ABNORMAL ASSESSMENT FINDINGS: Recognize Cues
Obtain information from various sources in different formats . TIME OUT!!! Do you have an accurate match or are additional data required, or does another cue from abnormal assessment findings need to be investigated?
Assessment: What are the identified abnormal findings:
List S&S=
Analysis Cues
Interprets cues from their existing knowledge base and nursing perspective, evaluate cues in terms of relevancy, importance, and interrelationship among other cues, organize cues in the mental representation of the scenario , and then develops a group of probable client needs/concerns and problems.
Prioritize Hypotheses
Evaluates the hypotheses generated previously in various dimensions , and organize them into an ordered list where the priority hypotheses are on the top.
Analysis/Hypothesis: What is the cause of the patients problem that must be prioritized at this time?
Evaluate the Hypothesis =
Planning , Must be SMART goals Generate Solutions
Develops a list of actions to address the priority hypothesis. The student nurse then selects the appropriate action from the list and carries out the action. TIME OUT!! The desired outcome must meet criteria to be accurate. The outcome must be specific, realistic, measurable, and include a time frame for completion. Does the action verb describe the patient’s behavior to be evaluated? Can the outcome be used in the evaluation step of the nursing process to measure the patient’s response to the nursing interventions listed below?
will
by the: or within:
Implementation : Take Action
Sorts the hypotheses in order and carries out the action(s) to address the hypothesis/hypotheses with highest priority.
Must contain the following: Assess {observe, auscultate, palpate, percuss}; Monitor; Prepare, administer; Collaborate w/ specific multi-disciplinary team; & teach, i.e., VERBS
1._____________________________________________________________________________________
2.____________________________________________________________________________________
3._____________________________________________________________________________________
4. ____________________________________________________________________________________
Evaluation TIME OUT!! Re-Assess the Patient: Do your interventions address further monitoring of the patient’s response to your interventions and to the achievement of the desired outcome? Are qualifiers: when, how, amount, time, and frequency used? Is the focus of the action’s verb on the nurse
Goal; Met or Not met or partially met and how to revise.
Goal: □ Met Goal: □ Not Met Goal: □ Partially Met Goal: □ Unable to Assess
