Template That Can Be Copied and Pasted to Develop Your Own Brief Clinical Application Exercises

Clinical Reasoning Case Study:

I. Data Collection Chief complaint/History of Present Illness:

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 Adaptation)

Rationale:

Personal/Social History:

Current Medications:

II. Patient Care Begins: (can be initial presentation to the ED or direct admission to the medical floor) Your Initial VS: T: P: R: BP: O2 sats:

What VS 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 Adaptation)

Rationale:

Your Initial Nursing Assessment: GENERAL APPEARANCE: Resting comfortably. Appears to be in no apparent distress. RESPIRATORY: Denies SOB. Breath sounds equal and with good aeration bilaterally. CARDIAC: Pulses 3+ throughout. No edema in extremities. Heart rate regular-S1S2. NEUROLOGIC: Alert and oriented x4. ABDOMEN/GI: Abdomen soft, non-tender with active bowel sounds. No guarding or point tenderness present. GENITOURINARY: Urine clear and yellow. EXTREMITIES/SKIN: Skin is warm and dry-normal for color of skin.

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 Adaptation)

Rationale:

© 2011 Keith Rischer/www.KeithRN.com III. Clinical Reasoning Begins… 1. What is the most likely medical problem that your patient is presenting with? (NCLEX Client Need Categories:Management of Care /Physiologic Adaptation)

2. What is the underlying cause /pathophysiology of this concern? (NCLEX Client Need Category:Physiologic Adaptation)

3. What is your primary nursing priority right now? (NCLEX Client Need Category:Management of Care)

4. What nursing diagnostic statement will guide your plan of care? (NCLEX Client Need Categories:Management of Care/Physiologic Adaptation)

5. What interventions will you initiate based on this priority? (NCLEX Client Need Category:Physiologic Adaptation)

6. What is the worst possible complication to anticipate? (NCLEX Client Need Category:Reduction of Risk Potential)

7. What nursing assessment(s) will you need to identify and respond if this complication develops? (NCLEX Client Need Category:Physiologic Adaptation)

Medical Management: Rationale for Treatment & Expected Outcomes (NCLEX Client Need Category:Physiologic Adaptation/Pharmacological Therapies)

Physician Rationale: Expected Outcome: orders:

Medication/Dose: Mechanism of Action: Volume/timeframe to Nursing Assessment/Considerations: safely administer:

Normal Range: Hourly rate IVPB: (high/low/mid?)

IV Push: Volume every 15 sec?

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?

How do these radiology findings relate to primary problem:

Lab Results (remove lab boxes or rows that you do not choose to use for this case study) (NCLEX Client Need Category:Reduction of Risk Potential)

CBC Current Most Recent WBC (4.5-11.0) HGB (12-16) PLTS (140-440) Neuts. % (42-72) Lymphs % (20-44)

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

Which labs when trended are showing improvement and/or reveal concerning potential complications?

Basic Metabolic panel Current Most Recent Sodium (135-145) Potassium (3.5-5.1) Glucose (65-100) Calcium (8.5-10.5) Magnesium (1.8-2.6) Lactate (<2.6) BUN (7-25) Creatinine (0.5-1.3) GFR (>60 mL/min) © 2011 Keith Rischer/www.KeithRN.com Identify the relevant lab results to this patient and their clinical significance:

UA Current Most Recent Color (yellow) Clarity (clear) Sp. Grav (1.002-1.030) Protein (neg) Glucose (neg) Ketones (neg) Blood (neg) Nitrate (neg) LET (neg) RBC’s (0-2) WBC’s (0-5) Bacteria (0-few) Epithelial (0-few) Identify the relevant lab results to this patient and their clinical significance:

Liver Panel and GI labs Current Most Recent Albumin (3.5-5): Total bili (<1.6): Alk Phos.(34-104): ALT (10-42): AST (10-42): Amylase (25-125): Lipase (22-51): Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement Cardiac Current Most Recent and/or reveal concerning potential complications? Troponin (<0.05): CK total (26-140): CK-MB (<8): BNP (<101):

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

Which labs when trended are showing improvement and/or reveal concerning potential complications? © 2011 Keith Rischer/www.KeithRN.com Coags Current Most Recent PT/INR (<1.3) PTT Heparin Identify the relevant lab results to this patient and their clinical significance:

Arterial Blood Gases Current Most Recent pH (7.35-7.45) pO2 (80-100) pCO2 (35-45) HCO3 (18-26) O2 sats (>92%) Oxygen delivery Identify the relevant lab results to this patient and their clinical significance:

F&E/Lab Values Application 9. Choose two of the most relevant abnormal labs for your patient and address the following: (NCLEX Client Need Category:Reduction of Risk Potential)

Lab Relevance Normal value What caused Treatment Nsg. Assessments/interventions derangement? required:

Value Critical value

High/Low

Lab Relevance Normal value What caused Treatment Nsg. Assessments/interventions derangement? required:

Value Critical value

High/Low

© 2011 Keith Rischer/www.KeithRN.com IV. Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management.

