CALLING ALL NURSES

CALLING ALL NURSES

© 2016 Keith Rischer/www.KeithRN.com

Cirrhosis

John Richards, 45 years old

Primary Concept

Nutrition

Interrelated Concepts (In order of emphasis) 1. Fluid and Electrolyte Balance 2. Perfusion 3. Cognition 4. Addiction 5. Clinical Judgment 6. Patient Education 7. Communication 8. Collaboration

© 2016 Keith Rischer/www.KeithRN.com

UNFOLDING Reasoning Case Study: STUDENT

Cirrhosis 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.

Personal/Social History: John is single, has never married, and lives alone in his own apartment. He has struggled with heroin use/abuse in the past,

but has not used in the past two years. John is currently unemployed and has no health insurance. He was diagnosed with

hepatitis C ten years ago but has had minimal follow-up medical care since.

What data from the histories are RELEVANT and have clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect.)

PMH: Home Meds: Pharm. Classification: Expected Outcome:

*Hepatitis C–past history of

IV drug abuse

*ETOH abuse x 25 years

Ibuprofen 600 mg PO prn

for headache

One disease process often influences the development of other illnesses. Based on your knowledge of

pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her

life?

 Circle the PMH problem that likely started FIRST.

 Underline the PMH problem(s) FOLLOWED as domino(s).

Patient Care Begins:

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

© 2016 Keith Rischer/www.KeithRN.com

Orthostatic BP’s:

What VS data are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT VS Data: Rationale:

What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Assessment Data: Rationale:

Lab Results:

Position: HR: BP:

Lying 110 128/88

Standing 132 124/80

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

© 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:

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:

PT/INR: 1.5

UP…worsening

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

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

Coags: Current: High/Low/WNL? Previous:

PT/INR (0.9–1.1 nmol/L) 1.5 1.2

Liver Function Test (LFT:) Current: High/Low/WNL? Previous:

Albumin (3.5–5.5 g/dL) 2.5 2.9

Total Bilirubin (0.1–1.0 mg/dL) 4.2 2.2

Alkaline Phosphatase male: 38–126 U/l female: 70–230 U/l

285 155

ALT (8–20 U/L) 128 65

AST (8–20 U/L) 124 85

Misc. Labs:

Ammonia (11–35 mcg/dL) 35 28

© 2016 Keith Rischer/www.KeithRN.com

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required:

ALT

Value:

128

Critical Value:

Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with?

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

Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome:

Establish peripheral IV

NS 0.9% bolus of 1000 mL

Ondansetron 4 mg IV every

4 hours PRN

Orthostatic BP

PRIORITY Setting: Which Orders Do You Implement First and Why? (Remember your ABCs!)

Care Provider Orders: Order of Priority: Rationale:

1. Establish peripheral IV

2. NS 0.9% bolus of 1000

mL

3. Ondansetron 4 mg IV every 4 hours PRN nausea

4. Orthostatic BP

© 2016 Keith Rischer/www.KeithRN.com

Medication Dosage Calculation: Medication/Dose:

Mechanism of Action: Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

Ondansetron 4 mg

IV 4mg/2 mL vial

IV Push:

Volume every 15 sec?

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one, list in order of PRIORITY)

4. What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

6. What is the worst possible/most likely complication to anticipate?

7. What nursing assessments will identify this complication EARLY if it develops?

8. What nursing interventions will you initiate if this complication develops?

9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?

10. How can the nurse address these psychosocial needs?

© 2016 Keith Rischer/www.KeithRN.com

Evaluation: Six Months Later… John continues to drink ETOH on a daily basis and has not followed through with his discharge plan when he was

discharged from the hospital six months ago. John is now homeless and lives in a shelter. He was brought into the ED by

emergency medical services (EMS) because he was found wandering aimlessly in the neighborhood and was completely

disoriented.

The primary care provider in the ED orders the following labs: CBC, BMP, LFT, and INR.

