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ASSESSMENT Refer to your actual nursing clinical assessment RASMUSSEN UNIVERSITY Multidimensional Care I Clinical Packets NURSING CARE PLAN QSEN: Evidence-Based Practice, Informatics, Client-Centered Care Teamrork and Collaboration, Quality improvement NURSING DIAGNOSIS Utilize nursing diagnosis approved by NANDA PLANNING Write (1) short-term/SMART goals or (1) long-term goals) INTERVENTIONS Write (1) independent, (1-2) dependent and (1-2) collaborative interventions related to the nursing diagnosis EVALUATION Did you meet your goals? If yes, what is/are your evidence? If No, explain why the goal wasn't met Subjective cues: Priority Problem #1: Nursing Diagnosis Related to: Objective Cues: As evidenced by: Subjective cues: Priority Problem #2: Nursing Diagnosis Objective Cues: Related to: As evidenced by: V.2 Medication Data Sheet 5

ASSESSMENT Refer to your actual nursing clinical assessment RASMUSSEN UNIVERSITY Multidimensional Care I Clinical Packets NURSING CARE PLAN QSEN: Evidence-Based Practice, Informatics, Client-Centered Care Teamrork and Collaboration, Quality improvement NURSING DIAGNOSIS Utilize nursing diagnosis approved by NANDA PLANNING Write (1) short-term/SMART goals or (1) long-term goals) INTERVENTIONS Write (1) independent, (1-2) dependent and (1-2) collaborative interventions related to the nursing diagnosis EVALUATION Did you meet your goals? If yes, what is/are your evidence? If No, explain why the goal wasn't met Subjective cues: Priority Problem #1: Nursing Diagnosis Related to: Objective Cues: As evidenced by: Subjective cues: Priority Problem #2: Nursing Diagnosis Objective Cues: Related to: As evidenced by: V.2 Medication Data Sheet 5

3-2-1 Code It
3-2-1 Code It
6th Edition
ISBN:9781337660549
Author:GREEN
Publisher:GREEN
Chapter19: Insurance And Reimbursement
Section: Chapter Questions
Problem 5MC
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A 69 year old with esophageal cancer, Ngtube, thyroidectomy, laryngectomy. Pain level is at 5 and a full code.
ASSESSMENT Refer to your actual nursing clinical assessment RASMUSSEN UNIVERSITY Multidimensional Care I Clinical Packets NURSING CARE PLAN QSEN: Evidence-Based Practice, Informatics, Client-Centered Care Teamrork and Collaboration, Quality improvement NURSING DIAGNOSIS Utilize nursing diagnosis approved by NANDA PLANNING Write (1) short-term/SMART goals or (1) long-term goals) INTERVENTIONS Write (1) independent, (1-2) dependent and (1-2) collaborative interventions related to the nursing diagnosis EVALUATION Did you meet your goals? If yes, what is/are your evidence? If No, explain why the goal wasn't met Subjective cues: Priority Problem #1: Nursing Diagnosis Related to: Objective Cues: As evidenced by: Subjective cues: Priority Problem #2: Nursing Diagnosis Objective Cues: Related to: As evidenced by: V.2 Medication Data Sheet 5
Transcribed Image Text:ASSESSMENT Refer to your actual nursing clinical assessment RASMUSSEN UNIVERSITY Multidimensional Care I Clinical Packets NURSING CARE PLAN QSEN: Evidence-Based Practice, Informatics, Client-Centered Care Teamrork and Collaboration, Quality improvement NURSING DIAGNOSIS Utilize nursing diagnosis approved by NANDA PLANNING Write (1) short-term/SMART goals or (1) long-term goals) INTERVENTIONS Write (1) independent, (1-2) dependent and (1-2) collaborative interventions related to the nursing diagnosis EVALUATION Did you meet your goals? If yes, what is/are your evidence? If No, explain why the goal wasn't met Subjective cues: Priority Problem #1: Nursing Diagnosis Related to: Objective Cues: As evidenced by: Subjective cues: Priority Problem #2: Nursing Diagnosis Objective Cues: Related to: As evidenced by: V.2 Medication Data Sheet 5
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