Clinical reasoning and decision making case study Help.

[plusplus]

Hi Everyone,

As I am a first year nurse, I try to look for the clinical decision making for one pt who is 50 yrs old ,95 kgs , 168 cms tall.

In the nursing care plan, vital sign record from the morning shift to the afternoon shift on his bed and during he is sitting on the chair.

In fact what is different, it is about the BP which from the morning BP 120/180 and in the afternoon 160/110

TPR morning : 36,5 and afternoon : 36.7 , PR 62, and 72 RR 16 and 18, O2 S 97 % , 99

The summarize is TPR 36.7, PR 72,RR 18, O2S 99% BP 160/110

I would like to get some idea about the clinical decision format,how I could analysis this case and how I would write down it into 1000 words.

[pharmgirl]

Let us know what you have so far and maybe we can help lead you in the right direction