10 Sep © 2016 Keith Rischer/www.KeithRN.com
© 2016 Keith Rischer/www.KeithRN.com
Step #1: THINK Like a Nurse by Recognizing RELEVANCE and
PRIORITIES Four Principles of Clinical Reasoning:
1. Identify and interpret RELEVANT clinical data. 2. TREND relevant clinical data to determine current status (stable vs. unstable). 3. Grasp the “essence” of the current clinical situation. 4. Determine nursing PRIORITY and plan of care.
History of Present Problem: John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and worsening
nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has had a poor appetite the
past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic binge drinking on most weekends.
John weighs 150 pounds (68.2 kg) and is 6’0″ (BMI 17.6). You are the nurse responsible for his care.
What data from the PRESENT PROBLEM are RELEVANT and must be interpreted as clinically significant by the
nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Patient Care Begins:
Orthostatic BP’s:
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Rationale:
Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 100.5 F/38.1 C (oral) Provoking/Palliative: Nothing/nothing
P: 110 (regular) Quality: Ache
R: 20 Region/Radiation: RUQ/epigastric
BP: 128/88 Severity: 6/10
O2 sat: 95% RA Timing: Continuous
Position: HR: BP:
Lying 110 128/88
Standing 132 124/80
© 2016 Keith Rischer/www.KeithRN.com
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Rationale:
Lab Results:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
Current Assessment: GENERAL
APPEARANCE:
Appears uncomfortable, body tense, occasional facial grimacing
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Pink, warm & dry,1+ pitting edema lower extremities, heart sounds regular–S1S2, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen distended, large–rounded–firm to touch, bowel sounds audible per auscultation in
all 4 quadrants
GU: Voiding without difficulty, urine clear/light orange, loss of pubic hair
SKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and
oral mucosa tacky dry, softball-sized ecchymosis on abdomen
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 12.8 9.5
Hgb (12–16 g/dL) 10.2 11.2
Platelets (150-450 x103/µl) 98 122
Neutrophil % (42–72) 88 75
Band forms (3–5%) 3 0
Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous:
Sodium (135–145 mEq/L) 135 138
Potassium (3.5–5.0 mEq/L) 3.5 3.8
Glucose (70–110 mg/dL) 78 88
BUN (7–25 mg/dl) 38 25
Creatinine (0.6–1.2 mg/dL) 1.5 1.1
© 2016 Keith Rischer/www.KeithRN.com
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT
Lab(s):
Clinical Significance: TREND: Improve/Worsening/Stable:
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
Put it All Together to THINK Like a Nurse! 1. What is the primary problem that your patient is most likely presenting?
2. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
Coags: Current: High/Low/WNL? Previous:
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