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
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