chief complaint and the situation surrounding the admission in a concise and clear format.
– Discuss each diagnosis by clearly explaining the etiology, the pathophysiology involved, specific risk factors of the patient, describe abnormal findings from your physical assessment and how they relate to the disease process.
Interpretation of Data
– Discuss the hospital course of care for the patient you have selected as well as diagnostic data such as; CXR for pneumonia patient if chosen and/or a 12 lead EKG, cardiac enzymes, electrolyte profile and hemodynamic values, if they are available.
– Discuss any other tests as appropriate and discuss the reason the particular test was ordered and the meaning of the test results.
Goals of Treatment
– Based on current literature, compare and contrast evidence-based practice goals of treatment with the actual patient care received.
Core Measure
– Discuss if the treatment rendered could be described as evidence-based practice utilizing Core Measures. (Discuss the treatment
rendered and compare it to what is stated in the current literature and the rationale).
Nursing Diagnosis
– Discuss the most important NANDA approved nursing diagnosis.
National Patient Safety Goals can be addressed here if applicable.
Collaborative Interventions and Rationale
? Discuss collaborative interventions and why they were ordered for the patient.
? Discuss if the prescribed collaborative interventions were effective.
? Evidenced-based practice may also be part of this collaborative process.
Evaluation
Examine the existing nursing care plan of your patient.
? Were the goals stated on the nursing care plan met or unmet at the time you evaluated them?
? Would you change the care plan in any way?
? You may include a copy of the patients care plan as an addendum to your paper.
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