Assignment task: Cliff Brown, a 50-year-old male, was admitted to the hospital one week ago. He presented with complaints of lethargy, nausea and vomiting, lower extremity edema, pruritus, and fatigue. He has a longstanding history of type 2 Diabetes mellitus and hypertension. He denies any other medical illnesses. Cliff is a well-nourished and developed male on physical assessment with moderate distress. B/P 195/118, Pulse 92, Respiration 28, temperature 97.8F, Oxygen saturation 94% on room air. Body weight 196Ibs. HEENT was remarkable for fundoscopic findings of A-V nicking and copper wire changes consistent with the hypertensive injury. The cardiac exam had an S1, S2, and S4 (loud A2 component over the aortic area and apical impulse low and out). A 2+ lower extremity edema and superficial excoriations of his skin from scratching were noted. 24-hour urine protein and creatinine - volume 850ml, protein 600mg/dl, creatinine 180 mg/dl, BUN 170.
Assessment (Recognizing Cues); Which client information is relevant? What client data is most important? Which client information is of immediate concern Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data.
Analysis (Analyzing Cues); Which client conditions are consistent with the cues? Do the cues support a particular client's 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 severe explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions.
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 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 client's care outlook or status improve?