Critical Thinking and Clinical Reasoning Map Admit Date: 09/16/24 Age:
Critical Thinking and Clinical Reasoning Map Admit Date: 09/16/24 Age: 83 Gender: male Allergies: no known allergies Admit Dx: upper lobe mass/ guided lung biopsy Code Status: full code Allergies: Activity: standard precautions Diet: cardiac Vital Signs 0800 1200 1600 T 37 HR 82 RR 16 BP 129 / 78 O2 97 In the event an assessment area below is not appropriate simply put NA in the box Neuro: A & O x ________ / Confused: _________________________ PERRLA / Cooperative /Clear speech / Other: ___________________________________________ Activity: Up ad lib / 1 or 2 person assist / Bed rest / BSC / Walker / Cane / Bed Alarm / Fall Risk / Neuro ✓ Normal… please answer all Alert and oriented Cardiac: Pink / Pale / Warm / Cool / Dry / Diaphoretic / Other_____________ Cap Refill time: ________ S1 / S2 / S3 / S4 / Tele / Rhythm: ________________ Auscultation: Reg / Irreg: Murmur: ___________________ Edema: None / Gen / R L / Bilateral Trace 1+ 2+ 3+ Pitting / Non-pitting Location____________ Pulses: Radial: Strong / Weak / Not palpated/ Doppler / equal / _____ Pedal: Radial pulses: Strong / Weak / Not palpated/ Doppler / equal / _____ Normal…please answer the all Respiratory: O2 @ __________L NC / Mask / NRB / Room air / Other ____________ FIO2: ________ L: ________ Breath Sounds: L: Clear / Diminished / Wheezing / Crackles / Coarse R: Clear / Diminished / Wheezing / Crackles / Coarse Increased WOB: Yes / No Cough: Yes / No Productive / Non-productive / NA Treatments: IS / SVN / Suction: Normal.. Please answer GI: BS: Hypo / Active / Hyper Assess: Nausea / Vomiting: ______ Last BM: _________ Consistency/ Color: _________________ Abd: Soft / Tense / Firm / Non tender / Tender / Distended normal.. Please answer all GU: Voiding / Foley / Incontinence / Anuria Clear / Cloudy / Yellow / Amber / Bloody / Other: ______________ BR / Urinal / BSC / Bedpan / External Cath normal: please answer all M/S: Upper Strength _____/5 in RUE / RLE Lower Strength _____/5 in LUE / LLE Weak/ Numb / Decreased ROM / Other: Gait: _____ Normal: please answer all Skin/Wounds Description: No negative pressure wound T Location: line drains: pleural right tube for pneumothorax IV: Site: _____ Gauge: _____ Saline-locked: Yes / No Maintenance Fluid: _____________ Rate: ________ Date placed: _____ S&S of infiltration or phlebitis: Yes / No Venous left wrist 20 Please answer all Precautions: Fall / Bleed / Contact / Airborne / Droplet / Protective standard All Complete Lab section if appropriate. In the event your patient does not have labs simply put NA in the box. Lab Result Date/Time PT/INR PTT Blood Glucose 1. ______ 2. _____ 3. ______ 4. ______ 1. _____ 2. _____ 3. _____ 4. _____ ABG pH PaCO2 HCO3 Diagnostic Tests: lung biopsy. Note: NA-141, Cl__, BUN-30, K-3.8, HCO3__, Cr-1.39, glucose-86 Please answer all lab Pathophysiology Complications/Potential Complications (Risk Reduction): Psychosocial Concerns (Psychosocial Integrity): Recognizing Cues: Assessment findings that warrant further investigation (VS/Subj./Obj./Labs/Diagnostics/Risk Factors/Psychosocial): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **May have more than 10 cues Prioritize Hypotheses: These are your Nursing Problem Statements. What do you think is the highest priority? What is it related to? Is it an actual problem or a risk problem? Take Action: These are your interventions. What will you do to help improve your client’s condition or prevent further deterioration? (Basic care & Comfort, Safety and infection control, Pharmacological therapies, Education, Health promotion, and management of care): Generate Solutions: Planning and goal setting. What do you want as an outcome for your client? Goals should be SMART goals. Analyze Cues: What do you think might be going on with the client? What does it mean? This is where you analyze the data you collected: Evaluate Outcomes: Did your actions result in the desired outcome for your client? Medication Name (Generic) and Drug class Patient’s Dose, Route, and Frequency Why is patientreceiving this medication? Nursing considerations (labs, assessment, etc.) Side effects and Major adverse effects Patient Teaching Eliquis 2.5 mg PO bid Apixaban 100 mg PO Daily Cozoar 100 MG PO daily Flomax 0.4 MG PO daily Lipitor Statin 20 MG PO daily Norvasc 10 MG PO daily Apresoline 10 MG IV Q4H PRN Lortab 1 tab Q4H PRN Melatonin 5 MG PO bedtime PRN Please answer all boxes in medication Patient Teaching (Health Promotion, Safety and Infection Control, and Management of Care): Summary Report to Healthcare Provider (SBAR Format): S- B- A- R-
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