History of Present Problem: Miriam Leary is a 66 year old femalewith a past medical history of hypertension, type 2 diabetesmellitus, coronary artery disease, non-ST elevated myocardialinfarction in 2016 treated with life-long daily aspirin, chronickidney disease; stage 4 requiring hemodialysis twice a week, formersmoker quit in 2017, and depression. Her home medications arelisted below. She presented to the emergency room two days ago withreports of increasing shortness of breath, feelings of heartpalpitations and lower extremity edema. She was admitted to themedical-telemetry unit for management of care. Home Medications: 1.Lisinopril 40mg daily PO 2. Furosemide 20mg daily PO 3. Aspirin81mg daily PO 4. Sevelamer 800mg TID PO with meals 5. Calciumcarbonate 500mg chewable daily PO 6. Insulin detemir injection8units BID Subcutaneous Personal/Social History: Miriam isdivorced. She has two adult children, ages 32 and 36. The 36 yearold helps to bring herr who comes twice a week to maintain herapartment and clean her laundry. She used to drive herself to theYMCA for open swimming with her friends, but stopped doing thislast year because her kidney disease was becoming too overwhelmingfor her. Her elderly mother, age 89, is still alive and well. Shevisits Miriam once a week to bring her any prescription refills sheneeds. Her father passed away at the age of 78 from complicationsof coronary artery disease. What data from the histories isimportant & RELEVANT; therefore, it has clinical significanceto the nurse? (2b) RELEVANT Data from Present Problem: ClinicalSignificance: RELEVANT Data from Social History: ClinicalSignificance: What is the RELATIONSHIP of your client’s pastmedical history (PMH) and current meds? (2c) (Which medicationtreats which condition? Draw lines to connect.) PMH: Home Meds:Pharm. Classification: Expected Outcome: 1. 2. 3. 4. 5. 6. 1. 2. 3.4. 5. 6. One disease process often influences the development ofother illnesses. Based on your knowledge of pathophysiology, (ifapplicable), which disease likely developed FIRST that theninitiated a “domino effect” in their life? (2c) • Circle what PMHproblem likely started FIRST. • Underline what PMH problem(s)FOLLOWED as domino(s). II. Patient Care Begins: The client isadmitted to the medical floor Current VS: WILDA Pain Assessment(5th VS): T: (oral) 98.9 Words: Denies pain at this time, 0 out of10 on a numeric scale P: (regular) 112 Intensity: R: (regular) 25Location: BP: 95/60 Duration: O2 sat: 92% on 2 L NC Aggravate:Alleviate: What VS data is RELEVANT that must be recognized asclinically significant to the nurse? (2b) RELEVANT VS Data:Clinical Significance: Current Physical Assessment: HEIGHT ANDWEIGHT 5’ 3” 155 lb (70.5 kg) GENERAL APPEARANCE: Clientrepositions self in bed frequently. Appears worried. RESP: Breathsounds crackles with equal aeration bilaterally, laboredrespiratory effort. CARDIAC: Cool, pallor and moist, 3+ pittinglower extremity edema, heart sounds irregular, pulses weak, equalwith palpation at radial/pedal/post-tibial landmarks NEURO: Alert& oriented to person, place, and time (x3), but needs frequentreminders to remain in bed due to her current health status GI:Abdomen soft/nontender, bowel sounds audible per auscultation inall four quadrants GU: Foley catheter in place, urinating 15mL/hr,clear dark amber urine SKIN: Skin integrity intact What assessmentdata is RELEVANT that must be recognized as clinically significantto the nurse? (2a, 2b, 2c) RELEVANT Assessment Data: ClinicalSignificance: During the admission process, the client verbalizesfeelings of emptiness and is worried that she is too much of aburden on her friends and family. She reports to the nurse that shedoes not enjoy life recently and has been considering changing herresuscitation status to “Do Not Resuscitate” (DNR). She mentionsthat her quality of life “isn’t like it used to be.” Whatadditional questions should the nurse ask to gather more data aboutthe client’s current condition? (1a, 2b) Pertinent assessmentquestions The nurse applies the cardiac telemetry leads. Which leadis placed where? (write green, white, brown, black, red in theappropriate anatomical locations) (5b, 6b) The nurse assesses the6-second cardiac telemetry strip after placing the client on themonitor. (2b) Cardiac Telemetry Strip: Tele #1: Time 0800Interpretation (2b): Tele #1: Clinical Significance (2c): Tele #1:Evidence-based practice treatment options (3a, 2c): Tele #1 Thisrhythm is new for the client. After communicating the dysrhythmiato the provider, the provider writes for a new medication order:Medication Math Heparin IV Infusion: Bolus the client with 60units/kg and start infusion at 12 units/kg/hr. Available: Heparinsodium 20,000 units in 1,000 mL D5W Calculate the following: 1.Heparin bolus dosage: ________________________ 2. Infusion rate forthe IV: ___________________ units/hr 3. Infusion rate in mL/hr:___________________ mL/hr III. Clinical Reasoning Begins… What isthe primary problem that your client is most likely presentingwith? (2c) What is the underlying cause/pathophysiology of thisconcern? (2c) What nursing priority(s) captures the “essence” ofyour client’s current status and will guide your plan of care? (ifmore than one-list in order of PRIORITY) (2b, 3c, 3b) Whatinterventions will you initiate based on this priority? (2b)Nursing Interventions: Rationale: Expected Outcome: What bodysystem(s) will you most thoroughly assess based on the primaryproblem or nursing care priority? (2b) What is the worstpossible/most likely complication to anticipate based on theprimary problem? (2c, 5a) What nursing assessments will identifythis complication EARLY if it develops? (3a, 3b) What nursinginterventions will you initiate if this complication develops? (2b,3a, 3b, 5a) Medical Management: Rationale for Treatment &Expected Outcomes Care Provider Orders: Rationale: ExpectedOutcome: Full code 1. Vital signs every 4 hours 2. Bedrest 3. NPO4. Maintain O2 saturation >95% on 1-4L NC 5. Indwelling foleycatheter 6. Monitor strict I&O 7. Renal specialty consult 8.Basal Metabolic Panel (BMP) every 8 hours 1. 2. 3. 4. 5. 6. 7. 8.1. 2. 3. 4. 5. 6. 7. 8. PRIORITY Setting: Which Orders Do YouImplement First and Why? (2b, 2c) Care Provider Orders: Order ofPriority: Rationale: 1. 2. 3. 4. 5. 6. Are there any orders youwould question at this time? (1b, 2e) Care Provider Order/s:Rationale: Radiology Reports: What diagnostic results are RELEVANTthat must be recognized as clinically significant to the nurse?(2c) RELEVANT Results: Clinical Significance: Echocardiogram:Ejection fraction 30% Portable chest x-ray: pulmonary congestionconsistent with congestive heart failure Lab Results: What labresults are RELEVANT that must be recognized as clinicallysignificant to the nurse? (2b, 2c) Basic Metabolic Panel (BMP:)Current: High/Low/WNL? Previous: Sodium 128 mEq/L 132 mEq/LPotassium 6.8 mEq/L 5.1 mEq/L Chloride 96 mEq/L 97 mEq/L CO2(Bicarb) 20 mmol/L 22 mmol/L Anion Gap 15 mEq/L 15 mEq/L Glucose 78mg/dL 91 mg/dL Calcium 7.4 mg/dL 7.9 mg/dL BUN 49 mg/dL 40 mg/dLCreatinine 3.1 mg/dL 2.5 mg/dL RELEVANT BMP Lab(s): ClinicalSignificance: TREND: Improve/Worsening/Stable:
