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
6th Edition
ISBN:9781337660549
Author:GREEN
Publisher:GREEN
Chapter19: Insurance And Reimbursement
Section: Chapter Questions
Problem 5MC
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A 78 year old male presented to the ED due to jejunostomy dysfunction and tube placed 10-2 for nutrition access secondary to esophageal carcinoma and Jejuno leakage
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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