Unfolding clinical reasoning case study answers

Primary Concept

Pain

Interrelated Concepts (In order of emphasis) • Reproduction

• Stress

• Clinical Judgment

NCLEX Client Need Categories Percentage of Items from Each

Category/Subcategory

Covered in

Case Study Safe and Effective Care Environment

• Management of Care 17-23% ✓

• Safety and Infection Control 9-15%

Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity

• Basic Care and Comfort 6-12% ✓

• Pharmacological and Parenteral Therapies 12-18% ✓

• Reduction of Risk Potential 9-15% ✓

• Physiological Adaptation 11-17% ✓

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Anne is a 17-year-old, gravida 1 para 0 who is 39 weeks gestation and admitted to the labor room for

observation at 1200. She began having contractions three hours ago at 8 to 10-minute intervals with each

contraction lasting 30 seconds. She states her pain is 3/10. Her membranes are intact. On admission, a vaginal

exam indicates cervical dilation is 1 cm, 80% effacement, and 0 station.

After two hours of observation, her cervix is 2-3 cm/ 80% effacement/0 station and contractions are now 4-

5 minutes apart, lasting 60-70 seconds and pain remains 3/10. Fetal lie is longitudinal with a cephalic

presentation. You have her prenatal records from her visits to the office. She is Group Beta Strep (GBS)

positive and received antibiotics at 36 weeks. Her blood type is B-.

Personal/Social History: Anne’s mother is with her. Anne is not married and the father of the baby is not involved. She appears to be

relaxed although she states she is a bit nervous. She wants a natural non-medicated birth and her mother will

help coach her. She plans on breastfeeding for “awhile”. She attended childbirth preparation classes with her

mother.

What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Anne is placed on a fetal monitor and

the nurse collects the following strip:

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

Fetal Heart Rate Strip Assessment: Fetal Monitoring Strip:

Interpretation:

Clinical Significance:

Patient Care Begins:

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

RELEVANT VS Data: Clinical Significance:

Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Began 3 hours ago

P: 76 (regular) Quality: Cramping that comes and goes, lasting 40 sec after 1 hour 60- 70 sec.

R: 18 (regular) Region/Radiation: Uterus

BP: 125/80 Severity: 3/10

O2 sat: 98 Timing: 8-10 min then 4-5 mins

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

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

RELEVANT Assessment Data: Clinical Significance:

Current Assessment:

General

Appearance:

Calm, body relaxed, no grimacing, appears to be slightly anxious.

Respiratory: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort

Cardiac: Pink, warm & dry, slight ankle edema, heart sounds regular with no abnormal beats, pulses

strong, equal with palpation at radial, brisk cap refill

Neuro: Alert and oriented to person, place, time, and situation (x4)

HEENT: Normal cephalic

Chest: Breasts tender on palpation, areola darkened and occasional veins present

Abdomen: Soft; no masses, uterus palpable above umbilicus, mild indenting with palpation, fetus is in

LOA position by palpation

Extremities: Mild spider varicose veins on medial aspect of left leg, deep tendon reflexes 2+

Vaginal Exam: Small amount clear mucous, 1cm/80%/0, membranes intact

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

Part II: Put it All Together to THINK Like a Nurse!

1. Interpreting relevant clinical data, what is the primary concern? 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:

Admit to Labor and Delivery

Intermittent fetal heart

monitoring ambulating as

tolerated

Ampicillin 2 g IVPB when

in active labor and 1 g every

4 hours while in labor

Vital Signs every hour

Limit vaginal exams.

May ambulate as tolerated

2. What nursing priority (ies) will guide your plan of care? (Management of Care)

Nursing PRIORITY:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

3. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

CARE/COMFORT:

Caring/compassion as a nurse

Physical comfort measures

EMOTIONAL (How to develop a

therapeutic relationship):

Discuss the following principles needed

as conditions essential for a therapeutic

relationship:

• Rapport

• Trust

• Respect

• Genuineness

• Empathy

Use Reflection to THINK Like a Nurse What did you learn that you can apply to future patients you care for? 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?

NCLEX Client Need Categories:
Safe and Effective Care Environment:
Management of Care:
915:
Health Promotion and Maintenance:
Psychosocial Integrity:
Physiological Integrity:
Basic Care and Comfort:
Reduction of Risk Potential:
Physiological Adaptation:
RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
RELEVANT Data from Social HistoryRow1:
Clinical SignificanceRow1_2:
Fetal Monitoring StripRow1:
InterpretationRow1:
Clinical SignificanceRow1_3:
Current VS:
PQRST Pain Assessment:
Began 3 hours ago:
P 76 regular:
Quality:
R 18 regular:
Uterus:
BP 12580:
Severity:
310:
O2 sat 98:
Timing:
810 min then 45 mins:
RELEVANT VS DataRow1:
Clinical SignificanceRow1_4:
Current Assessment:
General Appearance:
Calm body relaxed no grimacing appears to be slightly anxious:
Respiratory:
Cardiac:
Neuro:
Alert and oriented to person place time and situation x4:
HEENT:
Normal cephalic:
Chest:
Abdomen:
Extremities:
Small amount clear mucous 1cm800 membranes intact:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_5:
ProblemRow1:
Pathophysiology of Problem in OWN WordsRow1:
Primary ConceptRow1:
RationaleAdmit to Labor and Delivery Intermittent fetal heart monitoring ambulating as tolerated Ampicillin 2 g IVPB when in active labor and 1 g every 4 hours while in labor Vital Signs every hour Limit vaginal exams May ambulate as tolerated:
Expected OutcomeAdmit to Labor and Delivery Intermittent fetal heart monitoring ambulating as tolerated Ampicillin 2 g IVPB when in active labor and 1 g every 4 hours while in labor Vital Signs every hour Limit vaginal exams May ambulate as tolerated:
Nursing PRIORITY:
PRIORITY Nursing InterventionsRow1:
RationaleRow1:
Expected OutcomeRow1:
Psychosocial PRIORITIES:
RationaleCARECOMFORT Caringcompassion as a nurse Physical comfort measures:
Expected OutcomeCARECOMFORT Caringcompassion as a nurse Physical comfort measures:
RationaleEMOTIONAL How to develop a therapeutic relationship Discuss the following principles needed as conditions essential for a therapeutic relationship Rapport Trust Respect Genuineness Empathy:
Expected OutcomeEMOTIONAL How to develop a therapeutic relationship Discuss the following principles needed as conditions essential for a therapeutic relationship Rapport Trust Respect Genuineness Empathy:
What Did You LearnRow1:
What did you do well in this case studyRow1:
What could have been done betterRow1:
What is your plan to make any weakness a future strengthRow1: