Clinical Reasoning Case Study:

I. Data Collection
Chief complaint/History of Present Illness: Edward is a 68 y/o African American male presenting to the ED with right-sided wea ness! headache! and slurred speech" #is wife reports that she came home at $%&& from wor and found Edward sitting in his fa'orite chair! and only reali(ed there was a pro)lem when she )egan to tal to him! and when he tried to get up" She immediately )rought him to the ED" Edward e*hi)its mild situational confusion and is una)le to tell you what happened to him today"

What data is relevant to this patient that must be recognized as clinically significant to the nurse
(NCLEX Client Need Categories:Management of Care/Reduction of Risk/Physiologic Ada tation!

!ationale: Personal/"ocial History: Edward is married! drin s appro*imately four cans of )eer daily! smo es appro*imately $ pac of cigarettes a day for the past %& years" #e does not engage in the use of illegal su)stances" P#H: Edward has #ypertension! +ype ,, D-! #yperlipidemia! and .out" /ast surgeries include a hernia repair when he was %&! a prostatectomy at 6&! and a total nee replacement at 6%" Current #edications: 0loma* &"1 mg daily 2opressor %& mg twice daily 3or'asc % mg daily Colchicine &"6 mg daily Allopurinol $&&mg daily 4hat is the relationship of your patient5s /-# and disease process6 74hich medications treat which disease6

II. Patient Care $egins:

7can )e initial presentation to the ED or direct admission to the medical floor8 %our Initial &":
+: /: R: 9/: :; sats: What &" data is relevant to this patient that must be recognized as clinically significant to the nurse
(NCLEX Client Need Categories:Management of Care/Reduction of Risk/Physiologic Ada tation!

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!ationale:

%our Initial 'ursing (ssessment:

.E3ERA2 A//EARA3CE: Resting comforta)ly" Appears to )e in no apparent distress" RES/,RA+:R>: Denies S:9" 9reath sounds e?ual and with good aeration )ilaterally" CARD,AC: /ulses @A throughout" 3o edema in e*tremities" #eart rate regular-S$S;" 3EBR:2:.,C: Alert and oriented *1" A9D:-E3/.,: A)domen soft! non-tender with acti'e )owel sounds" 3o guarding or point tenderness present" .E3,+:BR,3AR>: Brine clear and yellow" EC+RE-,+,ES/S=,3: S in is warm and dry-normal for color of s in" What assessment data is relevant that must be recognized as clinically significant to the nurse
(NCLEX Client Need Categories:Management of Care/Reduction of Risk/Physiologic Ada tation!

!ationale:

III. Clinical !easoning $egins)

$" 4hat is the most li ely medical pro)lem that your patient is presenting with6
(NCLEX Client Need Categories:Management of Care /Physiologic Ada tation!

;" 4hat is the underlying cause /pathophysiology of this concern6

(NCLEX Client Need Category:Physiologic Ada tation!

@" 4hat is your primary nursing priority right now6

(NCLEX Client Need Category:Management of Care!

1" 4hat nursing diagnostic statement will guide your plan of care6
(NCLEX Client Need Categories:Management of Care/Physiologic Ada tation!

%" 4hat inter'entions will you initiate )ased on this priority6

(NCLEX Client Need Category:Physiologic Ada tation!

6" 4hat is the worst possi)le complication to anticipate6

(NCLEX Client Need Category:Reduction of Risk Potential!

D" 4hat nursing assessment7s8 will you need to identify and respond if this complication de'elops6
(NCLEX Client Need Category:Physiologic Ada tation!

#edical #anagement: !ationale for *reatment + ,-pected .utcomes

(NCLEX Client Need Category:Physiologic Ada tation/Pharmacological "hera ies! < ;&$$ =eith Rischer/www"=eithR3"com

Physician orders:

!ationale:

,-pected .utcome:

/. #edication Data/Dosage Calculation:

(NCLEX Client Need Category:Pharmacological "hera ies!

#edication/Dose:

#echanism of (ction:

&olume/timeframe to safely administer:

Hourly rate I&P$: I& Push: &olume every 01 sec

'ursing (ssessment/Considerations:

'ormal !ange:
7high/low/mid68

Radiology Reports:
(NCLEX Client Need Category:Reduction of Risk Potential!

What data above is relevant to this patient that must be recognized as clinically significant to the nurse Ho2 do these radiology findings relate to primary problem:

2a) Results (remo#e la$ $o%es or ro&s that you do not choose to use for this case study!
(NCLEX Client Need Category:Reduction of Risk Potential!