Two hours later…

VS: T: P: R: BP: O2 sats:

What VS 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 Adaptation)

Rationale:

Nursing Assessment: GENERAL APPEARANCE: Resting comfortably. Appears to be in no apparent distress. RESPIRATORY: Denies SOB. Breath sounds equal and with good aeration bilaterally. CARDIAC: Pulses 3+ throughout. No edema in extremities. Heart rate regular-S1S2. NEUROLOGIC: Alert and oriented x4. ABDOMEN/GI: Abdomen soft, non-tender with active bowel sounds. No guarding or point tenderness present. GENITOURINARY: Urine clear and yellow. EXTREMITIES/SKIN: Skin is warm and dry-normal for color of skin.

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 Adaptation)

Rationale:

1. Has the status of the patient improved or not as expected to this point? (NCLEX Client Need Category: Reduction of Risk/Physiologic Adaptation)

2. What data supports this evaluation assessment? (NCLEX Client Need Category: Reduction of Risk/Physiologic Adaptation)

3. Based on this assessment data, now what will be your nursing priorities and current plan of care? (NCLEX Client Need Categories:Management of Care/Reduction of Risk/Physiologic Adaptation)

© 2011 Keith Rischer/www.KeithRN.com Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient: (QSEN-Teamwork & Collaboration/Safety) (NCLEX Client Need Category:Management of Care)

Situation:

Background:

Assessment:

Recommendation:

V. Education Priorities/Discharge Planning (NCLEX Client Need Category:Health Promotion and Maintenance)

What will be the most important education priorities you will reinforce with their medical condition?

What modifications will you need to make related to your teaching methods based on the patient’s developmental stage, age, culture, preferences, and level of health literacy?

How will you assess the effectiveness of your teaching with this patient?

Patient Centered Care What can you do to demonstrate intentional caring and promote patient centered care with sensitivity and respect for your patient in the context of this clinical presentation? (QSEN-Patient Centered care)

How can you ensure and assess the effectiveness of communication with the patient and family? (QSEN-Patient Centered care)

How can you integrate your patient’s preferences/values as you coordinate your plan of care or provide any needed education? (QSEN-Patient Centered care)

How can you ensure that your patient is an active partner while under your care and promote self-care once they are discharged? (QSEN-Patient Centered care)

Teamwork & Collaboration What can you do to facilitate safe and effective update/report to the physician or oncoming nurse? (QSEN-Teamwork and Collaboration)

What would you do if you were not comfortable performing any new skill that was required to take care of this patient? (QSEN-Teamwork and Collaboration)

Evidence Based Practice As a new nurse, what resources could you utilize to provide current, evidence based and individualized care planning based on the needs of this patient? (QSEN-Evidence Based Practice)

Safety/Quality Improvement What would you as the nurse do if you almost gave the wrong dose of one of the ordered medications because of a similarity in the label provided by pharmacy to another drug? (QSEN-Safety/Quality Improvement)

Informatics What medical electronic data bases are available in your clinical setting that would be a resource if needed to obtain needed information on a medication you have not given before or an illness/surgery you have never seen before? (QSEN-Informatics)

Identify patients correctly What are the two patient identifiers that I must use at my clinical site each time I administer medications? (2012 National Patient Safety Goals-Identify patients correctly)

Improve staff communication If any of my patient’s lab results were “critical” or “panic values” what is the policy at my clinical site that guides me as to how quickly the physician must be notified? (2012 National Patient Safety Goals-Improve staff communication)

Use medicines safely What can I do with my patient to promote and ensure that they take their anti-coagulants such as Warfarin safely and with no harmful consequences? (2012 National Patient Safety Goals-Use medicines safely)

What are my responsibilities as a primary nurse when my patient is admitted to ensure that all of their home medications, dosages and when last taken are accurate for the physician? (2012 National Patient Safety Goals- Use medicines safely)

What are my responsibilities as a primary nurse when my patient is discharged to ensure that they are knowledgeable and compliant with their ordered home medications? (2012 National Patient Safety Goals- Use medicines safely)

Prevent infection What can I do before I go into my patient’s room and before I leave that will dramatically decrease the risk/rate of infection? (2012 National Patient Safety Goals-Prevent infections)

What are some practical, evidence based practices I can implement to prevent infection due to multidrug- resistant organisms such as MRSA or VRE? (2012 National Patient Safety Goals- Prevent infections)

What are some practical, evidence based practices I can implement to prevent bloodstream infection due to central lines including PICC? (2012 National Patient Safety Goals- Prevent infections)

What are some practical, evidence based practices I can implement to prevent surgical site infections? (2012 National Patient Safety Goals- Prevent infections)

What are some practical, evidence based practices I can implement to prevent indwelling urinary catheter infections? (2012 National Patient Safety Goals- Prevent infections)