Faith in Reason; and
Intellectual Sense of Justice.
Identify the problem;
Decide what outcome is desirable;
Plan what to do;
Implement the plan of care; and
Evaluate the plan of care.
SUBJECTIVE DATA are pieces of data provided verbally by the patient. It is documented normally in quotes (ex: “I feel out of breath” or “I have a headache”)
When recording SUBJECTIVE data use direct quotations as much as possible. Quotes accurately represent the patient’s view and are least open to interpretation.
H – How does it feel? Describe the quality.
A – Aggravating the alleviating factors. What makes it worse? What makes it better?
T – Timing. When did it start? How long does it last?
S – Severity. How bad is it? This can often be rated on a scale of 0 – 10
U – Useful other data. What other symptoms are present that might be related?
P – Patient’s perception of the problem. The patient often has an idea about what the problem is, or the cause, but may not believe that his or her thoughts are important to share unless specifically asked.
a. It highlights the obvious solution to the problem?
b. It can lead to a better outcome for the patient.
c. It simplifies the process.
d. It helps the nurse arrive at a solution more quickly.
Critical thinking is use of cognitive skills or strategies that increase the probability of a desirable outcome.
a. The nurse who is an expert at wounds care.
b. The nurse who reports an error to the supervisor.
c. The nurse who tries to empathize with the patient.
d. The nurse who asks a coworker about a new procedure.
Asking a question shows humility. The nurse does not “know it all.”
a. The patient’s respiratory rate is 28,.
b. The patient states, “I fell short of breath.”
c. The patient is short of breath.
d. The patient is feeling panicky.
A respiratory rate of 28 is observable (measurable/fact). Selections b, c, and d are patient perceptions.
Selections a, b, and c all include the nurse’s perceptions.
a. Frontal headache from stress of hospital admission.
b. Anxiety related to concern about leving children.
c. Shortness of breath from newly diagnosed pneumonia.
d. efficient knowledge about treatment plan.
Shortness of breath is a physiological need and should be addressed first.