C$C Current -ost Recent 49C 71"%-$$"&8 #.9 7$;-$68 /2+S 7$1&-11&8 3euts" E 71;-D;8 2ymphs E 7;&118 their clinical significance:
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Identify the relevant lab results to this patient and

Which labs 2hen trended are sho2ing improvement and/or reveal concerning potential complications

$asic #etabolic panel Sodium 7$@%-$1%8 /otassium 7@"%-%"$8 .lucose 76%-$&&8 Calcium 78"%-$&"%8 -agnesium 7$"8-;"68 2actate 7F;"68 9B3 7D-;%8 Creatinine 7&"%-$"@8 .0R 7G6& m2/min8

Current -ost Recent

Identify the relevant lab results to this patient and their clinical significance:

Which labs 2hen trended are sho2ing improvement and/or reveal concerning potential complications 3( Color 7yellow8 Clarity 7clear8 Sp" .ra' 7$"&&;$"&@&8 /rotein 7neg8 .lucose 7neg8 =etones 7neg8 9lood 7neg8 3itrate 7neg8 2E+ 7neg8 R9CHs 7&-;8 49CHs 7&-%8 9acteria 7&-few8 Epithelial 7&-few8 Current -ost Recent

Identify the relevant lab results to this patient

and their clinical significance: Which labs 2hen trended are sho2ing improvement and/or reveal concerning potential complications

4iver Panel and 5I Current -ost Recent labs Al)umin 7@"%-%8: +otal )ili 7F$"68: Al /hos"7@1-$&18: A2+ 7$&-1;8: AS+ 7$&-1;8: Amylase 7;%-$;%8: < ;&$$ =eith Rischer/www"=eithR3"com 2ipase 7;;-%$8:

Identify the relevant lab results to this patient and their clinical significance: Which labs 2hen trended are sho2ing improvement and/or reveal concerning potential complications

Cardiac +roponin 7F&"&%8: C= total 7;6$1&8: C=--9 7F88: 93/ 7F$&$8:

Current -ost Recent

Identify the relevant lab results to this patient and their clinical significance:

Which labs 2hen trended are sho2ing improvement and/or reveal concerning potential complications Coags /+/,3R 7F$"@8 /++ #eparin clinical significance: Which labs 2hen trended are sho2ing improvement and/or reveal concerning potential complications (rterial $lood 5ases p# 7D"@%-D"1%8 p:; 78&-$&&8 pC:; 7@%-1%8 #C:@ 7$8-;68 :; sats 7GI;E8 :*ygen deli'ery and their clinical significance: Which labs 2hen trended are sho2ing improvement and/or reveal concerning potential complications Current -ost Recent Current -ost Recent

Identify the relevant lab results to this patient and their

Identify the relevant lab results to this patient

6+,/4ab &alues (pplication

I" Choose two of the most rele'ant a)normal la)s for your patient and address the following:
(NCLEX Client Need Category:Reduction of Risk Potential!

2a) Jalue

Rele'ance

3ormal 'alue Critical 'alue

4hat caused derangement 6

+reatment

'sg. (ssessments/interventions re7uired:

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#igh/2ow

2a) Jalue #igh/2ow

Rele'ance

3ormal 'alue Critical 'alue

4hat caused derangement 6

+reatment

'sg. (ssessments/interventions re7uired:

I&. ,valuation:
E'aluate the response of your patient to nursing K medical inter'entions during your shift" All physician orders ha'e )een implemented that are listed under medical management" *2o hours later)

&":
+: /: R: 9/: :; sats: What &" data is relevant to this patient that must be recognized as clinically significant to the nurse
(NCLEX Client Need Categories:Management of Care/Reduction of Risk/Physiologic Ada tation!

!ationale:

'ursing (ssessment:
.E3ERA2 A//EARA3CE: Resting comforta)ly" Appears to )e in no apparent distress" RES/,RA+:R>: Denies S:9" 9reath sounds e?ual and with good aeration )ilaterally" CARD,AC: /ulses @A throughout" 3o edema in e*tremities" #eart rate regular-S$S;" 3EBR:2:.,C: Alert and oriented *1" A9D:-E3/.,: A)domen soft! non-tender with acti'e )owel sounds" 3o guarding or point tenderness present" .E3,+:BR,3AR>: Brine clear and yellow" EC+RE-,+,ES/S=,3: S in is warm and dry-normal for color of s in" What assessment data is relevant to this patient that must be recognized as clinically significant to the nurse (NCLEX Client Need Categories:Management of Care/Reduction of Risk/Physiologic Ada tation!
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!ationale: $" #as the status of the patient impro'ed or not as e*pected to this point6
(NCLEX Client Need Category: Reduction of Risk/Physiologic Ada tation!

;" 4hat data supports this e'aluation assessment6

(NCLEX Client Need Category: Reduction of Risk/Physiologic Ada tation!

