Part I: Emergency Department (ED)
SKINNY Reasoning
John Taylor, 68 years old
Primary Concept
Infection/Immunity
Interrelated Concepts (In order of emphasis)
• Clinical judgment
NCLEX Client Need Categories
Safe and Effective Care Environment
• Management of Care
• Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
• Basic Care and Comfort
• Pharmacological and Parenteral
Therapies
• Reduction of Risk Potential
• Physiological Adaptation
Covered in
Case Study
✓
✓
✓
NCSBN Clinical
Judgment Model
Step 1: Recognize Cues
Step 2: Analyze Cues
Step 3: Prioritize Hypotheses
Step 4: Generate Solutions
Step 5: Take Action
Step 6: Evaluate Outcomes
Covered in
Case Study
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
Initial Triage Assessment in ED
Present Problem:
John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension who came to the
emergency department (ED) triage window because he felt crummy; complaining of a headache, runny nose, feeling more
weak, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt
hot but began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty
“catching his breath” when he gets up to go the bathroom. John is visibly anxious and asks, “Do I have that killer virus
that I hear about on the news?”
Personal/Social History:
John lives in a large metropolitan area that has had over three thousand confirmed cases of COVID-19. He has been
married to Maxine, his wife of 45 years and is retired police officer and active in his local church.
1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem:
Clinical Significance:
RELEVANT Data from Social History:
Clinical Significance:
2. What additional clarifying questions does the triage nurse need to ask John to determine if his cluster of physical
symptoms are consistent with COVID-19?
3. Based on the clinical data collected, identify what measures need to be immediately implemented using the
following clinical pathway.
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
4. What type of isolation precautions does the nurse need to implement if COVID-19 is suspected? What specific
measures must be implemented to prevent transmission?
Type of Isolation:
Implementation Components:
5. What are the six steps in the chain of infection? Apply what is known about COVID-19 to each step.
Six Steps:
1.
Coronavirus COVID-19:
2.
3.
4.
5.
6.
6. Is this patient a susceptible host? What step in the chain of infection does proper isolation precautions impact?
Why?
Patient Care Begins:
John is brought back to a room. As the nurse responsible for
his care, you collect the following clinical data:
Current VS:
T: 100.3 F/38.8 C (oral)
P: 118 (regular)
R: 20 (regular)
BP: 164/88 MAP: 113
O2 sat: 92% room air
P-Q-R-S-T Pain Assessment:
Provoking/Palliative: “moving makes it worse”
“achy”
Quality:
“all over”
Region/Radiation:
5/10
Severity:
continuous
Timing:
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
1. What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and
Maintenance)
RELEVANT VS Data:
Clinical Significance:
2. What body system(s) will you assess most thoroughly performing a FOCUSED assessment based on the
primary/priority problem? Identify correlating specific nursing assessments.
(NCLEX: Reduction of Risk Potential/Physiologic Adaptation)
PRIORITY Body System: PRIORITY Nursing Assessments:
Current FOCUSED Nursing Assessment:
GENERAL SURVEY:
Appears anxious, body tense
NEUROLOGICAL:
Alert & oriented to person, place, time, and situation (x4), generalized weakness
HEENT:
Head normocephalic with symmetry of all facial features. Lips, tongue, and oral mucosa pink
and moist.
RESPIRATORY:
Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration
in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic nonproductive cough
CARDIAC:
No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial
landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M
cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees.
ABDOMEN:
Deferred
GU:
Deferred
INTEGUMENTARY:
Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no
tenting present.
3. What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data:
Clinical Significance:
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
4. Interpreting clinical data collected, what problems are possible? Which problem is the PRIORITY? Why?
(NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care)
Problems:
Priority Problem:
Rationale:
5. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN:
Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care)
Nursing PRIORITY:
GOAL of Care:
Nursing Interventions:
Rationale:
Expected Outcome:
Caring and the “Art” of Nursing
6. What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with
this patient’s experience, and show that they matter to you as a person? (NCLEX: Psychosocial Integrity)
What Patient is Experiencing:
How to Engage:
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
Reflect on Your Thinking to Develop Clinical Judgment
To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the
following questions:
What did you do well in this case study?
