Describe independent nursing care you provided in the care of the criticallyill individual..
PURPOSE The purpose of this assignment is for the student to reflect on the nursing care of a critically-ill individual from a clinical experience. The student will demonstrate clinical reasoning skills and will discuss interdisciplinary care that had been incorporated and/or anticipated during the care of the criticallyill individual. REQUIREMENTS: THE FOLLOWING ELEMENTS MUST BE INCLUDED IN THE PAPER Background Information Summary: Demographics History of present illness Relevant past medical and surgical history Admitting diagnosis (diagnoses) Course of current hospitalization to date Significant assessment findings during day(s) of care. Include vital signs, focused assessment, and data from monitoring devices. (This information can be presented in a table). Laboratory and Diagnostic Tests: Identify and list a summary of relevant and significant lab values and diagnostic tests/procedures performed. Comprehensively include the rationales for performing the tests and for any abnormal results. Comprehensively provide an analysis of the relationships between/among the diagnostic tests and lab results with the criticallyill individuals current condition(s). Medications: Identify and list a summary of relevant and significant medications. Indicate the trade name and generic name, the medication classification, the therapeutic use, major adverse effects, timing, dosage, route of administration, and the nursing implications. Comprehensively also include the rationale(s) as to why the medication is prescribed for treatment. For example, document the rationale for how the treatment corrects the criticallyill individuals condition or a side effect of another drug that is prescribed for treatment. *This information can be presented in a table. Nursing Diagnoses: In order of priority, identify three (3) nursing diagnoses for the individualized plan of care for this patient. Two of the nursing diagnoses must address actual problems, and one of the nursing diagnoses must be a “Risk for” or “Potential Complication” (PC). For each nursing diagnosis, include three (3) nursing outcomes, three (3) nursing interventions, and three (3) collaborative interventions. *This section can be presented as a table or concept map. Interventions ROUTINE NURSING MANAGEMENT: Describe independent nursing care you provided in the care of the criticallyill individual. Examples include, but are not limited to: activity level, position, ongoing monitoring, and nutrition (prescribed diet, tube feedings/TPN, formula, rate, and calculation of basal energy expenditure (BEE), patient education, wound care etc.). The rationale must be included for each intervention. Interdisciplinary (ID) Care Collaborative Management: Comprehensively identify the members of the interdisciplinary team caring for the criticallyill individual. Provide a brief description of their roles and responsibilities. Interdisciplinary team members include, but are not limited to: physician, pharmacist, lab/diagnostic tests personnel, respiratory therapy, physical therapy, occupational therapy, speech therapy, social work/case management, pastoral care, ethicist, etc. Therapeutic Modalities: Comprehensive and accurate describe the various therapeutic modalities used in the management of care for the criticallyill individual. Comprehensive discuss the extent of the nurses responsibilities and skills required to manage the therapeutic modality in comparison to the responsibilities of the members of the interdisciplinary team. Therapeutic modalities include but are not limited to: oxygen therapy (mode, FiO2,), dialysis/CRRT (settings), ventilator therapy (mode of ventilation, settings, FiO2). Comprehensive and properly referenced the rationale must be included for each modality. Nursing Role Reflection: For ALL Criteria Provide a comprehensive summary of how your role interacted with the members of the interdisciplinary team. Include in your summary: Analysis of communication style preferences among interdisciplinary team members and with the criticallyill individual and family members. What is the impact of your own communication style on others? System barriers and facilitators. Did the organizational framework for interdisciplinary management of care facilitate or hinder the quality of care/outcomes for the criticallyill individual? What recommendations can you make to the organizational system for enhancing interdisciplinary collaboration? Provide at minimum two (2) evidencebased literature sources to support your recommendations. Professional Development. Based on your experience(s), write ideas for your own professional selfdevelopment plan to enhance your potential for becoming an effective member in an interdisciplinary team. PREPARING THE PAPER Style and Format The paper should be typed and presented in APA format, including an APA title page, use of headings, and references with intext citations. Spelling and grammar will be evaluated with this assignment. Page Limits The body of the paper should be between 710 pages, NOT including the Title and Reference pages. Background Summary 1 to 1.5 pages Laboratory and Diagnostic Tests 1 to 1.5 pages Medications 1 to 1.5 pages Nursing Diagnoses 1 to 1.5 pages Interventions 1 page Interdisciplinary Care 1 to 1.5 pages Nursing Role Reflection 1 to 1.5 pages