@" 9ased on this assessment data! now what will )e your nursing priorities and current plan of care6
(NCLEX Client Need Categories:Management of Care/Reduction of Risk/Physiologic Ada tation!

Effecti'e and concise handoffs are essential to e*cellent care and if not done well can ad'ersely impact the care of this patient" >ou ha'e done an e*cellent Lo) to this point! now finish strong and gi'e the following S9AR report to the nurse who will )e caring for this patient:
('(EN)"eam&ork * Colla$oration/(afety! (NCLEX Client Need Category:Management of Care!

"ituation: $ac ground: (ssessment: !ecommendation:

&. ,ducation Priorities/Discharge Planning

(NCLEX Client Need Category:+ealth Promotion and Maintenance!

4hat will )e the most important education priorities you will reinforce with their medical condition6

4hat modifications will you need to ma e related to your teaching methods )ased on the patientHs de'elopmental stage! age! culture! preferences! and le'el of health literacy6

#ow will you assess the effecti'eness of your teaching with this patient6
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.ptional 8",' 8uestions to Incorporate Into Case "tudy:

Patient Centered Care 4hat can you do to demonstrate intentional caring and promote patient centered care with sensiti'ity and respect for your patient in the conte*t of this clinical presentation6
('(EN)Patient Centered care!

#ow can you ensure and assess the effecti'eness of communication with the patient and family6
('(EN)Patient Centered care!

#ow can you integrate your patientHs preferences/'alues as you coordinate your plan of care or pro'ide any needed education6
('(EN)Patient Centered care!

#ow can you ensure that your patient is an acti'e partner while under your care and promote self-care once they are discharged6
('(EN)Patient Centered care!

*eam2or9 + Collaboration 4hat can you do to facilitate safe and effecti'e update/report to the physician or oncoming nurse6
('(EN)"eam&ork and Colla$oration!

4hat would you do if you were not comforta)le performing any new s ill that was re?uired to ta e care of this patient6
('(EN)"eam&ork and Colla$oration!

,vidence $ased Practice As a new nurse! what resources could you utili(e to pro'ide current! e'idence )ased and indi'iduali(ed care planning )ased on the needs of this patient6
('(EN)E#idence ,ased Practice!

"afety/8uality Improvement
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4hat would you as the nurse do if you almost ga'e the wrong dose of one of the ordered medications )ecause of a similarity in the la)el pro'ided )y pharmacy to another drug6
('(EN)(afety/'uality -m ro#ement!

Informatics 4hat medical electronic data )ases are a'aila)le in your clinical setting that would )e a resource if needed to o)tain needed information on a medication you ha'e not gi'en )efore or an illness/surgery you ha'e ne'er seen )efore6
('(EN)-nformatics!

.ptional :;0: 'ational Patient "afety 5oals 8uestions to Incorporate Into Case "tudy:
Identify patients correctly 4hat are the two patient identifiers that , must use at my clinical site each time , administer medications6
(./0. National Patient (afety 1oals)-dentify atients correctly!

Improve staff communication ,f any of my patientHs la) results were McriticalN or Mpanic 'aluesN what is the policy at my clinical site that guides me as to how ?uic ly the physician must )e notified6
(./0. National Patient (afety 1oals)-m ro#e staff communication!

3se medicines safely 4hat can , do with my patient to promote and ensure that they ta e their anti-coagulants such as 4arfarin safely and with no harmful conse?uences6
(./0. National Patient (afety 1oals)2se medicines safely!

4hat are my responsi)ilities as a primary nurse when my patient is admitted to ensure that all of their home medications! dosages and when last ta en are accurate for the physician6
(./0. National Patient (afety 1oals) 2se medicines safely!

4hat are my responsi)ilities as a primary nurse when my patient is discharged to ensure that they are nowledgea)le and compliant with their ordered home medications6
(./0. National Patient (afety 1oals) 2se medicines safely!

Prevent infection 4hat can , do )efore , go into my patientHs room and )efore , lea'e that will dramatically decrease the ris /rate of infection6
(./0. National Patient (afety 1oals)Pre#ent infections!

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4hat are some practical! e'idence )ased practices , can implement to pre'ent infection due to multidrugresistant organisms such as -RSA or JRE6
(./0. National Patient (afety 1oals) Pre#ent infections!

4hat are some practical! e'idence )ased practices , can implement to pre'ent )loodstream infection due to central lines including /,CC6
(./0. National Patient (afety 1oals) Pre#ent infections!

4hat are some practical! e'idence )ased practices , can implement to pre'ent surgical site infections6
(./0. National Patient (afety 1oals) Pre#ent infections!

4hat are some practical! e'idence )ased practices , can implement to pre'ent indwelling urinary catheter infections6
(./0. National Patient (afety 1oals) Pre#ent infections!

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