What weaknesses did this case study identify?
What is your plan to make any weakness a strength?
How will you apply what was learned to future patients?
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
Initial Triage Assessment in ED
Present Problem: John Taylor is a 68-year-old African-American male with a history
of type II diabetes and hypertension who came to the emergency department (ED)
triage window because he felt crummy; complaining of a headache, runny nose,
feeling more weak, “achy all over” and hot to the touch and sweaty the past two
days. When he woke up this morning, he no longer felt hot but began to develop a
persistent “nagging cough” that continued to worsen throughout the day. He has
difficulty “catching his breath” when he gets up to go the bathroom. John is visibly
anxious and asks, “Do I have that killer virus that I hear about on the news?”
Personal/Social History: John lives in a large metropolitan area that has had over
three thousand confirmed cases of COVID-19. He has been married to Maxine, his
wife of 45 years and is retired police officer and active in his local church.
1. What data from the histories are
clinically significant by the nurse.
RELEVANT Data from Present
Problem:
68 year old African American
Type II Diabetes
Hypertension
Headache
Weak & “Achy all over”
Hot
Nagging Cough
Difficulty “catching his breath”
RELEVANT Data from Social History:
Large metropolitan area w/3,000
COVID-19 cases confirmed
Has a spouse
RELEVANT and must be NOTICED as
Clinical Significance:
This patient’s age puts him at high risk, and
a weakened immune system due to his
medical history. Symptoms of COVID-19 are
cough, fever, tiredness, and difficulty
breathing, which his symptoms match to
what the virus shows.
Clinical Significance:
Living in a large area with so many
confirmed cases can put an elderly man at
risk for contracting it from even going to the
grocery store, or from his significant other.
Making sure that the spouse isn’t
experiencing the same symptoms since
either she was exposed to it by him or she
exposed it to him.
2.What additional clarifying questions does the triage nurse need to ask
John to determine if his cluster of physical symptoms are consistent with
COVID-19?
Asking the patient how long these symptoms have been going on, also asking the
patient if he has lost his sense of smell or taste. Asking if the patient has been
experiencing any chest pain or pressure, assess for any confusion, and bluish lips or
face. Collect any information on who the patient been around since feeling ill.
3.Based on the clinical data collected, identify what measures need to be
immediately implemented using the following clinical pathway.
Isolation precaution needs to be implemented immediately to make sure no one
else is exposed to the virus.
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
4.What type of isolation precautions does the nurse need to implement if
COVID-19 is suspected? What specific measures must be implemented to
prevent transmission?
Type of Isolation:
Implementation Components:
Airborne Precaution
Negative Pressure Room
N95 Mask, Gown, Gloves
Hand Washing
Disinfecting any equipment or
making sure that equipment is
only used for that patient.
5.What are the six steps in the chain of infection? Apply what is known
about COVID-19 to each step.
Six Steps:
Coronavirus COVID-19:
1. Infectious Agent
Respiratory Virus
2. Reservoir
Air, Inanimate Objects (Metal, Plastic,
Electronics), Animals, Humans
3. Portal of Exit
Mouth & Nose
4. Mode of Transmission
Direct & Indirect Contact, Sneezing,
Coughing, Breathing
5. Portal of Entry
Mouth, Nose, & Eyes
6. Susceptible Host
Over 65 years old, Immunosuppressed,
Diabetic, Severe Asthma or Lung
Disease, Severe Obesity, CVD, CKD, &
Liver Disease
6.Is this patient a susceptible host? What step in the chain of infection
does proper isolation precautions impact? Why? Yes he would be a susceptible
host because of his underlying medical conditions (Diabetes, and Hypertension), he
is also elderly as well so that puts him at a higher risk. Proper isolation precautions
could impact the portal of exit, and mode of transmission. Teaching the patient
proper respiratory technique, handwashing, proper PPE, and placing the patient in a
negative air pressure room.
