Examine your patient’s Electronic Medical Record. What are the pertinent lab values given the admitting diagnosis and current condition of your patient?

Clinical care plan

NOTICING – UTILIZING OBSERVATIONS TO RECOGNIZE PATTERNS, AND GATHER INFORMATION.

ASSESSMENT/RECOGNIZING CUES – The mental process involved in identifying relevant and important information

60 second initial visual assessment

(completed while receiving report and prior to physically assessing patient)

What do you see?

Visual cues such as room cleanliness, hygiene of patient, IV pump, O2, other lines, drains, tubes.

What information is relevant/irrelevant?

What information is most important?

What is of immediate concern?

Focused Physical Assessment

Recognize abnormal vs. normal – Recognizing signs and symptoms

What will you focus on based on this information? Perform appropriate focused assessment. Include the findings of your focused assessment

Normal	Abnormal

Admitting diagnosis:

Include the pathophysiology of the client’s admitting diagnosis, including the risk factors, signs/symptoms, diagnostics, prognosis, and treatments. You must include a resource for this information.

Patho:

Risk factors:

Diagnostics:

Prognosis/Treatments:

Identify History Of

Medical/Surgical/Home Medication/Social, Occupational History cues

Recognize contributing past history

Interview your patient.

What is their pertinent medical/surgical history?

What home meds do they take?

Where do they work, live, socialize?

Vital Signs, Lab Values and Diagnostics

Recognize abnormal vs. normal as well as pertinent information related to patient diagnosis

Document the patient’s vital signs.

Include reasoning for any abnormal vital signs.

Examine your patient’s Electronic Medical Record.

What are the pertinent lab values given the admitting diagnosis and current condition of your patient?

Lab Value

Normal Range

Patient’s Lab Value Result

Reason for Abnormal Value

What diagnostic tests has the client undergone? Include the results of the test.

INTERPRETING – MAKING SENSE OF THE DATA AND PRIORITIZING INFORMATION UTILIZING YOUR REASONING ABILITIES TO INTERPRET THE FACTS AND FORSEE POSSIBLE INTERVENTIONS
ANALYZING CUES – clustering and linking related information to create groups of individual cues
PRIORITIZE HYPOTHESIS – Evaluate and rank potential causes or risk factors to address
Based on findings from 60 second initial visual assessment Hypothesize regarding needed interventions
What will require action? Prioritizing action (i.e. bathe patient, tidy room, fluid replacement, adjust O2 etc)
Based on findings from Focused Physical Assessment Analyze and form hypothesis for future action
What assessment findings are most concerning? What makes you say that? Are there any findings that seems contradictory? (i.e. findings that may point to an alternative or additional concern) What findings are consistent with admitting diagnosis?
Based on Identifying History Of Medical/Surgical/Home Medication/Social, Occupational History cues Analyze and form hypothesis for future action
What findings did you expect based on the client’s diagnosis/concern? What medications would you expect based on the client’s diagnosis, concern, history? Are there any findings that seem contradictory? (i.e. meds expected but not present, meds present but not expected, assessment findings without interventions) What else could be going on?
Based on Vital Signs, Lab Values and Diagnostics Analyze and form hypothesis for future action
What will require action? (i.e. BP requiring treatment, increase or decrease O2, treat electrolyte imbalance, intervene regarding fluid volume status, etc.)
GENERATE SOLUTIONS – Generate a set of feasible solutions to handle emergent concerns based on prioritized hypothesis above
Things to address? What are the desirable outcomes? Things to avoid? What interventions are indicated? Which hypothesis is the most important and should be managed first? What makes you say this?

RESPONDING – UTILIZING YOUR CLINICAL JUDGMENT TO MAKE DECISIONS AND JUDGMENTS
TAKE ACTION – Implementation of the solutions based on generated hypothesis
Based on generated solutions
What are the critical safety issues and what did you do to protect the client? What interventions are needed immediately? How will you implement them? What interventions can be delegated and to whom? What specific items will you teach the client? How did you respond to patient, family and caregivers?

REFLECTING – EVALUATION OF PERSONAL EXPERIENCE AND UTILIZING JUDGMENT SKILLS

EVALUATING OUTCOMES – Understanding signs of clinical improvement or decline and reflecting on the effective outcomes of interventions

What follow-up data is needed?

What findings show interventions have been effective?

What interventions require formulating a new hypothesis?

What values show a need for continued monitoring (i.e. labs, vital signs, interventions)

What went well and what did not go well and why?

What would you do differently?

Would other interventions have been more effective?

What priorities, skills do you think you need to improve in order to care for future patients?

For the problem statements, you need to ask, “What issue could kill this patient if not addressed”? The problem needs to be a current issue, not something that has already been addressed, like surgery. The interventions need to be NURSING interventions. Nurses cannot perform surgeries, order medications or labs, etc. Use your Conceptual Nursing Care Planning textbook for ideas on appropriate nursing interventions.

Problem Statement 1
1.
Intervention Statement 1
1.
Problem Statement 2
2.
Intervention Statement 2
2.
Problem Statement 3
3.
Intervention Statement 3
3.

Medication Administration Log: In your own words please provide the following

Medication Name
Explain how this relates to the primary diagnosis
Administration route and reasoning
Common side effects
Nursing/Safety concerns
Patient/Caregiver teaching

Clincle care plan