ABNORMAL ASSESSMENT FINDINGS: Recognize Cues

Obtain information from various sources (e.g., the environment, the pt., the family, another nurse, EHR) in different formats (e.g., visual observation, audio perception, lab results, text description, etc.). 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= (Signs and symptoms, i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc.)

 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 (e.g., organize cues in clusters), and then develops a group of probable client needs/concerns and problems.

Prioritize Hypotheses

Evaluates the hypotheses generated previously in various dimensions (e.g., urgency, likelihood, risk/difficulty/time/cost of providing care to that hypothesis, etc.), and organize them into an ordered list where the priority hypotheses (i.e., client needs/concerns/problems) are on the top.

Analysis/Hypothesis: What is the cause of the patients problem that must be prioritized at this time?

Evaluate the Hypothesis = (Signs and symptoms, i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc.)

Planning (Patient goals focus on resolving the problem), 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 (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain)

by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.)

Implementation (Specific nursing interventions that were performed during your shift): Take Action

Sorts the hypotheses (probable client needs, concerns, problems) in order (based on their evaluation in various dimensions) 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.

Evaluation (What was the outcome: Did you meet your desired goal?) 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