Patient Care Begins
John is brought back to a room. As the nurse responsible for his care, you
collect the following clinical data:
Current VS
P-Q-R-S-T Pain Assessment
Temp: 100.3F/38.8C (oral)
Provoking/Palliative:
“Moving makes it worse”
Pulse: 118 (regular)
Quality:
“Achy”
Respirations: 20 (regular)
Region/Radiation:
“All over”
Blood Pressure: 164/88 MAP: Severity:
5/10
113
O2 Sat: 92% (room air)
Timing:
Continuous
1. What VS data are RELEVANT and must be NOTICED as clinically significant by
the nurse?
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
Relevant VS Data:
Temp: 100.3F (oral)
Pulse: 118
Blood Pressure: 164/88
O2 Sat: 92%
Clinical Significance:
-Possibly indicating an illness or infection
-Indicating possible hypoxia
-Indicating possible hypoxia or other CV concern
-Mild hypoxemia
2. What body system(s) will you assess most thoroughly performing a
FOCUSED assessment based on the primary/priority problem? Identify
correlating specific nursing assessments.
PRIORITY Body System:
PRIORITY Nursing Assessments:
Respiratory
-Lung sounds
-Monitor O2 saturation
-Respiratory effort & cough
Current FOCUSED Nursing Assessment
GENERAL SURVEY:
NEUROLOGICAL:
HEENT:
RESPIRATORY:
CARDIAC:
ABDOMEN:
GU:
INTEGUMENTARY:
Appears anxious, body tense
Alert & oriented to person, place, time, and
situation (x4), generalized weakness
Head normocephalic with symmetry of all
facial features. Lips, tongue, and oral mucosa
pink and moist.
Breath sounds fine dry crackles bilat. with
diminished aeration on inspiration and
expiration in all lobes anteriorly, posteriorly,
and laterally, non-labored respiratory effort,
episodic nonproductive cough
No edema, heart sounds regular, pulses
strong, equal with palpation at
radial/pedal/post-tibial landmarks, brisk cap
refill. Heart tones audible and regular, S1 and
S2 noted over A-P-T-M cardiac landmarks with
no abnormal beats or murmurs. No JVD noted
at 30-45 degrees.
Deferred
Deferred
Skin hot, dry, intact, normal color for ethnicity.
Skin integrity intact, skin turgor elastic, no
tenting present.
3. What assessment data is RELEVANT and must be NOTICED as clinically
significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Anxious
-Could alter the patient’s breathing
Fine dry crackles bilaterally
causing SOB & tachycardia
Episodic nonproductive cough
-Fluid in the lungs, possible pneumonia
Skin hot
-Attempting to clear airways, altering
breathing
-Fever; infection or illness
4. Interpreting clinical data collected, what problems are possible? Which
problem is the PRIORITY? Why?
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
Problem
Fine dry crackles bilaterally
Priority Problem:
Pneumonia
Rationale:
If patient is suspected to
have COVID-19, this could
alter the lungs from
functioning properly, and
fluid building up in the lungs
causing pneumonia.
5. What nursing priority(ies) and goal will guide how the nurse RESPONDS to
formulate a plan of care?
Nursing Priority:
Impaired Gas Exchange
Goal of Care:
Maintain clear lung fields & remain free of signs of
respiratory distress.
Nursing Interventions:
Rationale:
Expected Outcome:
Auscultate breath sounds every
Presence of crackles
Clear of crackles & wheezes.
1-2 hours, listening for crackles
and wheezes may
& wheezes.
exacerbate existing
hypoxia. Teach patient
to turn, cough, & deep
breathe to prevent
stasis of secretions.
Monitor O2 continuously w/pulse A drop in O2 can result
Maintain O2 above 95%.
oximetry.
in hypoxemia, providing
supplemental oxygen
may prevent it.
Caring & the “Art” of Nursing
6.What is the patient likely experiencing/feeling right now in this
situation? What can you do to engage yourself with this patient’s
experience, and show that they matter to you as a person?
What Patient is Expernencing:
How to Engage:
Patient is feeling anxious.
