RLE 2

• involves gathering patient data via the health history and examination.
• Clinical reasoning process is used to analyze the patient data and develop hypotheses as to the patient’s problem or problems.
• Three things you learned: 1
• Two things that you’d like to learn more about: 1
• This closure activity is to evaluate what the students learned after the discussion and the activity.
• One question you still have: 1
• Once the problems are defined, the nurse develops the plan of care and implements and evaluates it.
• During the process, the nurse records the patient assessment findings and the plan of care in the patient record to communicate the patient’s story and the nurse’s clinical reasoning and plan to the other health care team members.
• Nursing assessment and critical thinking are intricately intertwined and neither exists in isolation.
• Plan is often more fluid, encompassing changes and modifications that emerge from each patient encounter.
• Develop a plan agreeable to the patient.
• Develop and record a plan for each patient problem.
• Specify which action is next.
• Your plan flows logically from the problems or diagnoses you have identified.
• Test the hypotheses and establish a working nursing diagnosis.
• The plan should reference the diagnosis, therapy, and patient education for each individual.
• By consulting the clinical literature, you embark on the lifelong goal of evidence-based decision making.
• The comprehensive health history and physical assessment build the foundation of the clinical assessment.
• The decision to do an entire head-to-toe physical assessment or a systems-specific assessment is based on observable signs and symptoms.
• When obtaining the patient history, additional information to try and pinpoint the patient’s “real problem” might include more information regarding family history, secondary complaints, laboratory data, and psychosocial issues.
• The next step in caring for a patient is to formulate nursing diagnoses.
• For each patient problem, a plan should begin discharge planning, include referral to dietician, flow logically from identified diagnoses, specify which steps are needed next, and identify timing of family involvement.
• The pivotal aspect in determining how to move from each patient problem to its goals is your clinical reasoning process.
• Extraocular movements are full and equal on exam.
• Subjective data are what the patient tells you, while objective data are what you detect during the examination.
• The history, from Chief Complaint through Review of systems, is part of the health history.
• All physical examination findings are part of the physical examination.
• Rapport develops between the nurse and the patient and a mutual trust begins during the history taking.
• As the fact-finding mission of the health history proceeds and data are collected, the nurse is putting pieces of the patient’s puzzle together.
• By asking questions, the nurse clarifies the patient’s problems and teaching needs during the history taking.
• Each time the patient has a positive response to a question, the topic should be addressed further during the history taking.
• As a new nurse, the questions you need to ask seem endless, and the use of the mnemonic “OLD CART” is beneficial as an instrument in assisting the new nurse to formulate relevant and inter-related questions.
• The five steps of the nursing process are all incorporated into the patient’s plan of care and revised as the patient’s health status changes.
• The first step of assessment involves gathering patient data via the health history and examination.
• Implementation of the interventions can be completed by the patient, the family or members of the health care team.
• Identifying abnormal or positive findings involves making a list of the patient’s symptoms, the signs that you observed during the physical examination and any laboratory reports available to you.
• The assessment phase continues throughout the entire patient encounter, which provides the potential for updates in the plan of care based on new assessments and data.
• Clustering the findings involves analyzing the data to evaluate the patient’s health status.
• Making hypotheses about the nature of the patient’s problem involves drawing on all the knowledge and experience you can muster.
• Planning, the third element of the nursing process, involves devising the best course of action to address the patient’s diagnosis.