Description

This is paper is like a story telling about what care that was rendered to the patient, APA format and min pages of 10 pages not including the title page and the reference page. Patient information is attached. I need one documentation paper.

READ THE ATTACHED DOCUMENT

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. Include the rationales for performing the tests and for any abnormal results. Provide
    an analysis of the relationships between/among the diagnostic tests and lab results with the
    critically‐ill individual’s current condition(s).

NR341 RUA Interdisciplinary Care.docx Revised 06/2016

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Chamberlain College of Nursing NR341 Complex Adult Health

Medications This Part is also completed

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. 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 critically‐ill individual’s 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 critically‐ill 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

Identify the members of the interdisciplinary team caring for the critically‐ill 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

Describe the various therapeutic modalities used in the management of care for the critically‐ill
individual. Discuss the extent of the nurse’s 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).
The rationale must be included for each modality.

Nursing Role Reflection

Provide a brief 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 critically‐ill 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 hindered the quality of care/outcomes for the critically‐ill
    individual? What recommendations can you make to the organizational system for enhancing

NR341 RUA Interdisciplinary Care.docx Revised 06/2016

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interdisciplinary collaboration? Provide at minimum two (2) evidence‐based literature sources

to support your recommendations.
 Professional Development. Based on your experience(s), write ideas for your own professional

self‐development 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 in‐text citations. Spelling and grammar will be evaluated with this assignment.

Page Limits

The body of the paper should be between 7‐10 pages, NOT including the Title and Reference pages.

  •  Background Summary
  •  Laboratory and Diagnostic Tests
  •  Medications
  •  Nursing Diagnoses
  •  Interventions
  •  Interdisciplinary Care
  •  Nursing Role Reflection
    GRADING CRITERIA

1 to 1.5 pages
1 to 1.5 pages
1 to 1.5 pages
1 to 1.5 pages
1 page

1 to 1.5 pages
1 to 1.5 pages

Assignment
Criteria

Points

%

Description

Background
Information

10

10%

Includes ALL the elements as described in the assignment guidelines:

  •  Demographics
  •  History of present illness
  •  Relevant past medical and surgical history
  •  Admitting diagnosis(es)
  •  Course of current hospitalization to date
  •  Significant assessment findings during day(s) of care. Include vital signs,

    focused assessment, and data from monitoring devices.

Laboratory
and
Diagnostic
Tests

10

10%

  •  Identifies and lists relevant and significant lab values and diagnostic
    tests/procedures performed.
  •  Includes the rationales for performing the tests and for any abnormal results.
  •  Provides an analysis of the relationships between/among the diagnostic tests
    and lab results with the critically‐ill individual’s current condition(s).

Medications

10

10%

  •  Identifies and lists relevant and significant medications.
  •  Indicates the trade name and generic name, the medication classification, the
    therapeutic use, major adverse effects, and nursing implications.
  •  Includes the rationale(s) as to why the medication is prescribed for treatment.

Nursing
Diagnoses

15

15%

  •  Identifies three (3) nursing diagnoses in order of priority: 2 actual problems
    and 1 risk for or potential complications for the plan of care.
  •  Includes 3 nursing outcomes, 3 nursing interventions, and 3 collaborative
    interventions for each nursing diagnosis.

NR341 RUA Interdisciplinary Care.docx Revised 06/2016

3

Chamberlain College of Nursing NR341 Complex Adult Health

Interventions:
Routine
Nursing
Management

10

10%

  •  Describes independent nursing care provided in the care of the critically‐ill
    individual.
  •  The rationales are included for each intervention.

ID Care:
Collaborative
Management

10

10%

  •  Provides a comprehensive list of the interdisciplinary team members caring
    for the critically‐ill individual.
  •  Provides a brief description of the roles and responsibilities of each respective
    interdisciplinary team members.

ID Care:
Therapeutic
Modalities

10

10%

  •  Describes the various therapeutic modalities used in the management of
    care for the critically‐ill individual.
  •  Discusses the extent of the nurse’s responsibilities and skills required to
    manage the therapeutic modality in comparison to the responsibilities of the
    members of the interdisciplinary team.
  •  The rationales are included for each respective modality.

Nursing Role
Reflection

20

20%

Summary includes:

  •  Analysis of communication style preferences among interdisciplinary team
    members and with the critically‐ill individual and family members;
  •  Analysis of the impact of own communication style on others
  •  Description of system barriers and facilitators in relation to the quality of
    care/outcomes for the critically‐ill individual
  •  Discussion of recommendations to the organizational system for enhancing
    interdisciplinary collaboration, which are supported by at least two (2)
    evidence‐based literature
  •  Description of ideas for own professional self‐development plan to enhance
    own potential for becoming an effective member in an interdisciplinary
    team.

APA Format,
Spelling,
Grammar,
and
Mechanics

5

5%

  •  Proper APA format for title page, headings, references and in‐text citations.
  •  No errors in spelling, grammar, and mechanics