Therapeutic communication can help
alleviate patient’s anxiety. Talking to
the patient at eye level, giving truthful
information, and not providing false
hope. Listen to the patient & their
concerns, position body facing toward
the patient, make eye contact.
Collaborative Care: Medical Management
7. State the rationale
care.
Care Provider
Orders:
Contact-AirborneDroplet Precaution
Influenza Swab
and expected outcomes for the medical plan of
Rationale:
Expected Outcome:
Placing that patient on
isolation precaution to
limit exposure to others.
Testing to rule out the
Stopping the spread of
infection.
If negative for the flu, then
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
flu.
COVID-19 Swab (only if
influenza negative)
Viral swab to test for
suspected virus.
Chest X-Ray
Imaging of the lungs to
reveal fluid in or around
the lungs.
Measuring the counts of
RBC, WBC (if infection
illness suspected).
Complete Blood Count
(CBC)
Metabolic Panel
A blood sample to
determine patient’s
overall chemical balance
and metabolism is
functioning properly.
Lactate
Measures the amount of
lactic acid in blood, acid
produced in RBC and
muscle cells.
Nasal Canula Titrate to
keep O2 Sat>92%
Delivering supplemental
oxygen or increased
airflow.
8. Which orders do you implement first? Why?
Care Provider Orders:
Order of Priority:
Contact-Airborne-Droplet
1st
Precaution
COVID-19 Swab
3rd
Nasal Canula Titrate to
keep O2 Sat>92%
2nd
COVID-19 being the
suspected diagnosis due to
the symptoms the patient
presents.
Patient’s symptoms
correlate with COVID-19, so
if influenza was negative
likely to be positive for
COVID-19.
If fluid is present then the
patient would have
pneumonia.
If WBC are high indicated
that the immune system is
working to destroy an
infection.
Monitoring patient’s kidney
and liver functions,
suspected to come back in
normal range. Assessing
that his Blood Glucose is
controlled.
High levels of lactate
indicate infection or
disease, a condition that
makes it hard to breathe in
enough oxygen (severe
lung disease/respiratory
failure).
Providing O2 to keep the O2
saturation above 92%, and
preventing it from
dropping.
Rationale:
Immediate precaution to
limit exposure to others.
Once patient is on
precautions then perform
the swab to determine if
patient is positive for
suspected infection.
Placing the patient on O2
after putting them on
precautions to make sure
the patients ABC’s are
stable.
Interpreting Diagnostic Data
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
The following diagnostic results just posted in the electronic health
record:
Radiology Reports
8. What diagnostic results are RELEVANT and must be NOTICED as
clinically significant by the nurse?
The radiography showing airspaces with fluid causing pulmonary edema, which is
complication of COVID-19.
Radiology: Chest X-Ray
Clinical Significance:
These changes are consistent with a viral pneumonia that is a common
complication or progression of COVID-19.
Results:
Diffuse bilateral
pulmonary infiltrates
Lab Results:
Hematology (CBC)
Normal
Range:
Current:
WBC
HGB
PLTS
(4.511mm3
)
3.5
(12-16
g/dL)
(150450
x103/µl)
224
12.8
Neutrophil
s%
(55%-70%)
Lymphocyte
s%
(20%-40%)
Monocytes
%
(2%-8%)
Eosinophil
s%
(1%-4%)
Bands
%
(3%5%)
84
11
0
0
5
Metabolic Panel
Normal
Range:
Current:
NA
K
Cl
CO2
AG
135145
mEq/L
3.55.0
mEq/L
101111
mmol/L
20-29
mmol/L
141
3.9
105
16
7-16
mEq/L
14
Glucose
64-110
mg/dL
178
Ca
8.5-10.2
mg/dL
8.9
BUN
10-20
mg/dL
18
Creatinin
e
0.8-1.2
mg/dL
GFR
>60
mL/mi
n
1.10
>60
Miscellaneous
Influenza
Normal Range:
Current:
Negative
Negative
COVID-19
Negative
Positive
Lactate (Ven)
(0.5-2.2 mmol/L)
2.1
9. What lab results are RELEVANT and must be NOTICED as clinically significant
by the nurse?
