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:

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

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

Nursing Interventions: Rationale: Expected Outcome:

4. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family?

RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
Current VS:
PQRST Pain Assessment 5th VS:
Nothingnothing:
P 110 regular:
Quality:
Ache:
R 20:
RUQepigastric:
BP 12888:
Severity:
610:
O2 sat 95 RA:
Timing:
Continuous:
BP:
Lying:
RELEVANT VS DataRow1:
RationaleRow1:
Current Assessment:
GENERAL APPEARANCE:
Appears uncomfortable body tense occasional facial grimacing:
RESP:
CARDIAC:
NEURO:
Alert oriented to person place time and situation x4:
GI:
GU:
SKIN:
RELEVANT Assessment DataRow1:
RationaleRow1_2:
Current:
Previous:
WBC 45110 mm 3:
HighLowWNL128:
95:
Hgb 1216 gdL:
HighLowWNL102:
112:
HighLowWNL98:
122:
Neutrophil 4272:
HighLowWNL88:
75:
Band forms 35:
HighLowWNL3:
0:
RELEVANT LabsRow1:
Clinical SignificanceRow1_2:
TREND ImproveWorseningStableRow1:
Current_2:
Previous_2:
HighLowWNL135:
138:
HighLowWNL35:
38:
HighLowWNL78:
88:
BUN 725 mgdl:
HighLowWNL38:
25:
Hi