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How to THINK Like a Nurse by Recognizing Clinical RELATIONSHIPS Six Essential Clinical Relationships:

How to THINK Like a Nurse by Recognizing Clinical RELATIONSHIPS Six Essential Clinical Relationships:

How to THINK Like a Nurse by Recognizing Clinical RELATIONSHIPS Six Essential Clinical Relationships:

1. RELATIONSHIP of the past medical history and current medications 2. RELATIONSHIP between RELEVANT present problem data and the primary medical problem 3. RELATIONSHIP between RELEVANT clinical data and the primary problem 4. RELATIONSHIP between the primary medical problem and nursing priority 5. RELATIONSHIP between the primary care provider’s orders and primary problem 6. RELATIONSHIP between diseases in PMH that may have contributed to the development of the current problem

History of Current Problem: John Gates is a 59-year-old male with a history of diabetes type II and hypertension who was at work when he had sudden

onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency

department (ED) where these symptoms continue to persist. It has been one hour from the onset of his neurologic

symptoms when he presents to the ED. You are the nurse responsible for his care.

1. What is the RELATIONSHIP of the past medical history and current medications? (Which medication treats which condition? Draw lines to connect)

Past Medical History Home Meds:

Diabetes mellitus type II-poorly controlled

Hypertension

Hyperlipidemia

Gouty arthritis

Smokes 1 ppd x 40 years

Lisinopril

Indomethacin

Aspirin

Metformin

Simvastatin

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment: T: 99.2 F/37.3 C (oral) Provoking/Palliative: Unable

P: 118 (irregular) Quality:

R: 20 (regular) Region/Radiation:

BP: 198/94 Severity:

O2 sat: 99% room air Timing:

Current Assessment:

GENERAL

APPEARANCE:

Appears anxious–he is aware and appears to be concerned about changes in neuro status.

RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort

CARDIAC: Pink, warm & dry, no edema, heart sounds irregular–S1S2, telemetry rhythm is atrial

fibrillation, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO: Is anxious, restless, and agitated, speech is currently slurred and difficult to understand, facial droop present on right side, pupils equal and reactive to light (PEARL), both right

upper extremity (RUE) and right lower extremity (RLE) notably weak (3/5) in comparison to

left, which is strong (5/5), right pronator drift present, unable to hold right arm up, right

visual deficit cut present

GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants

Able to swallow saliva

GU: Voiding without difficulty, 700 mL urine clear/yellow,

SKIN: Skin integrity appears intact, right foot not assessed at this time

© 2016 Keith Rischer/www.KeithRN.com

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