1. What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data: Rationale:

RELEVANT Assessment Data: Rationale:

Compare & Contrast: Last Nursing Assessment 6 Months Ago: Emphasize that the nurse should look back at previous admissions, especially admission H&P, consultation H&P,

discharge summary, and labs/diagnostics as time allows. Discharge summary may be most important if time is of the

essence. An essential component of clinical reasoning is TRENDING clinical data. This TREND can be established from

most recent documentation in the medical record that could be hours, days or even months ago. This data is still relevant

and needed to establish this trend!

Current VS: Current PQRST: T: 99.5 F/37.5 C (oral) Provoking/Palliative: DENIES P: 118 (reg) Quality: R: 22 (reg) Region/Radiation: BP: 88/50 Severity: O2 sat: 94% room air Timing:

Current

Assessment:

GENERAL

APPEARANCE:

Disheveled, clothing dirty, has strong body odor, appears unkempt, does not smell of ETOH

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

CARDIAC: Jaundiced, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,

equal with palpation at radial/pedal/post-tibial landmarks

NEURO: Confused and disoriented to person, place, time, and situation (x4)

GI: Abdomen protuberant–distended, bowel sounds audible per auscultation in all 4 quadrants

GU: Voiding without difficulty, urine clear/orange

SKIN: Skin integrity intact, skin is yellow/jaundiced in color with yellow sclera

© 2016 Keith Rischer/www.KeithRN.com

2. Compare the current nursing assessment with his last assessment above. What has changed most

dramatically from his last assessment six months ago that is clinically significant?

3. Has his status improved or not as expected to this point?

Lab Results:

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable:

Last Nursing Assessment 6 Months Ago: GENERAL

APPEARANCE:

Appears uncomfortable, restless

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

CARDIAC: Pink, warm & dry, no edema, 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 large–rounded–firm to touch, bowel sounds audible per auscultation in all 4

quadrants

GU: Voiding without difficulty, urine clear/light orange

SKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips

and oral mucosa tacky dry

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

WBC (4.5–11.0 mm 3) 6.9 12.8

Hgb (12–16 g/dL) 8.9 10.2

Platelets (150-450 x103/µl) 47 98

Neutrophil % (42–72) 68 88

Band forms (3–5%) 3 3

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

Sodium (135–145 mEq/L) 127 135

Potassium (3.5–5.0 mEq/L) 2.8 3.5

Glucose (70–110 mg/dL) 74 78

BUN (7–25 mg/dl) 55 38

Creatinine (0.6–1.2 mg/dL) 1.8 1.5

© 2016 Keith Rischer/www.KeithRN.com

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable:

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Coags: Current: High/Low/WNL? Previous:

PT/INR (0.9–1.1 nmol/L) 2.6 1.5

Liver Function Test (LFT:) Current: High/Low/WNL? Previous:

Albumin (3.5–5.5 g/dL) 2.2 2.5

Total Bilirubin (0.1–1.0 mg/dL) 7.2 4.2

Alkaline Phosphatase male: 38–126 U/l female: 70–230 U/l

140 285

ALT (8–20 U/L) 59 128

AST (8–20 U/L) 62 124

Misc. Labs:

Ammonia (11–35 mcg/dL) 78 30

© 2016 Keith Rischer/www.KeithRN.com

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required:

Ammonia

Value:

78

Critical Value:

Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Rationale: Expected Outcome:

Lactulose 200 g/300 mL

rectal x1 NOW

Banana bag (thiamine 100

mg-folic acid 1 mg-

multivitamin 10 mL) in 1000

mL of 0.9% NS over 2 hours

Potassium Chloride 10 mEq

IVPB (x4) each dose over 1

hour. Recheck potassium per

hospital protocol

Transfer to ICU

4. Does your nursing priority or plan of care need to be modified in any way after this evaluation and assessment of all

clinical data including labs?

5. Based on your current evaluation, and assessment of all clinical data, what are your nursing priorities and plan of

care?

John is going to be admitted to ICU. 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:

© 2016 Keith Rischer/www.KeithRN.com

Situation: Name/age:

BRIEF summary of primary problem:

Day of admission/post-op #:

Background: Primary problem/diagnosis:

RELEVANT past medical history:

RELEVANT background data:

Assessment: Current vital signs:

RELEVANT body system nursing assessment data:

RELEVANT lab values:

TREND of any abnormal clinical data (stable-increasing/decreasing):

How have you advanced the plan of care?

