NURSING PROCESS TEMPLATE: Scenario: A 70-year-old male

NURSING PROCESS TEMPLATE: Scenario: A 70-year-old male with a history of hypertension fairly controlled by medication, a heavy smoker for the past 30 years. He also weighs 300 pounds, complaining of left-side weakness and both extremities. He also had a headache for the past two days. The patient also experience fatigue, and this morning he woke up with a blurry vision, confusion, difficulty speaking, and drooping of the left side of his face. The daughter was concerned so she called 911 and the 70-year-old male was transported to the hospital. In the hospital, physical exam or vital signs findings are the following. Heart rate 118 bpm, Blood Pressure 180/95, Respiratory rate 24 bpm, O2 saturation is 89%, arm and leg weakness 3/5, and decreases sensation. Assessment (Recognizing Cues) Which patient information is relevant? What patient data is most important? Which patient information is of immediate concern? Considersigns and symptoms, lab work, patient statements, H & P, and others. Consider subjective and objective data. 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? Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most seriousexplanation? What is the priority order for safe and effective care? 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) 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) Evaluation (Evaluating Outcomes) What signs point to improving/declining/unchanged status? What interventions were effective? Are there other interventions that could be more effective? Did the patient’s care outlook or status improve? CONCEPT MAP TEMPLATE: Recognizing Cues, (S&S) A B C Disease Process/Pathophysiology/Risk Factors A B C Analyzing Cues/Concerns A B C Prioritizing Hypotheses A B C Generate Solutions/Outcomes/Interventions SMART Planning 1 2 3 4 5 Takin Actions 1 2 3 4 5 Evaluating Outcomes 1 2 3 4 5 SCIENCE HEALTH SCIENCE NURSING NUR 242

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