Novel Coronavirus Disease (COVID-19)
UNFOLDING Reasoning
John Taylor, 68 years old
Primary Concept
Immunity
Interrelated Concepts (In order of emphasis)
• Clinical judgment
• Communication
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
Covered in
Case Study
Step 1: Recognize Cues
Step 2: Analyze Cues
Step 3: Prioritize Hypotheses
✓
✓
✓
Step 4: Generate Solutions
Step 5: Take Action
Step 6: Evaluate Outcomes
✓
✓
✓
✓
✓
© 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
Part I: Initial Nursing Assessment
Present Problem:
John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension. He came to the
emergency department (ED) triage window because he felt crummy, complaining of a headache, runny nose, feeling
weaker, “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 get worse throughout the day. 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 a 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 is consistent with COVID-19?
3. Based on the clinical data collected, identify what measures need to be immediately implemented using the
following clinical pathway.
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:
© 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
Part II: Patient Care Begins in the ED:
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: 22 (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:
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 /Health Promotion and Maintenance)
RELEVANT VS Data:
Clinical Significance:
Nursing Intervention (if needed):
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.
© 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
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:
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
The ED physician assesses John
and orders the following:
Collaborative Care: Medical Management
7. State the rationale and expected outcomes for the medical plan of care. (NCLEX: Pharm. and Parenteral Therapies)
Care Provider Orders:
Rationale:
Expected
Outcome:
Contact-Airborne-Droplet
precautions
Influenza swab
COVID-19 swab
(only if influenza neg)
Chest x-ray
Complete blood count
(CBC)
Metabolic panel (BMP)
Lactate
Nasal cannula titrate to keep
O2 sat
>90%
8. Which orders do you implement first? Why? (NCLEX: Management of Care)
Care Provider Orders:
Order of Priority:
Rationale:
• Contact-Airborne-Droplet
precautions
• COVID-19 swab
• Nasal cannula titrate to
keep O2 sat >95%
© 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
Part III: Interpreting Diagnostic Data
The following diagnostic results just posted
in the electronic health record:
Radiology Reports:
What diagnostic results 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/Physiologic Adaptation)
Radiology: Chest X-Ray
Clinical Significance:
Results:
Diffuse bilateral pulmonary
infiltrates
Lab Results:
Hematology (CBC)
% Neuts % Lymphs
WBC
HGB
PLTS
% Monos
% Eosin
Bands
Norms:
(4.5-11.0
mm 3)
(12-16 g/dL)
(150-450x
103/µl)
(55-70)
(20-40)
(2-8)
(1-4)
(3-5%)
Current:
3.5
12.8
224
92
8
0
0
0
Current:
Metabolic Panel (BMP)
CO2
AG
Na
K
Cl
135-145
mEq/L
3.5-5.0
mEq/L
101-111
mmol/L
20-29
mmol/L
141
3.9
105
16
(7-16
mEq/L)
Gluc
Ca
BUN
Creat
GFR
64-110
mg/dL
8.5-10.2
mg/dL
10-20
mg/dL
0.8-1.2
mg/dL
>60
mL/min
18
1.10
>60
178
Misc.
Influenza
COVID-19
Lactate (Ven)
Neg
Neg
(0.5-2.2 mmol/L)
Neg
Pos
1.9
Current:
What lab results 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/Physiologic Adaptation)
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
© 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
No change in John’s status in the ED and he is currently stable. He is
being 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!
Situation:
Name/age:
BRIEF summary of primary problem:
Day of admission/post-op #:
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):
Recommendation:
Suggestions to advance the plan of care:
© 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
Grading Rubric for KeithRN Case Studies
•
•
•
If there is not a question for a category, there will not be a grade given for that category and
the total number of points will be changed.
Points reflect acceptable percentage of at least > 70% as a minimum standard to pass
< 70% identify areas of weakness and assign activities to remediate that to a strength!
Initial Scenario
Part one: recognizing
RELEVANT clinical
data
Level of Thinking:
What data from the
histories are
RELEVANT and must
be interpreted as
clinically significant by
the nurse?
10 points
Identify the relationship
between the PMH and
home medications.
Which medication
treats which condition?
5 points
Is there a relationship
between any problem in
his past medical history
and the present
problem?
5 points
Excellent 90-100% of
the info is present
Good 70-90% of
information is present
Needs improvement
Purchase answer to see full
attachment