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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:

PMH:

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:

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 orders: |Rationale: |Expected Outcome: |

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8. Medication Data/Dosage Calculation:

(NCLEX Client Need Category:Pharmacological Therapies)

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

| | |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 (60 mL/min) | | |

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?

|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:

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

|Liver Panel and GI labs |Current |Most Recent |

|Albumin (3.5-5): | | |

|Total bili ( ................
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