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 TestsIdentify and list a summary of relevant and significant lab values and diagnostic tests/proceduresperformed. Include the rationales for performing the tests and for any abnormal results. Providean analysis of the relationships between/among the diagnostic tests and lab results with thecritically‐ill individual’s current condition(s).

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 andgeneric 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 towhy the medication is prescribed for treatment. For example, document the rationale for how thetreatment corrects the critically‐ill individual’s condition or a side effect of another drug that isprescribed 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 thispatient. Two of the nursing diagnoses must address actual problems, and one of the nursingdiagnoses 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) collaborativeinterventions. *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, andnutrition (prescribed diet, tube feedings/TPN, formula, rate, and calculation of basal energyexpenditure (BEE), patient education, wound care etc.). The rationale must be included for eachintervention.

Interdisciplinary (ID) CareCollaborative Management

Identify the members of the interdisciplinary team caring for the critically‐ill individual. Providea brief description of their roles and responsibilities. Interdisciplinary team members include,but are not limited to: physician, pharmacist, lab/diagnostic tests personnel, respiratorytherapy, physical therapy, occupational therapy, speech therapy, social work/casemanagement, pastoral care, ethicist, etc.

Therapeutic Modalities

Describe the various therapeutic modalities used in the management of care for the critically‐illindividual. Discuss the extent of the nurse’s responsibilities and skills required to manage thetherapeutic modality in comparison to the responsibilities of the members of theinterdisciplinary 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 interdisciplinaryteam. Include in your summary

•  Analysis of communication style preferences among interdisciplinary team members and withthe critically‐ill individual and family members. What is the impact of your owncommunication style on others?
•  System barriers and facilitators. Did the organizational framework for interdisciplinarymanagement of care facilitate or hindered the quality of care/outcomes for the critically‐illindividual? What recommendations can you make to the organizational system for enhancing

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 aninterdisciplinary 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 ReflectionGRADING CRITERIA

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Chamberlain College of Nursing NR341 Complex Adult Health