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Evidences adequate
inquiry, research and
use of best resources.
CHARACTERISTICS OF
AN EXCELLENT NCP
Evidences adequate
inquiry, research and
use of best resources.
How can the student achieve this objective?
The groundwork for an excellent care plan
begins with the utilization of inquiry, research
and resources at the clinical site.
It begins in preconference when
the student receives report.
Preconference exercise
You receive report on the following client:
79 y/o female admitted for pneumonia, exacerbation
of COPD who has CHF by history with the following
orders:
nasal cannula oxygen at 2 lpm
albuterol drug nebs q 4hrs and q 2 hours prn
IV D51/2 NS at 75 cc/hr
Solumedrol 80 mg IVP q 6 hrs
ABGs on room air and electrolytes to be
drawn this AM.
Exercise your
inquiry,research and
best resources.
Reflect on knowledge and skills
79 y/o female admitted for pneumonia,
exacerbation of COPD who has CHF by history
with the following orders:
nasal cannula oxygen at 2 lpm
albuterol drug nebs q 4hrs and q 2 hours prn
IV D51/2 NS at 75 cc/hr
Solumedrol 80 mg IVP q 6 hrs
ABGs on room air and electrolytes to be
drawn this AM.
ASK YOURSELF WHO, WHAT WHY, WHERE, WHEN AND
HOW?
Identify your best resources and
references
What handbooks would you access immediately to
prepare for caring for your client?
How can each resource facilitate the attainment of
knowledge and skills?
MED/SURG handbook
drug reference
lab test reference
nursing diagnosis handbook
hospital procedure manual
Develop a plan to evidence
adequate inquiry and assess your
client.
Initial client assessment:
LOC: level of consciousness
A: airway
B: breathing
C: circulation/bleeding
I/O: everything going in/out
wound: what does it look like?
Pain: present? Scale? Treatment?
safety:bed low? Call bell? Siderail?
After performing the initial assessment, gather any
additional information you need from the chart and
return to perform a focused assessment.
The Interview
SPECIFIC
QUESTIONS
RELATED TO
THE CHIEF
COMPLAINT
AND RELATED
SYSTEMS
The Interview
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
Dont just fill in the blanks.
Use all available space to communicate the pertinent
findings integrating the health assessment framework.
Seek clarification