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Jenna Simpson is a 24-year-old Caucasian female who weighs 210 pounds (95.5 kg-BMI of 36.5) who presents to the emergency department with sudden onset of sharp pain in the right side of her lower back that radiates to the right side of her abdomen and into her groin. The pain started ten hours ago, but lasted only 15 minutes and then went away. She took ibuprofen 600 mg PO an hour ago but has not helped, and the pain persists. She states that this pain is different than when she has epigastric pain because of gastroesophageal reflux disease (GERD). She feels nauseated but has not vomited. Jenna appears uncomfortable and pleads with the triage nurse, “Please do something to get rid of this pain! What is wrong with me?” What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: 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. Class: Mechanism of Action (own words): Anxiety Gastroesophageal reflux disease (GERD) Alprazolam 0.5 mg PO every 8 hours PRN Pantoprazole 10 mg PO BID Jenna is quickly brought to a room. You are the nurse and quickly collect the following assessment data: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.9 F/ 37.2 C (oral) Provoking/Palliative: Nothing changes the level of pain P: 92 (regular) Quality: Sharp, severe R: 28 (regular) Region/Radiation: Right back/flank that radiates into RLQ and groin BP: 148/84 Severity: 10/10 O2 sat: 99% room air Timing: Constant the past hour What vital signs are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion and Maintenance) Abnormal VS: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Obese female is sitting upright in bed. Alert, oriented, pleasant, in moderate distress, dress appropriate for the season, hygiene and grooming normal for age and gender, anxious, body tense, + grimacing, appears to be uncomfortable. RESP: Breath sounds clear on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, with equal aeration bilaterally ant/post, nonlabored respiratory effort with + tachypneic. Posture erect, sitting in bed, in moderate distress, on room air, AP diameter 1:2, symmetry of the thoracic cavity noted with inspiration and expiration CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, carotid pulse 3+ and regular bilaterally. Heart tones audible and regular, S1 and S2, noted over the 5 cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. NEURO: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. GI: Abdomen flat, soft, bowel sounds audible per auscultation in all four quadrants, nontender to gentle palpation in all four quadrants GU: Voiding without difficulty, dark amber/rusty color with recent void to collect urine specimen INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds. Hair short, brown, soft. Hair distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present What assessment findings are abnormal? What is the reason (pathophysiology) for these findings? RELEVANT Assessment Data: Clinical Significance: Put it All Together and Think Like a Nurse! 1. Interpreting relevant clinical data, what is the most likely primary problem? What body system(s) will you assess most thoroughly based on the primary/priority concern? What's the problem? What's causing the problem? (explain pathophysiology in OWN words) PRIORITY Body System to Assess 2. ​Which specific nursing assessments for this body system are most important? Validate successful completion of each nursing assessment on a manikin (if available) identified with peer or faculty initials. PRIORITY Nursing Assessments: Rationale: Validate Student Performance: 3. What is the current nursing priority and plan of care? Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: State the rationale and expected outcomes for the medical plan of care. Medical Management: Rationale: Expected Outcome: Establish peripheral IV Hydromorphone 1 mg IVP Ketorolac 15 mg IVP Ondansetron 4 mg IVP Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Radiology: CT Pelvis Results: Clinical Significance: 4 mm stone in the distal right ureter Clinical Significance Results: Urinalysis + UA Micro What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: Complete Blood Count (CBC) WBC:10.2 HGB: 14.2 PLTs: 285 % Neuts:72 Bands:0 RELEVANT Lab(s): Clinical Significance Current VS: Most Recent: Current PQRST: T: T: 98.9 F/ 37.2 C (oral) Provoking/Palliative: P: P: 92 (regular) Quality: R: R: 28 (regular) Region/Radiation: BP: BP: 148/84 Severity: O2 sat: O2 sat: 99% room air Timing: 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable: RELEVANT Assessment Data: Clinical Significance: TREND: Improve/Worsening/Stable: 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: 3. What did you learn that you can apply to future patients in your care? