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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
Admitting diagnosis:
What will you focus
on based on this
information?
Perform appropriate
focused assessment.
Include the findings
of your focused
assessment
Normal
Abnormal
Patho:
Include the
Risk factors:
pathophysiology of
the client’s admitting
diagnosis, including
the risk factors,
signs/symptoms,
Diagnostics:
diagnostics,
prognosis, and
treatments. You
must include a
resource for this
Prognosis/Treatments:
information.
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.
Lab Value
Examine your
patient’s Electronic
Medical Record.
What are the
pertinent lab values
given the admitting
diagnosis and
current condition of
your patient?
What diagnostic
tests has the client
undergone? Include
the results of the
test.
Normal Range
Patient’s
Lab Value
Result
Reason for Abnormal Value
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
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