Download FUNDAMENTAL-TEMPLATE-Relationships1

Fundamental Reasoning:
Developing Critical/Clinical Thinking by Identifying Relationships:
Clinical Scenario:
Chief complaint/History of Present Illness:
Social/Personal History:
Initial Assessment:
VS:
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T:
P:
R:
BP:
O2 sats:
Assessment:
 RESP: breath sounds clear with equal aeration bilat., non-labored
 CARDIAC: pink, warm & dry, S1S2, no edema, pulses 3+ in all extremities
 NEURO: alert & oriented x4
 GI/GU: active BS in all quads, abd. soft/non-tender, voiding without difficulty, urine clear/yellow
 MISC: denies pain, skin integrity intact
Physician Orders:
Diagnostic Tests:
1. What is the relationship of your patient’s past medical history (PMH) and current medications?
(Which medication treats which disease? Draw a line to connect)
PMH:
Home Medications:
2. One disease process often influences the development of other illnesses. Based on your knowledge
of pathophysiology, in your patient (if applicable) which disease likely developed first that then
initiated a “domino effect” in their life?
PMH:
© 2011 Keith Rischer/www.KeithRN.com
What Came First:
What then followed:
3. What is the relationship of your patient’s PMH and current chief complaint?
What prior medical history above is relevant and likely influenced his current problem and chief complaint?
Explain your rationale
RELEVANT PMH:
Rationale:
4. Based on your knowledge of nursing theory and assessment findings, what is the most likely
medical problem that your patient is presenting with?
5. What is the relationship between your patient’s chief complaint & identified primary medical
problem? (look at pathophysiology and how it influences what you are seeing with your assessment findings)
Chief Complaint:
Relationship to primary medical problem:
6. What is the relationship between your patient’s abnormal VS and assessment data & identified
primary medical problem?
RELEVANT VS/assessment data:
© 2011 Keith Rischer/www.KeithRN.com
Relationship to primary medical problem:
7. What is the relationship between your patient’s RELEVANT abnormal diagnostic labs& identified
primary medical problem?
RELEVANT Diagnostic results:
Relationship to primary medical problem:
8. What is the relationship between the following physician orders/meds and your patient’s primary
medical problem?
(how will mech. of action of these meds/treatments impact this patient at a pathophys level to help resolve his primary problem?)
Physician orders:
How it will help resolve primary problem:
© 2011 Keith Rischer/www.KeithRN.com