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? • • Amy's age and pregnancy status (28 years old, Gravida 2 Parity 1, 34 weeks' gestation) Her symptoms (severe headaches, blurry vision) Her vital signs (BP 160/100, then 160/95) Physical examination findings (soft non-tender abdomen, hyper-reflexia with 2 beats of clonus) Lab results (proteinuria 2+, moderately elevated transaminase levels, normal platelet count, normal creatinine and haematocrit, urine protein creatinine ratio at 45mg/mmol) Her treatment (commenced on Labetalol, admitted for BP monitoring/stabilisation) Ultrasound findings (normal fetal growth and wellbeing) Preeclampsia: Preeclampsia is diagnosed based on the presence of high blood pressure (160/100 mmHg), proteinuria (2+), severe headaches, and blurred vision. Usually manifesting after 20 weeks of pregnancy, this illness is marked by hypertension and symptoms of end- organ failure, such as protein in the urine. Pregnant Hypertension: Amy might be suffering from pregnant hypertension in light of her increased blood pressure readings and lack of a history of hypertension. After 20 weeks of pregnancy, this condition is described as new-onset hypertension without proteinuria or other preeclamptic symptoms. 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