19 Sep © 2018 Keith Rischer/www.KeithRN.com UNFOLDING Cl
© 2018 Keith Rischer/www.KeithRN.com UNFOLDING Clinical Reasoning Case Study History of Present Problem: Jeremy Brown is a 30-year-old Caucasian male who was brought to the emergency department (ED) by the police after being involved in an altercation at work. Jeremy was at work today, and he threw a large piece of metal at a coworker and began yelling, “Stop following me, I know what you have been up to!” Because Jeremy was very agitated and upset, and the police were called. Since arriving in the ED, he has been agitated, displaying rapid pressured speech and repeating the phrases he hears the police and others in the ED said. Jeremy reported that he recently stopped taking his risperidone and citalopram because he believed his coworkers have been breaking into his house and poisoning his medications. Jeremy’s manager reports that he was diagnosed with schizophrenia five years ago. Personal/Social History: Jeremy graduated from college with a 4.0 GPA and was in his first year at law school when he experienced the first episode of acute mental illness and was diagnosed with schizophrenia. He had to drop out of law school at age 24 and never finished. Jeremy lives at home with his mother and father and recently broke up with his girlfriend. Jeremy likes his job at the foundry but feels he is a disappointment because both of his sisters are lawyers, as is his father. Jeremy has no close friends and only a few acquaintances. Jeremy’s mental health had been stable up until the last three months. He has been feeling more paranoid the past three months and experienced a dramatic increase in symptoms when he stopped taking all of his medications one month ago. 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: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 97.8 F/36.6 C (oral) Provoking/Palliative: Denies pain P: 100 (regular) Quality: R: 22 (regular) Region/Radiation: BP: 130/84 Severity: O2 sat: 98% room air Timing: © 2018 Keith Rischer/www.KeithRN.com What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present Mental Status Examination: APPEARANCE: Diaphoretic, uncombed shoulder-length, somewhat greasy hair; cloths are stained and torn. Cooperative with the admission process. MOTOR BEHAVIOR: No abnormal muscle movements SPEECH: Rapid and pressured. Client often repeats words and phrases he hears others in the emergency room say. The client says, “He was brought to the emergency room” over and over again when he is not distracted or engaged in conversation. MOOD: Reports feeling very upset AFFECT: Becomes agitated/anxious when talking about his co-workers and his meds; guarded and suspicious, mood and affect are congruent. THOUGHT PROCESS: Linear but irrational THOUGHT CONTENT: Displays paranoid delusions that coworkers are following him to hurt him and are poisoning his medication. PERCEPTION: Denies auditory or visual hallucinations, or feelings of depersonalization (feeling detached from self or environment) INSIGHT: Poor-believes he was brought in to the emergency room for protection from his coworkers JUDGMENT: Poor-stopped meds and is acting aggressively towards co-workers COGNITION: Alert and oriented times 4 (person, place, time and purpose), is easily distracted INTERACTIONS: Is in good control when talking with nursing staff, his boss, and police. SUICIDAL/HOMICIDAL: Denies any suicidal thoughts or thoughts of self-harm. Stated he wants to “punish” his co-workers. © 2018 Keith Rischer/www.KeithRN.com RELEVANT Mental Status Exam Data: Clinical Significance: Lab Results: What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Clinical Reasoning Begins 1. What is the primary problem that your patient is most likely presenting? 2. What is the underlying cause/pathophysiology of this primary problem? Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Most Recent: Sodium (135–145 mEq/L) 130 135 Potassium (3.5–5.0 mEq/L) 3.5 3.8 Glucose (70–110 mg/dL) 160 128 Creatinine (0.6–1.2 mg/dL) 1.1 1.0 Complete Blood Count (CBC:) Current: High/Low/WNL? Most Recent: WBC (4.5–11.0 mm 3) 6.5 8.2 Neutrophil % (42–72) 60 68 Hgb (12–16 g/dL) 12.5 12.8 Platelets (150-450 x103/μl) 250 289 © 2018 Keith Rischer/www.KeithRN.com Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Admit to the inpatient mental health unit on a voluntary status Risperidone 2mg PO BID Citalopram 20mg PO at HS Lorazepam 1mg PO every 6 hours PRN for anxiety or agitation Haloperidol 5mg IM every 4 hours PRN for severe agitation PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: Lorazepam 1mg Citalopram 20mg Haloperidol 5mg Risperidone 2mg Admit to inpatient mental health unit 1. 2. 3. 4. 5. 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: © 2018 Keith Rischer/www.KeithRN.com 5. What body system(s) will you assess most thoroughly 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 family likely have that will need to be addressed? 10. How can the nurse address these psychosocial needs? Evaluation: Six Hours Later The client has been admitted to the adult inpatient mental health unit, and you are now the nurse caring for the client. Current VS: Most Recent: Current PQRST: T: 97.4 F/36.3 C (oral) T: 97.8 F/36.6 C (oral) Provoking/Palliative: Denies pain P: 78 (regular) P: 100 (regular) Quality: R: 16 (regular) R: 22 (regular) Region/Radiation: BP: 118/70 BP: 130/84 Severity: O2 sat: 99% room air O2 sat: 98% room air Timing: Mental Status Examination: APPEARANCE: Recently showered, dressed in hospital gown and clothing MOTOR BEHAVIOR: No abnormal muscle movements SPEECH: Normal rate and rhythm MOOD/AFFECT: Flat, watchful THOUGHT PROCESS: Linear THOUGHT CONTENT: Continues to believe meds at home are poison; willing to take meds in the hospital because they are sealed. Continues to state people at work were out to harm him PERCEPTION: Denies auditory or visual hallucinations INSIGHT/JUDGMENT: Fair- Client acknowledges his diagnosis of schizophrenia and understands this is why he is in the hospital COGNITION: Alert and oriented times 4 INTERACTIONS: Sitting at table with other clients but not engaging in conversation SUICIDAL/HOMICIDAL: Denies any thoughts of suicide or self-harm or thoughts to harm others. © 2018 Keith Rischer/www.KeithRN.com 1. What clinical data are RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: RELEVANT Assessment Data: Clinical Significance: 2. Has the status improved or not as expected to this point? 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? It is now the end of your shift. 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: Current Assessment: GENERAL APPEARANCE: Resting comfortably appears in no acute distress RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact Situation: Name/age: BRIEF summary of the primary problem: Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data: © 2018 Keith Rischer/www.KeithRN.com Education Priorities/Discharge Planning 1. What educational/discharge priorities will be needed to develop a teaching plan for this patient and family? 2. How can the nurse assess the effectiveness of patient and family teaching and discharge instructions? 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/she 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 at 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?
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