RELEVANT VS Data: Clinical Significance DQ RELEVANT VS Data: Clinical Significance DQ Current VS: P-Q-R-S-T Pain Assessment: T: 103.4 F/39.7 C (oral) Provoking/

RELEVANT VS Data: Clinical Significance DQ

RELEVANT VS Data: Clinical Significance DQ

Current VS: P-Q-R-S-T Pain Assessment: T: 103.4 F/39.7 C (oral) Provoking/Palliative: Not responsive verbally, withdraws to pain, no other indicators of

pain

P: 135 (irregular) Quality:

R: 32 (regular) Region/Radiation:

BP: 76/39 MAP: 51 Severity:

O2 sat: 91% 2 liters n/c Timing:

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Determine current Glasgow coma scale score based on neurological assessment data:

Glasgow Coma Scale Eye Opening

Spontaneous 4

To sound 3

To pain 2

Never 1

Motor Response

Obeys commands 6

Localizes pain 5

Normal flexion (withdrawal) 4

Abnormal flexion 3

Extension 2

None 1

Verbal Response

Oriented 5

Confused conversation 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

Total

What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: Clinical Significance:

Current Assessment:

GENERAL

APPEARANCE: Pale and warm to touch. Appears tense.

RESP: Tachypneic and working hard to breathe, intercostal and suprasternal retractions present. Breath sounds diminished and light crackles in lower lobes bilat. Nail beds have noticeable

clubbing, barrel chest present.

CARDIAC: Pale, 1+ pitting edema lower extremities, systolic murmur with an irregular rhythm, radial pulses weak and thready, cap refill 3 seconds

NEURO: Does not open eyes to sound or pain, withdraws to pain, incomprehensible sounds to painful stimuli, does not follow commands but does not resist when moved on a stretcher. PERRL

GI: Distended abdomen, firm/nontender, bowel sounds hypoactive in all quadrants RELEVANT VS Data: Clinical Significance DQ

GU: Foley catheter placed to monitor urine output. 50 mL tea-colored urine with no sediment,

and no odor present

SKIN: Stage IV decubitus to coccyx 1 cm x 0.5 cm x 0.5 cm depth, wound bed with visual bone

noted at the base with large areas of necrosis on both sides of the sacrum bone. When

dressing was removed, a large amount of yellow/green purulent drainage on dressing with a

foul odor. Mucus membranes dry and pale.

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Cardiac Telemetry Strip:

Regular/Irregular: P wave present? PR: QRS:

Interpretation:

Clinical Significance:

Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

Radiology: Chest X-Ray

Results: Clinical Significance:

Cardiac silhouette slightly

enlarged. No infiltrates present.

Lab Results: Complete Blood Count (CBC)

WBC HGB PLTs % Neuts Bands

Current: 18.5 13.1 250 85.2 3

Most Recent: 12.4 13.2 175 64 0

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: TREND: Improve/Worsening/Stable:

Basic Metabolic Panel (BMP)

Na K Gluc. Creat.

Current: 147 5.2 172 1.6

Most Recent: 138 4.4 98 0.88

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: TREND: Improve/Worsening/Stable:

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Misc.

Lactate PT/INR GFR

Current: 7.4 1.6 45

Most Recent: n/a 0.9 >60

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: TREND: Improve/Worsening/Stable:

Liver Panel

Albumin Total Bili Alk. Phos. ALT AST

Current: 2.9 5.1 285 134 175

Most Recent: 3.1 0.9 48 17 12

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: TREND: Improve/Worsening/Stable:

Urinalysis + UA Micro

Color: Clarity: Sp. Gr. Protein Nitrite LET RBCs WBCs Bacteria Epithelial

Current: Tea Clear 1.050 NEG NEG NEG <5 <5 NEG None RELEVANT VS Data: Clinical Significance DQ

Most Recent: Yellow Clear 1.025 NEG NEG NEG <5 <5 NEG 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: TREND: Improve/Worsening/Stable:

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation)

Lab: Normal

Value:

Clinical Significance: Nursing Assessments/Interventions Required:

Lactate

Value:

7.4

Critical Value:

Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this

primary problem represent? (Management of Care/Physiologic Adaptation)

Problem: Pathophysiology of Problem in OWN Words: Primary Concept:

Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome:

Two large bore (18 g) IVs

Fluid bolus 0.9% NS 30 mL/kg (2250 mL)

Blood cultures x2

Urine culture

Wound culture

Vancomycin 2 g IV after cultures collected

Clindamycin 600 mg IV every 6 hours

If MAP remains <65 after 2250 mL of

0.9% NS…start Norepinephrine 1-12

mcg/min to maintain MAP >65

If MAP remains <65 after norepinephrine

at 1 mcg/kg/min…start

Vasopressin 0.04 units/minute to maintain

MAP >65

Continuous cardiac monitor

VS every 5-15”

Acetaminophen 1000 mg PR every 6 hours

PRN for fever >101

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale:

• 2 large bore (18 g) IVs

• Vancomycin 2 gram IV after cultures collected

• Clindamycin 600mg IV every 6 hours

• Fluid bolus 0.9% NS 30 mL/kg (2250 mL) RELEVANT VS Data: Clinical Significance DQ

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