Competed nursing process (clinical reasoning table) for Mr. F's first problem statement
Consider the assessments: There is a lot of valuable information included in the Case Study. But you'll notice that only a small fraction of it is included in this CRT. This is because only data associated with this problem is included here. Thus they are called "focused assessment".
Take a look at the goal statements A lot of things have to happen before Mr. F. is back to his baseline best health. Some goals we'd like to see accomplished include
1. The patient's hgb will trend toward normal within 2 days.
2. The patient's will diurese 2 liters today and will be down to baseline weight within 3 days.
These are goals that must be met. But do they fit THIS problem statement? No. They will contribute to his overall improvement but are actually goals for other problem statements that would be formulated for this patient. Because this problem statement was about gas exchange at the alveolar capillary membrane , one fitting goal statement would be "Within the next 12 hours the patient's %sat on room air will be above 94 ".
Look at the nursing actions: Some nursing actions will directly relate to meeting this goal. For example: For now the patient needs supplemental oxygen, frequent vital signs and specialized monitoring. He needs to conserve energy. Some nursing actions directed at this problem will be collaborative (the patient may be given sympathomimetic drugs like dobutamine or may be given digoxin to strengthen the contractile force of his ventricles). Other actions are indirectly related to this problem, but overlap so much they can appropriately be included here. For example, Mr. F. is fluid overloaded (a fluid and electrolyte problem) but diuresis is necessary to get the fluid out of Mr. F's lungs. Therefore nursing actions such as IV lasix, q 4 hour urine outputs, daily weights, and po fluid restriction could reasonably be mentioned with this oxygenation issue.
Take a look at the goal statements A lot of things have to happen before Mr. F. is back to his baseline best health. Some goals we'd like to see accomplished include
1. The patient's hgb will trend toward normal within 2 days.
2. The patient's will diurese 2 liters today and will be down to baseline weight within 3 days.
These are goals that must be met. But do they fit THIS problem statement? No. They will contribute to his overall improvement but are actually goals for other problem statements that would be formulated for this patient. Because this problem statement was about gas exchange at the alveolar capillary membrane , one fitting goal statement would be "Within the next 12 hours the patient's %sat on room air will be above 94 ".
Look at the nursing actions: Some nursing actions will directly relate to meeting this goal. For example: For now the patient needs supplemental oxygen, frequent vital signs and specialized monitoring. He needs to conserve energy. Some nursing actions directed at this problem will be collaborative (the patient may be given sympathomimetic drugs like dobutamine or may be given digoxin to strengthen the contractile force of his ventricles). Other actions are indirectly related to this problem, but overlap so much they can appropriately be included here. For example, Mr. F. is fluid overloaded (a fluid and electrolyte problem) but diuresis is necessary to get the fluid out of Mr. F's lungs. Therefore nursing actions such as IV lasix, q 4 hour urine outputs, daily weights, and po fluid restriction could reasonably be mentioned with this oxygenation issue.
Important: Is this the only "correct" clinical reasoning that could be formulated for this patient and this problem? No. The nursing process is a logical progression of thought. There are no 2 nurses who think and speak identically. There are going to be differences in how a plan of care is articulated (as well as differences of opinion about things like priority needs.) This is an example of planned care that meets most of the general principles of the nursing process.