Download Alternative-Clinical-Assignment-Putting-the-Pieces

Putting the Pieces Together:
Digging Deeper to Promote Clinical Reasoning
Part I. INITIAL Data Collection from the Medical Record
(Start with admission or when complication developed)
Chief complaint/Presenting signs & symptoms:
What data is relevant to this patient that must be recognized as clinically significant to the nurse?
Rationale:
Part I. Developing Critical Thinking by Identifying Relationships:
1. What is the relationship of your patient’s past medical history (PMH) and current medications?
(if >10 PMH or home meds choose no more than 10 that are most relevant and contributory to chief complaint)
Home Meds:
Mechanism of Action (be brief):
Expected Outcome:
PMH:
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© 2011 Keith Rischer/www.KeithRN.com
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:
What Came First:
What then followed:
3. What is the medical problem that your patient is presenting with?
4. What is the relationship between your patient’s chief complaint & medical problem?
(Look at pathophysiology and how it influences what you are seeing with your assessment findings)
Chief Complaint:
Relationship to primary medical problem:
5. What is the relationship between your patient’s INITIAL abnormal VS and assessment data &
identified primary medical problem?
RELEVANT VS/assessment data:
Relationship to primary medical problem:
© 2011 Keith Rischer/www.KeithRN.com
Lab Results:
Lab Test INITIAL
Na+
K+
Mg+
Creat.
WBC
Neut. %
Hgb.
CURRENT
Which labs when trended are showing improvement and/or reveal concerning potential complications?
What is the relationship between your patient’s RELEVANT diagnostic labs & identified primary
problem?
RELEVANT Diagnostic results:
Relationship to primary medical problem:
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PRIORITY LAB: Choose most relevant lab for your patient and address the following:
Lab
Normal value
Value
Critical value
Why
Relevant???
Nsg. Assessments/interventions required:
Radiology Reports:
How do these radiology findings relate to primary problem?
© 2011 Keith Rischer/www.KeithRN.com
INITIAL Clinical Reasoning Begins
1. What body system(s) will you focus on and thoroughly assess based on their INITIAL primary
problem/complication?
2. What nursing priority will guide your plan of care?
#1 Nursing PRIORITY:
Data to support:
3. What interventions will you initiate based on this priority?
Nursing Interventions
Rationale:
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4. What is the worst possible complication to anticipate?
5. What nursing assessment(s) will you need to identify and respond if this complication develops?
INITIAL Medical Management: Rationale for Treatment & Expected Outcomes
Choose at least 3-5 Physician orders (new medications/treatments/labs) written that are most relevant to your patient
when they first experienced their change in status
NEW-MD Orders/Meds: Rationale:
Expected Outcome:
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© 2011 Keith Rischer/www.KeithRN.com
Part II: CURRENT: Bedside Patient Data Collection Begins:
Your Initial VS:
T:
P:
R:
BP:
O2 sats:
What VS data is relevant to this patient that must be recognized as clinically significant to the nurse?
Rationale:
CV
Resp
Heart Tones:
Breath sounds:
Color:
Temp:
Pulses:
Resp. effort:
Neuro
a/o to:
person:
place:
time:
situation:
GI
GU
BS:
Urine color:
Abd:
Clarity:
Skin/Pain
Incision:
Musculo
Strength:
Tol. to activity:
Dry/moist:
Appetite:
Foley:
O2:
Fall risk?:
Integrity:
Edema:
LOC:
Flatus:
IS volume:
Tele:
I/O:
Braden:
BM:
Drains:
What assessment data is relevant that must be recognized as clinically significant to the nurse?
Rationale:
CURRENT Medical Management: Rationale for Treatment & Expected Outcomes
Choose at least 3-5 Physician orders (new medications/treatments/labs) written that are most relevant to your patient from
the last 24 hours (yesterday & today)…Go to primary physicians progress note today/yesterday
NEW-MD Orders/Meds: Rationale:
Expected Outcome:
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© 2011 Keith Rischer/www.KeithRN.com
Current Clinical Reasoning Begins
1. What nursing priorities will NOW guide your plan of care?
#1 Nursing PRIORITY
Data to support:
2. What interventions will you initiate based on this #1 priority?
Nursing Interventions
Rationale:
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3. What body system(s) will you focus on and thoroughly assess based on their CURRENT primary
problem?
4. What is the worst possible complication to anticipate? Has it changed from admission?
5. What nursing assessment(s) will you need to identify and respond if this complication develops?
Part V: Education Priorities/Discharge Planning
1. What will be the most important education priorities you will reinforce with their medical condition to
prevent readmission?
2. What modifications will you need to make related to your teaching methods based on the patient’s age,,
culture, and level of health literacy?
© 2011 Keith Rischer/www.KeithRN.com
Quality & Safety Education for Nurses: QSEN Competencies
What is QSEN and why is it relevant to the professional nurse? (go to: www.qsen.org)
Answer the following questions in your own words based on your application of QSEN competencies
Patient Centered Care
How can you ensure and assess the effectiveness of communication with the patient and family?
(QSEN-Patient Centered Care)
How can you ensure that your patient is an active partner while under your care and promote self-care
once they are discharged? (QSEN-Patient Centered Care)
Teamwork & Collaboration
What can you do to facilitate safe and effective update/report to the physician or oncoming nurse?
(QSEN-Teamwork and Collaboration)
Informatics
What medical electronic data bases are available in your clinical setting that would be a resource if
needed to obtain needed information on a medication you have not given before or an illness/surgery you
have never seen before? (QSEN-Informatics)
Safety/Quality Improvement
What would you as the nurse do if you almost gave the wrong dose of one of the ordered medications
because of a similarity in the label provided by pharmacy to another drug? (Use this institution’s policy)
(QSEN-Safety/Quality Improvement)
Evidence Based Practice
As a new nurse, what resources could you utilize to provide current, evidence based and individualized
care planning based on the needs of this patient? (QSEN-Evidence Based Practice)
© 2011 Keith Rischer/www.KeithRN.com