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1. Consider the patient situation – Who are they? This is your first impression. What do you notice? What information do you have eg. name, age, allergies, family situation if relevant? What led up to this admission?
2. Collect cues/information – Find out about the patient in front of you. Review available information through handover, patient history, charts, previous assessments. Do you need any additional information eg. any physical assessments, psychosocial assessments that need to be done, vital signs? Demonstrate your knowledge of pathophysiology and pharmacology, cultural safety, the law and ethics by linking it to the individual patient situation.
3. Process the information - By looking at all the information you have collected and forming links between information where appropriate eg. high BGL + confusion + fruity smelling breath = hyperglycaemia; tachycardia + hypertension + verbal pain score 10/10 = poor pain control, and so on. Note what is relevant information and what is irrelevant. Are there any abnormal results that need urgent attention?
4. Identify a problem/issue - After synthesising the information above so that you can make a nursing diagnosis. This is written as the problem/issue related to the cause of the problem/issue as evidenced by the cues/information collected. For example: Dehydration related to post operative vomiting, evidenced by dry mucous membranes, poor skin turgor, and decreased urine output.
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