Assessment (Recognizing Cues)
Which patient information is relevant? What patient data is most important? Which patient information is of immediate concern? Consider signs and symptoms, lab work, patient statements, H & P, and others. Consider subjective and objective data. Pt is a 58-year-old fem...
assessment recognizing cues which patient information is relevant what patient data is most important which patient information is of immediate concern cons
lOMoAR cPSD|18634763 lOMoAR cPSD|18634 Concept Map Assignment Worksheet 346 #1 NIGHTINGALE COLLEGE DIRECT -FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET NURSING PROCESS TEMPLATE: Renal - Renal failure Assessment (Recognizing Cues) Which patient information is relevant? What patient data is most important? Which patient information is of immediate concern? Consider signs and symptoms, lab work, patient statements, H & P, and others. Consider subjective and objective data. Pt is a 58-year-old female with type 2 diabetes mellitus, COPD, and chronic heart failure. She arrives today with complaints of loss of appetite, trouble sleeping, shortness of breath, nausea, edema, vomiting, as well as decreased urine output. Pt admits to not taking medications in the last two weeks, eats poorly, but has continued to maintain hydration. Labs, glucose, and vitals were obtained. BP 209/103, GFR 40, Glucose 385. Analysis (Analyzing Cues) Which patient conditions are consistent with the cues? Do the cues support a particular patient condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? The patient presenting with these symptoms are consistent with renal failure. The patient having decreased output and has not changed their oral intake. Other information that would help distinguish the diagnosis is blood work and asking further questions regarding trends, daily habits, etc. Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and efective care? Completing routine lab work such as serum creatinine, GFR, BUN can be used to indicate how severe kidney failure is. Oral medications such as ACE inhibitors, diuretics, calcium, and vitamin D. Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning - specific, measurable, attainable, realistic/relevant, time -restricted - Goal setting) Pt will take prescribed medications and have better lab values by the next visit Pt will have lower lab test results by the next visit. Pt will follow the recommended diet plan by the next visits. Implementation (Take actions) How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk) Education was presented to patient regarding *fluid intake monitoring*, diet to include low sodium, potassium, and phosphorus, and *taking all prescribed medications* and following up with her primary care provider. Pt will be referred to a nephrologist to continue to monitor kidney function. Evaluation (Evaluating Outcomes) What signs point to improving/declining/unchanged status? What interventions were efective? Are there other interventions that could be more efective? Did the patient’s care outlook or status improve? Patient verbalizing understanding and showing understanding with repeating back what was educated. Pt understands the outcomes that can occur if she does not follow the recommended interventions. Patient improved with proper education. Renal -Kidney Failure
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