During morning assessment, the nurse identifies that Mr. John Smith, room 304, admitted for infection, has hives covering most of his back, a finding that was not reported during the patient handoff at change of shift. The nurse assesses the patient further and notes no other patient complaints or symptoms. In reviewing the patient’s documentation from the previous 24 hours, the nurse finds no mention of hives. Considering causes of hives, the nurse reviews the medication list and identifies that the patient had an antibiotic added to his treatment regimen 12 hours ago.

1.

What CUES (Assessment) might the nurse identify in this situation?

2.

What HYPOTHESIS (Diagnosis) will the nurse consider based on the available information?

3.

What safety strategy ACTION (Plan and Implement) would be most effective for the nurse to use to advocate for the patient in this situation?

4.

How will the nurse evaluate the effectiveness of actions taken and the patient’s OUTCOME (Evaluation)?