Reference no: EM133657881
Mrs. Smith Carlo is a 38-year-old female who turned up at my place of work having an appointment with the MD; upon reporting to the physician's office, she had a rash over her arms, back, and abdomen, accompanied by itching. She says that she occasionally has some seasonal allergies for which she takes over-the-counter antihistamines when symptomatic. Once, when she was young, she experienced Wheezing and difficulty breathing. She was taken to the emergency department and given an injection of epinephrine. Her goal is to find the cause of her rash and relieve the discomfort it is causing, like body image, among others.
1. Assessment (Recognizing Cues); Which client information is relevant? What client data is most important? Which client information is of immediate concern? Considersigns and symptoms, lab work, client statements, and H & P. Consider subjective and objective data.
2. 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?
3. 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.
4. 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)
5. Implementation (Take actions); How should the intervention or combination be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk)
6. 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?