Clinical Case Study1

please complete and fill boxes based on information on case file enclosed

© 2016 Keith Rischer/www.KeithRN.com

STEP #2: How to THINK Like a Nurse by Recognizing Clinical RELATIONSHIPS Six Essential Clinical Relationships:

1. RELATIONSHIP of the past medical history and current medications 2. RELATIONSHIP between RELEVANT present problem data and the primary medical problem 3. RELATIONSHIP between RELEVANT clinical data and the primary problem 4. RELATIONSHIP between the primary medical problem and nursing priority 5. RELATIONSHIP between the primary care provider’s orders and primary problem 6. RELATIONSHIP between diseases in PMH that may have contributed to the development of the current problem

History of Current Problem: John Gates is a 59-year-old male with a history of diabetes type II and hypertension who was at work when he had sudden

onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency

department (ED) where these symptoms continue to persist. It has been one hour from the onset of his neurologic

symptoms when he presents to the ED. You are the nurse responsible for his care.

1. What is the RELATIONSHIP of the past medical history and current medications? (Which medication treats which condition? Draw lines to connect)

Past Medical History Home Meds:

Diabetes mellitus type II-poorly controlled

Hypertension

Hyperlipidemia

Gouty arthritis

Smokes 1 ppd x 40 years

Lisinopril

Indomethacin

Aspirin

Metformin

Simvastatin

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment: T: 99.2 F/37.3 C (oral) Provoking/Palliative: Unable

P: 118 (irregular) Quality:

R: 20 (regular) Region/Radiation:

BP: 198/94 Severity:

O2 sat: 99% room air Timing:

Current Assessment:

GENERAL

APPEARANCE:

Appears anxious–he is aware and appears to be concerned about changes in neuro status.

RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort

CARDIAC: Pink, warm & dry, no edema, heart sounds irregular–S1S2, telemetry rhythm is atrial

fibrillation, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO: Is anxious, restless, and agitated, speech is currently slurred and difficult to understand, facial droop present on right side, pupils equal and reactive to light (PEARL), both right

upper extremity (RUE) and right lower extremity (RLE) notably weak (3/5) in comparison to

left, which is strong (5/5), right pronator drift present, unable to hold right arm up, right

visual deficit cut present

GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants

Able to swallow saliva

GU: Voiding without difficulty, 700 mL urine clear/yellow,

SKIN: Skin integrity appears intact, right foot not assessed at this time

© 2016 Keith Rischer/www.KeithRN.com

Lab/diagnostic Results: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Results: Clinical Significance: No abnormalities noted,

no mass, no bleed, no

shift present

Make a clinical JUDGMENT. Is a PROBLEM present? Based on your identification and TRENDING of RELEVANT clinical data, is a problem present?

If a problem is present, what is it?

What is the underlying cause/pathophysiology of this primary problem?

THINK Like a Nurse by Recognizing Clinical RELATIONSHIPS 2. What is the RELATIONSHIP between RELEVANT current problem data and the primary medical

problem?

Complete Blood Count (CBC) Current High/Low/WNL? Previous:

WBC (4.5-11.0 mm 3) 6.8 7.9

Hgb (12-16 g/dL) 14.8 16.1

Platelets(150-450x 103/µl) 228 201

Neutrophil % (42-72) 71 79

Basic Metabolic Panel (BMP) Current High/Low/WNL? Previous:

Sodium (135-145 mEq/L) 133 139

Potassium (3.5-5.0 mEq/L) 4.1 4.5

Glucose (70-110 mg/dL) 222 128

Creatinine (0.6-1.2 mg/dL) 1.5 1.1

Coag

PT/INR (0.9-1.1 nmol/L) 1.1 n/a

RELEVANT Current Problem Data: How Does it Relate to Primary Medical Problem?

© 2016 Keith Rischer/www.KeithRN.com

3. What is the RELATIONSHIP between RELEVANT clinical data and the primary problem? RELEVANT VS Data: How Does it Relate to Primary Problem?

RELEVANT Assessment Data: How Does it Relate to Primary Problem?

RELEVANT Lab Data: How Does it Relate to Primary Problem?

4. What is the RELATIONSHIP between the primary medical problem and nursing priority(ies)?

Nursing Priority(ies): How Nursing Priority will help Resolve Primary Medical Problem:

© 2016 Keith Rischer/www.KeithRN.com

5. What is the RELATIONSHIP between the primary care provider’s orders and primary problem? Care Provider Orders: How it Will Resolve Primary Problem:

Establish peripheral IV

12 lead EKG stat

Labetalol 10-20 mg IV prn every 15

minutes to keep SBP 160-180

CT head stat

Cardiac monitor continuous

NPO

Alteplase IV dose per pharmacy

(if CT negative for bleed)

6. Is there a RELATIONSHIP between diseases in the patient’s past medical history that may have contributed to the development of the current problem?

(Which disease likely developed FIRST, then started a “domino effect”?)

Past Medical History What Came FIRST:

Diabetes mellitus type II-poorly

controlled

Hypertension

Hyperlipidemia

Gouty arthritis

Smokes 1 ppd x 40 years

What Then Followed:

Lisinopril Indomethacin Aspirin Metformin Simvastatin:
Current VS:
PQRST Pain Assessment:
P 118 irregular:
UnableQuality:
R 20 regular:
UnableRegionRadiation:
BP 19894:
UnableSeverity:
UnableTiming:
Current Assessment:
Appears anxioushe is aware and appears to be concerned about changes in neuro status:
RESP:
CARDIAC:
NEURO:
GI:
GU:
Voiding without difficulty 700 mL urine clearyellow:
SKIN:
Clinical SignificanceNo abnormalities noted no mass no bleed no shift present:
Current:
Previous:
WBC 45110 mm 3:
HighLowWNL68:
79:
Hgb 1216 gdL:
HighLowWNL148:
161:
HighLowWNL228:
201:
Neutrophil 4272:
HighLowWNL71:
79_2:
Current_2:
Previous_2:
HighLowWNL133:
139:
HighLowWNL41:
45:
Glucose 70110 mgdL:
HighLowWNL222:
128:
HighLowWNL15:
15Coag:
HighLowWNLCoag:
11Coag:
HighLowWNL11:
na:
RELEVANT Current Problem DataRow1:
How Does it Relate to Primary Medical ProblemRow1:
RELEVANT VS DataRow1:
How Does it Relate to Primary ProblemRow1:
RELEVANT Assessment DataRow1:
How Does it Relate to Primary ProblemRow1_2:
RELEVANT Lab DataRow1:
How Does it Relate to Primary ProblemRow1_3:
Nursing PriorityiesRow1:
How Nursing Priority will help Resolve Primary Medical ProblemRow1:
How it Will Resolve Primary ProblemEstablish peripheral IV 12 lead EKG stat Labetalol 1020 mg IV prn every 15 minutes to keep SBP 160180 CT head stat Cardiac monitor continuous NPO Alteplase IV dose per pharmacy if CT negative for bleed:
What Then Followed:
Answer1:
Answer2:
Answer3:

Nursing Assessment

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