Description
SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted
to the pediatric unit of the hospital from the walk-in clinic with an acute asthma exacerbation. Jared started complaining
of increased chest tightness and shortness of breath one day prior to admission. He has been at 50 percent of his personal
best measurement for his peak expiratory flow (PEF) meter reading which did not improve with the use of albuterol
metered dose inhaler (MDI) (per his written asthma management plan).
In the walk-in clinic Jared is alert, speaking in short sentences due to breathlessness at rest. He has coarse expiratory
wheezes throughout both lung fields with decreased breath sounds at the right base. His oxygen saturation on room air is
90%. His color is ashen and he has dark circles under his eyes. He is sitting upright and using his accessory chest muscles
to breath and has moderate intercostal and substernal retractions. He is complaining of tightness in his chest. Jared was
diagnosed with asthma at age 6 years and has three prior hospitalizations for asthma with one admission to the pediatric
intensive care unit. He has never had to be intubated with these episodes.
Personal/Social History:
He is accompanied by his mother and 16-year-old sister. Jared lives with his mother, maternal grandmother, and sister in
an older housing development in the inner city. He is in the 5th grade and a good student despite two to three absences per
school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of
friends at school and likes his teacher, Mr. Bates, who is also his soccer coach. Both Jared and his mother deny tobacco
smoke at home.
What data from the histories are important and RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History:
Clinical Significance:
Patient Care Begins:
Current VS:
T: 99.9 F/37.7 C (oral)
P: 120 (regular)
R: 30 (regular)
BP: 114/78
O2 sat:
90% on room air
End Tidal CO2: 30
P-Q-R-S-T Pain Assessment (5th VS):
Provoking/Palliative: Worsens when tries to take a deep breath. Feels better when
Quality:
Region/Radiation:
Severity:
Timing:
? 2018 Keith Rischer/www.KeithRN.com
allowed to sit upright on gurney
Tightness
Across anterior chest
8/10
Constant
What VS data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
Current Assessment:
GENERAL
Ashen, anxious appearing, moderate respiratory distress. Sitting upright on gurney.
APPEARANCE:
Only able to talk in short sentences due to breathlessness. Has intercostal and substernal retractions with increased respiratory rate, using accessory muscles to
breathe (sternocleidomastoid muscles).
RESP:
Breath sounds with inspiratory and expiratory wheezing and prolonged expiration.
Has tight-sounding non-productive cough, decreased breath sounds in right base
CARDIAC:
Pale, warm & moist at forehead, no edema, heart sounds regular with no abnormal
beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO:
Alert & oriented to person, place, time, and situation (x4)
GI:
Abdomen soft/non-tender, bowel sounds audible per auscultation in all four
quadrants
GU:
Voiding without difficulty, urine clear/yellow
SKIN:
Skin integrity intact, moist on forehead
What assessment data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Diagnostic Results:
Current:
Na
138
Current:
WBC
10.0
Radiology:
Chest x-ray
Basic Metabolic Panel (BMP)
K
Gluc.
3.7
80
Creat.
0.6
Complete Blood Count (CBC)
% Neuts
HGB
55
14.1
PLTs
350
Hyper-expansion of airways with otherwise clear lung fields.
What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT
Clinical Significance:
Diagnostic Data:
? 2018 Keith Rischer/www.KeithRN.com
Part II: Put it All Together to THINK Like a Nurse!
1. After interpreting relevant clinical data, what is the primary problem?
(Management of Care/Physiologic Adaptation)
Problem:
Pathophysiology in OWN Words:
Collaborative Care: Medical Management
2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Medical Management:
Vital signs every 1 hour and
as needed
Rationale:
Continuous oxygen
saturation monitoring
Continuous end tidal CO2
monitoring
Start peripheral IV then
saline lock
O2 to keep saturations >93%
Albuterol 2.5 mg and
ipratropium bromide 0.25
mg via face mask nebulizer
every 20 minutes as needed
for respiratory distress
Methylprednisolone IV
loading dose 2mg/kg then
start Methylprednisolone IV
0.5 mg/kg every 6 hours for
48 hours
Diet as tolerated
? 2018 Keith Rischer/www.KeithRN.com
Expected Outcome:
Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (Management of Care)
Nursing PRIORITY:
PRIORITY Nursing Interventions:
Rationale:
Expected Outcome:
4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity)
Psychosocial PRIORITIES:
PRIORITY Nursing Interventions:
Rationale:
Expected Outcome:
CARING/COMFORT:
How can you engage and show that this
pt. matters to you?
Physical comfort measures:
EMOTIONAL SUPPORT:
Principles to develop a therapeutic
relationship
SPIRITUAL CARE/SUPPORT:
5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or
family? (Health Promotion and Maintenance)
? 2018 Keith Rischer/www.KeithRN.com
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