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength? What Did You Learn? What did you do well in this case study? What could have been done better? What is your plan to make any weakness a future strength? © 2019 Keith Rischer/www.KeithRN.com Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: INTEGUMENTARY: 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable: RELEVANT Assessment Data: Clinical Significance: TREND: Improve/Worsening/Stable: 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: 3. What did you learn that you can apply to future patients in your care? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength? What Did You Learn? What did you do well in this case study? What could have been done better? What is your plan to make any weakness a future strength? © 2019 Keith Rischer/www.KeithRN.com Lab Results: Urinalysis + UA Micro Color: Clarity: Sp. Gr. Glucose Ketone LET RBCs WBCs Bacteria Epithelial Current: Dark amber/ Rusty Clear 1.012 Neg © 2019 Keith Rischer/www.KeithRN.com Current Assessment: GENERAL APPEARANCE: Obese female is sitting upright in bed. Alert, oriented, pleasant, in moderate distress, dress appropriate for the season, hygiene and grooming normal for age and gender, anxious, body tense, + grimacing, appears to be uncomfortable. RESP: Breath sounds clear on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, with equal aeration bilaterally ant/post, nonlabored respiratory effort with + tachypneic. Posture erect, sitting in bed, in moderate distress, on room air, AP diameter 1:2, symmetry of the thoracic cavity noted with inspiration and expiration CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, carotid pulse 3+ and regular bilaterally. Heart tones audible and regular, S1 and S2, noted over the 5 cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. NEURO: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. GI: Abdomen flat, soft, bowel sounds audible per auscultation in all four quadrants, nontender to gentle palpation in all four quadrants GU: Voiding without difficulty, dark amber/rusty color with recent void to collect urine specimen INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds. Hair short, brown, soft. Hair distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present What assessment findings are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Put it All Together and Think Like a Nurse! 1. Interpreting relevant clinical data, what is the most likely primary problem? What body system(s) will you assess most thoroughly based on the primary/priority concern? What's the problem? What's causing the problem? (explain pathophysiology in OWN words) PRIORITY Body System to Assess: © 2019 Keith Rischer/www.KeithRN.com 2. ​Which specific nursing assessments for this body system are most important? Validate successful completion of each nursing assessment on a manikin (if available) identified with peer or faculty initials. PRIORITY Nursing Assessments: Rationale: Validate Student Performance: 3. What is the current nursing priority and plan of care? Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: 4. State the rationale and expected outcomes for the medical plan of care. Medical Management: Rationale: Expected Outcome: Establish peripheral IV Hydromorphone 1 mg IVP Ketorolac 15 mg IVP Ondansetron 4 mg IVP Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Radiology: CT Pelvis Results: Clinical Significance: 4 mm stone in the distal right ureter © 2019 Keith Rischer/www.KeithRN.com Lab Results: Urinalysis + UA Micro Color: Clarity: Sp. Gr. Glucose Ketone LET RBCs WBCs Bacteria Epithelial Current: Dark amber/ Rusty Clear 1.012 Neg Neg Neg >100 2 None None What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 10.2 14.2 285 72 0 RELEVANT Lab(s): Clinical Significance: Evaluate the response to nursing and medical interventions. All orders have been implemented. What would be the EXPECTED response in clinical data collected if her pain and anxiety are decreased? Evaluation: Thirty Minutes Later… Current VS: Most Recent: Current PQRST: T: T: 98.9 F/ 37.2 C (oral) Provoking/Palliative: P: P: 92 (regular) Quality: R: R: 28 (regular) Region/Radiation: BP: BP: 148/84 Severity: O2 sat: O2 sat: 99% room air Timing: © 2019 Keith Rischer/www.KeithRN.com Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: INTEGUMENTARY: 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable: RELEVANT Assessment Data: Clinical Significance: TREND: Improve/Worsening/Stable: 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: 3. What did you learn that you can apply to future patients in your care? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength? What Did You Learn? What did you do well in this case study? What could have been done better? What is your plan to make any weakness a future strength?
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NURSING

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