Patient response:

INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation: Suggestions to advance plan of care:

© 2016 Keith Rischer/www.KeithRN.com

Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with their medical condition to

prevent future readmission with the same problem?

Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation?

2. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person?

Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention

in the moment as the events are unfolding to make a correct clinical judgment.

1. What did I learn from this scenario?

2. How can I use what has been learned from this scenario to improve patient care in the future?

  1. RELEVANT Data from Present ProblemRow1:
  2. Clinical SignificanceRow1:
  3. RELEVANT Data from Social HistoryRow1:
  4. Clinical SignificanceRow1_2:
  5. PMH:
  6. Home Meds:
  7. Pharm ClassificationIbuprofen 600 mg PO prn for headache:
  8. Expected OutcomeIbuprofen 600 mg PO prn for headache:
  9. Current VS:
  10. PQRST Pain Assessment 5th VS:
  11. Nothingnothing:
  12. P 110 regular:
  13. Quality:
  14. Ache:
  15. R 20:
  16. RUQepigastric:
  17. BP 12888:
  18. Severity:
  19. 610:
  20. O2 sat 95 RA:
  21. Timing:
  22. Continuous:
  23. BP:
  24. Lying:
  25. RELEVANT VS DataRow1:
  26. RationaleRow1:
  27. Current Assessment:
  28. GENERAL APPEARANCE:
  29. Appears uncomfortable body tense occasional facial grimacing:
  30. RESP:
  31. CARDIAC:
  32. NEURO:
  33. Alert oriented to person place time and situation x4:
  34. GI:
  35. GU:
  36. SKIN:
  37. RELEVANT Assessment DataRow1:
  38. RationaleRow1_2:
  39. Current:
  40. Previous:
  41. WBC 45110 mm 3:
  42. HighLowWNL128:
  43. 95:
  44. Hgb 1216 gdL:
  45. HighLowWNL102:
  46. 112:
  47. HighLowWNL98:
  48. 122:
  49. Neutrophil 4272:
  50. HighLowWNL88:
  51. 75:
  52. Band forms 35:
  53. HighLowWNL3:
  54. 0:
  55. RELEVANT LabsRow1:
  56. Clinical SignificanceRow1_3:
  57. TREND ImproveWorseningStableRow1:
  58. Current_2:
  59. Previous_2:
  60. HighLowWNL135:
  61. 138:
  62. HighLowWNL35:
  63. 38:
  64. HighLowWNL78:
  65. 88:
  66. BUN 725 mgdl:
  67. HighLowWNL38:
  68. 25:
  69. HighLowWNL15:
  70. 11:
  71. RELEVANT LabsRow1_2:
  72. Clinical SignificanceRow1_4:
  73. TREND ImproveWorseningStableRow1_2:
  74. Coags:
  75. Current_3:
  76. Previous_3:
  77. HighLowWNL15_2:
  78. 12:
  79. RELEVANT Labs:
  80. Clinical SignificancePTINR 15:
  81. UPworsening:
  82. Current_4:
  83. Previous_4:
  84. Albumin 3555 gdL:
  85. HighLowWNL25:
  86. 29:
  87. HighLowWNL42:
  88. 22:
  89. HighLowWNL285:
  90. 155:
  91. ALT 820 UL:
  92. HighLowWNL128_2:
  93. 65:
  94. AST 820 UL:
  95. HighLowWNL124:
  96. 124Misc Labs:
  97. HighLowWNLMisc Labs:
  98. 85Misc Labs:
  99. HighLowWNL35_2:
  100. 28:
  101. RELEVANT LabsRow1_3:
  102. Clinical SignificanceRow1_5:
  103. TREND ImproveWorseningStableRow1_3:
  104. Why RelevantCritical Value:
  105. Nursing AssessmentsInterventions RequiredCritical Value:
  106. RationaleEstablish peripheral IV NS 09 bolus of 1000 mL Ondansetron 4 mg IV every 4 hours PRN Orthostatic BP:
  107. Expected OutcomeEstablish peripheral IV NS 09 bolus of 1000 mL Ondansetron 4 mg IV every 4 hours PRN Orthostatic BP:
  108. Order of Priority1 Establish peripheral IV 2 NS 09 bolus of 1000 mL 3 Ondansetron 4 mg IV every 4 hours PRN nausea 4 Orthostatic BP:
  109. Rationale1 Establish peripheral IV 2 NS 09 bolus of 1000 mL 3 Ondansetron 4 mg IV every 4 hours PRN nausea 4 Orthostatic BP:
  110. MedicationDose:
  111. Mechanism of ActionOndansetron 4 mg IV 4mg2 mL vial:
  112. Nursing AssessmentConsiderationsIV Push Volume every 15 sec:
  113. Nursing InterventionsRow1:
  114. RationaleRow1_3:
  115. Expected OutcomeRow1:
  116. Current VS_2:
  117. Current PQRST:
  118. P 118 reg:
  119. DENIESQuality:
  120. R 22 reg:
  121. DENIESRegionRadiation:
  122. BP 8850:
  123. DENIESSeverity:
  124. DENIESTiming:
  125. Current Assessment_2:
  126. Disheveled clothing dirty has strong body odor appears unkempt does not smell of ETOH:
  127. RESP_2:
  128. CARDIAC_2:
  129. NEURO_2:
  130. GI_2:
  131. GU_2:
  132. Voiding without difficulty urine clearorange:
  133. SKIN_2:
  134. RELEVANT VS DataRow1_2:
  135. RationaleRow1_4:
  136. RELEVANT Assessment DataRow1_2:
  137. RationaleRow1_5:
  138. Last Nursing Assessment 6 Months Ago:
  139. GENERAL APPEARANCE_2:
  140. Appears uncomfortable restless:
  141. RESP_3:
  142. CARDIAC_3:
  143. NEURO_3:
  144. Alert oriented to person place time and situation x4_2:
  145. GI_3:
  146. GU_3:
  147. Voiding without difficulty urine clearlight orange:
  148. SKIN_3:
  149. Current_5:
  150. Previous_5:
  151. WBC 45110 mm 3_2:
  152. HighLowWNL69:
  153. 128:
  154. Hgb 1216 gdL_2:
  155. HighLowWNL89:
  156. 102:
  157. HighLowWNL47:
  158. 98:
  159. Neutrophil 4272_2:
  160. HighLowWNL68:
  161. 88_2:
  162. Band forms 35_2:
  163. HighLowWNL3_2:
  164. 3:
  165. RELEVANT LabsRow1_4:
  166. Clinical SignificanceRow1_6:
  167. TREND ImproveWorseningStableRow1_4:
  168. Current_6:
  169. Previous_6:
  170. HighLowWNL127:
  171. 135:
  172. HighLowWNL28:
  173. 35:
  174. HighLowWNL74:
  175. 78:
  176. BUN 725 mgdl_2:
  177. HighLowWNL55:
  178. 38_2:
  179. HighLowWNL18:
  180. 15:
  181. RELEVANT LabsRow1_5:
  182. Clinical SignificanceRow1_7:
  183. TREND ImproveWorseningStableRow1_5:
  184. Coags_2:
  185. Current_7:
  186. Previous_7:
  187. HighLowWNL26:
  188. 15_2:
  189. RELEVANT LabsRow1_6:
  190. Clinical SignificanceRow1_8:
  191. TREND ImproveWorseningStableRow1_6:
  192. Current_8:
  193. Previous_8:
  194. Albumin 3555 gdL_2:
  195. HighLowWNL22:
  196. 25_2:
  197. HighLowWNL72:
  198. 42:
  199. HighLowWNL140:
  200. 285:
  201. ALT 820 UL_2:
  202. HighLowWNL59:
  203. 128_2:
  204. AST 820 UL_2:
  205. HighLowWNL62:
  206. 62Misc Labs:
  207. HighLowWNLMisc Labs_2:
  208. 124Misc Labs_2:
  209. HighLowWNL78_2:

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