STUDENT-Asthma-SKINNY_Reasoning

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: P-Q-R-S-T Pain Assessment (5th VS): T: 99.9 F/37.7 C (oral) Provoking/Palliative: Worsens when tries to take a deep breath. Feels better when

allowed to sit upright on gurney

P: 120 (regular) Quality: Tightness

R: 30 (regular) Region/Radiation: Across anterior chest

BP: 114/78 Severity: 8/10

O2 sat:

90% on room air Timing: Constant

End Tidal CO2: 30

What VS data are RELEVANT and must be recognized as clinically significant to the nurse?

RELEVANT VS Data: Clinical Significance:

What assessment data are RELEVANT and must be recognized as clinically significant to the nurse?

RELEVANT Assessment Data: Clinical Significance:

Diagnostic Results: Basic Metabolic Panel (BMP)

Na K Gluc. Creat.

Current: 138 3.7 80 0.6

Complete Blood Count (CBC)

WBC % Neuts HGB PLTs

Current: 10.0 55 14.1 350

Radiology:

Chest x-ray

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

Diagnostic Data:

Clinical Significance:

Current Assessment:

GENERAL

APPEARANCE:

Ashen, anxious appearing, moderate respiratory distress. Sitting upright on gurney.

Only able to talk in short sentences due to breathlessness. Has intercostal and sub-

sternal 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

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: Rationale: Expected Outcome:

Vital signs every 1 hour and

as needed

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

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)

RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
RELEVANT Data from Social HistoryRow1:
Clinical SignificanceRow1_2:
Current VS:
PQRST Pain Assessment 5th VS:
T 999 F377 C oral:
ProvokingPalliative:
P 120 regular:
Quality:
Tightness:
R 30 regular:
Across anterior chest:
BP 11478:
Severity:
810:
O2 sat 90 on room air:
TimingEnd Tidal CO2 30:
ConstantEnd Tidal CO2 30:
RELEVANT VS DataRow1:
Clinical SignificanceRow1_3:
Current Assessment:
GENERAL APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
Abdomen softnontender bowel sounds audible per auscultation in all four:
GU:
SKIN:
Skin integrity intact moist on forehead:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_4:
Basic Metabolic Panel BMPRow1:
Creat:
Current:
06:
Complete Blood Count CBCRow1:
PLTs:
Current_2:
350:
100:
Hyperexpansion of airways with otherwise clear lung fields:
RELEVANT Diagnostic DataRow1:
Clinical SignificanceRow1_5:
ProblemRow1:
Pathophysiology in OWN WordsRow1:
RationaleVital signs every 1 hour and as needed Continuous oxygen saturation monitoring Continuous end tidal CO2 monitoring Start peripheral IV then saline lock O2 to keep saturations 93 Albuterol 25 mg and ipratropium bromide 025 mg via face mask nebulizer every 20 minutes as needed for respiratory distress Methylprednisolone IV loading dose 2mgkg then start Methylprednisolone IV 05 mgkg every 6 hours for 48 hours Diet as tolerated:
Expected OutcomeVital signs every 1 hour and as needed Continuous oxygen saturation monitoring Continuous end tidal CO2 monitoring Start peripheral IV then saline lock O2 to keep saturations 93 Albuterol 25 mg and ipratropium bromide 025 mg via face mask nebulizer every 20 minutes as needed for respiratory distress Methylprednisolone IV loading dose 2mgkg then start Methylprednisolone IV 05 mgkg every 6 hours for 48 hours Diet as tolerated:
Nursing PRIORITY:
PRIORITY Nursing InterventionsRow1:
RationaleRow1:
Expected OutcomeRow1:
Psychosocial PRIORITIES:
RationaleCARINGCOMFORT How can you engage and show that this pt matters to you Physical comfort measures:
Expected OutcomeCARINGCOMFORT How can you engage and show that this pt matters to you Physical comfort measures:
RationaleEMOTIONAL SUPPORT Principles to develop a therapeutic relationship:
Expected OutcomeEMOTIONAL SUPPORT Principles to develop a therapeutic relationship:
RationaleSPIRITUAL CARESUPPORT:
Expected OutcomeSPIRITUAL CARESUPPORT:
Answer5: