CONCEPT MAP TEMPLATE: Recognizing Cues (S&S) Disease Process/Pathophysiology/Risk Factors Analyzing Cues/Conditions 1. Generate Solutions/Outcomes/Interventions SMART Planning 1. 2. 3. 4. 5. Evaluating Outcomes 1. 2. 3. 4. 5. 2. 3. 1. 2. 3. 4. 5. ↓ Prioritizing Hypotheses Taking Action-(How To) NIGHTINGALE COLLEGE DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET NURSING PROCESS TEMPLATE: Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. 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) Implementation (Take actions) How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk) 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?

3-2-1 Code It

6th Edition

ISBN:9781337660549

Author:GREEN

Publisher:GREEN

Chapter6: Icd-10-cm Outpatient And Physician Office Coding

Section: Chapter Questions

Problem 10MC

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Hello,

Can you help me with the assessment and analysis of the next case please? Assessment (Recognizing Cues), Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data.

Analysis (Analyzing Cues), Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue?

I chose the next case but it can be any, just in case you have a better sugestion.

"Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma."

Thank you in advance!