Relevant Labs:
Clinical Significance:
Neutrophils (Elevated)
-Neutrophils blood levels increase in response to
infection, injury, or other types of stress.
Neutrophils are a type of WBC that helps heal
damaged tissue and resolve infections.
Lymphocytes (Decreased)
-Lymphocytes are important to the immune
system, help fight off infection. Low counts
indicate a possible infection or illness.
CO2 (Decreased)
-Kidney’s & lungs maintain the concentration of
CO2 in the blood, changes in the levels suspects
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
Glucose (Elevated)
COVID-19 (Positive)
that someone is losing or retaining normal body
fluids. Retaining too much CO2 in the body could
lead to metabolic acidosis.
Uncontrolled diabetes. Could also cause
headaches, and fatigue.
Patient suspected diagnosis is confirmed, and
prevent any further complications.
Most Recent Vital Signs:
Current VS:
Temp: 100.6F/38.8C (oral)
Pulse: 112 (regular)
Respirations: 18 (regular)
Blood Pressure: 142/84 MAP: 103
O2 Sat: 93% (2 L Nasal Canula)
Relevant VS Data:
Temp: 100.6F
Pulse: 112
BP: 142/84
O2 Sat: 93%
Current VS
Temp: 100.3F/38.8C (oral)
Pulse: 118 (regular)
Respirations: 20 (regular)
Blood Pressure: 154/88 MAP: 110
O2 Sat: 90-91% (room air)
Clinical Significance:
Infection/Illness
Anxiety/Mild Hypoxia
Mild Hypoxia
Mild Hypoxia
Trend:
Up
Down
Down
Down
John is admitted to the general med/surg floor for observation. To ensure a
hand-off that will promote safe patient care to the next nurse,
communicate a concise SBAR that captures the essence of John’s status
and summarizes the excellent care you have provided!
SBAR Handoff to MedSurg Nurse:
Situation:
Name/Age
Brief summary of primary problem
Background:
Primary problem/Diagnosis:
Relevant past medical history:
Assessment:
Most recent vital signs
Relevant body system nursing
assessment data
Relevant lab values
How have you advanced the plan of care?
Patient response
Interpretation of current clinical status
(stable/unstable/worsening)
John Taylor, Male 68, African American,
presented to the ED w/SOB, nagging cough,
and crackles bilaterally. COVID-19 came
back positive, and radiography came back
viral pneumonia.
NKDA. Hx: Hypertension & Diabetes Type II.
Primary Diagnosis: COVID-19 & Pneumonia.
Patient appears anxious.
A&Ox4, Cardio: WNL, Resp: Fine dry crackles
bilaterally w/diminished aeration on
inspiration and expiration in all lobes
anteriorly, posteriorly, & laterally. Episodic
non-productive cough. GI: Deferred, GU:
Deferred, Musculoskeletal: Weakness but
can ambulate, Integumentary: Skin hot,
Pain: 5/10, reports continuous aching all
over, and states “moving makes it worse”.
Contact-Airborne-Droplet Precaution. Vital
Signs: Temp 100.6F, Pulse 112, Respirations
18, BP 142/84, O2 Sat 93% on 2 L N/C.
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
Recommendation:
Suggestions to advance the plan of care
Neutrophils elevated, lymphocytes
decreased, CO2 decreased, glucose
elevated. COVID Swab: Positive. Diffuse
bilateral pulmonary infiltrates shown on xray. Patient O2 improving on N/C. Patient is
stable.
Turn Cough & Deep Breath, Incentive
Spirometer. Analgesics for the overall
aching, stabilize glucose. Monitor lung
sounds & O2.Antianxiety medical to relieve
patient’s anxiety.
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
This study source was downloaded by 100000757694223 from CourseHero.com on 03-04-2022 14:12:12 GMT -06:00
https://www.coursehero.com/file/86115642/Student-Simulation-Assignment-3docx/
Powered by TCPDF (www.tcpdf.org)
Purchase answer to see full
attachment
