Autism And Accommodations In Higher Education: Insights From The Autism Community
Background Information Summary
| Client initials: | Age: | Gender: | Primary Language |
| Allergies: | |||
| Code status: | Wt: | Ht: | BMI: |
| Admit date: | Hospital Day # | ||
|
Isolation Y N Indication |
Bleeding Precautions Y N Indication |
Fall Risk Y N Aspiration Risk Y N |
|
| Admitting diagnosis/symptoms (chief complaint upon admission): | |||
| Current medical diagnoses: | |||
| Summary of hospitalization to date: (what happened from admission to time you took care of them) | |||
| PMH/PSH: | |||
| Social history (ethnicity, occupation, marital status, family support, living situation): |
Relevant Medical ORDERS
| VS freq: | ||
| Diet: | Blood sugars frequency: | |
| Activity order: | ||
| Oxygen order: | Respiratory Tx: | |
| Dressing changes: | ||
| Other relevant orders: |
Assessment and Analysis
| Physical Assessment Findings |
Analysis of Findings (Explain significance related to current diagnosis and/or PMH.) |
|
Vital signs: I: O: |
Why and how it relates to the patient’s diagnosis. |
| Neurological/Sensory: | |
| Cardiovascular: | |
| Respiratory: | |
| Gastrointestinal & Nutrition: | |
| Musculoskeletal: | |
| Genitourinary/Reproductive: | |
| Integumentary (including incisions and drains): | |
| IV Assessment: | |
| Pain: | |
| Psychosocial: | |
Laboratory Tests (relevant admission and current labs)
| Date | Lab Test | Abnormal Lab Results | Normal Range | Rationale for performing test | Relationship between/among test results with client’s condition |
| Why and how it relates to the patient’s diagnosis. | |||||
Diagnostic Tests (x-rays, CT scans, endoscopies, etc.)
| Date | Test | Reason for test | Results/Findings | Analysis of relationship between diagnosis test and client’s condition |
| “my dog is named blue” (Davis, 2020, p1) | ||||
| Why and how it relates to the patient’s diagnosis. | ||||
(Davis, 2020)
Medications
| Trade Name | Generic Name | Medication Classification | Therapeutic Use | Major adverse effects | Time dosage | Route of administration | Nursing Consideration |
| Significant information | Significant information | ||||||
Nursing Diagnoses
List 3 pertinent nursing diagnoses for your patient and prioritize them. Two actual problems and one at-risk problem. Outcomes need to be SMART – specific, measurable, attainable, realistic and time specific. The collaborative interventions are what you do with another healthcare discipline (resp therapy, PT/OT, pharmacy, case manager, dietician, wound ostomy specialists, etc. It is not another nurse, nurse tech or notifying the MD/HCP) (Remember to delete the instructions once completed here)
| Nursing Diagnosis #1: | |
| R/T: | AEB: |
| Interventions (3) | Expected Outcome (3 -Measurable): | Collaborative Interventions (3) |
| Nursing Diagnosis #2: | |
| R/T: | AEB: |
| Interventions (3) | Expected Outcome (3 – Measurable): | Collaborative Interventions (3) |
| Primary Doctor, Nurse, Tech are not collaborative in this section | ||
| Examples of collaborative healthcare and what is the intervention | ||
| Nursing Diagnosis #3: | |
| R/T: | AEB: |
| Interventions (3) | Expected Outcome (3 – Measurable): | Collaborative Interventions (3) |
| RT-Will help in administering the ordered neb treatment for patient. | ||
| OT-How are they going to help | ||
| Diet-How are they going to help |
Routine Nursing Management – what you can do independently. Each rationale needs to have evidence-based peer-journal reference cited (Remember to delete the instructions once completed here)
Paragraph format APA. Make sure to have an in-text citation. Double spaced.
Interdisciplinary Care
· Collaborative Management
| Member of the Team | Brief description of the role & responsibilities |
| Primary Doctor | |
| Primary Nurse | |
| Tech | |
| Respir | |
| Diet | |
| OT |
· Therapeutic Modalities – The rationale must be included for each modality. The rationale must be evidence-based peer-journal referenced cited. (Remember to delete the instructions once completed here)
Nursing Reflection
Must include: (Remember to delete the instructions once completed here)
· 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.
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