I. Data CollectionChief complaint/History of Present Illness:
➢ Patient admitted 10/4 presented with fever of 102 and generalized fatigue (patient was day 9 of
first cycle of chemotherapy and found to have neutropenic fever/sepsis). On the oncology unit
since 10/8.
What data is relevant to this patient that must be recognized as clinically significant to the nurse?
➢ The patient’s fever of 102°F and the fact that the patient is on the ninth day of their first cycle of
chemotherapy is a crucial and critical piece of information that is clinically significant to the
nurse.
Rationale ADD SOURCE and Expand on what is said:
➢ The patient’s fever of 102°F is a critical piece of information because it indicates an elevated body
temperature, which can be a sign of infection or other underlying medical issues.People getting
cancer treatments have a higher risk for infections because cancer treatment can cause
neutropenia, a condition in which you have fewer white blood cells than normal to help fight
infections.
Personal/Social History:
➢ W.F is a 81 year old male who was born in the Bronx, but has lived in multiple states. He lives at
home with his wife (louis) who is his main caregiver. He has 4 children and 11 grandchildren. W.F
attended the University of North Carolina in hopes of becoming a psychologist. Before retiring, he
had his own private practice and taught Psychology at Ramapo College. Prior to being admitted to
the hospital he was part of a chemotherapy trial in New York City. During his hospital stay he had
a 1 to 1 sitter which has been discontinued. Patient is expected to be discharged to Daughters of
Israel rehab sub acute care today (10/24)
PMH:
➢ Atrial fibrillation, dementia, Deep Vein Thrombosis/Pulmonary Embolism, Chronic lymphoid leukemia
transformed into B cell lymphoma, Gastroesophageal reflux disease (GERD), Hyperlipidemia,
Neutropenia, thrombopenia, Neutropenic fever/sepsis, Anemia, ascites
Current Medications:
Active inpatient medications:
Active PRN Medications:
Allopurinol
Apixaban
multivitamin with minerals
Pantoprazole
sodium chloride (Normal Saline Flush)
spironolactone (aldactone)
sucralfate (Carafate)
thiamine
Al hydroxide/MG hydroxide/simethicone
(maalox/mylanta)
lorazepam (ativan)
diphenhyd/lidocaine/AIOH/MgOH/simeth topical
docusate
Ondansetron
saliva substitutes
What is the relationship of your patient’s past medical history (PMH) and current medications?
(Which medication treats which disease? Draw a line to connect PMH disease with the correct medication)
●
●
●
●
●
●
●
●
Allopurinol – Manage Hyperuricemia due to Chronic lymphoid leukemia transformed into B cell
lymphoma
Apixaban – Deep Vein Thrombosis/Pulmonary Embolism
Multivitamin with minerals – nutritional deficiency due to dietary restrictions or poor appetite, general
health
Pantoprazole – Gastroesophageal reflux disease (GERD)
Sodium chloride (Normal Saline Flush) – Flush PICC line on right arm
Spironolactone – Ascites
Sucralfate – Gastroesophageal reflux disease (GERD), stress ulcers/stomach ulcers from oral
medication
Thiamine – thiamine deficiency
Patient Care Begins:
Your Initial VS:
T: 97.9°F
P: 91 bmp
R: 21 breaths per minute
BP: 122/77 mm/Hg
O2 sats: 97% on room air
What VS data is relevant to this patient that must be recognized as clinically significant to the nurse?
Rationale ADD SOURCE and EXPAND on why :
Your Initial Nursing Assessment:
GENERAL APPEARANCE: Patient appears his stated age. Patient is alert, oriented, confused (takes a long
time to respond; AAOx3. Pigmentation matches genetic background, color tone even. Pink moist mucosa, dry
skin and lips. Patient is well groomed and appropriately dressed (although patient attempts to take off gown)
and appears clean. Stated dietary intake (soft diet) is adequate, the patient seems well nourished. Patient
sitting upright, watching television, no abnormalities detected.Some signs of distress or anxiety due to altered
mental staus. Face is symmetrical with movement. Patient displays a normal affect. Patients’ speech is
appropriate, clear and understandable.
NEUROLOGIC: Patient is alert, oriented, confused (takes a long time to respond; AAOx3. Patient wasn’t sure
where he was.He is often confused with a tendency to forget. Patient is forgetful but responds well to
redirection. No pain: noted 0 on a 0-10 pain scale. The strength test is 3+. Pupils are equal, round and reactive
to light and accommodation (PERRLA)
RESPIRATORY: Respiratory rate is 21 breaths/minute, symmetric chest expansion bilaterally. Breathing
pattern is regular and even. Exhibiting unlabored breathing. Lung sounds clear bilaterally in all lobes anteriorly
and posteriorly.No adventitious lung sounds noted. SpO2 saturation 97% of room air.
CARDIAC: The patient’s BP is 122/77 mm/Hg taken on the left arm, sitting – within normal range. Pulse is 91
bmp. S1 and S2 normal, no S3, S4 sounds or murmurs noted. Capillary refill is less than two seconds. Pulses
(radial, dorsalis pedis, and posterior tibial) are present +2 regular and equal bilaterally.
ABDOMEN/GI: Abdomen is flat, symmetric, and non-tender without distention. No visible lesions, scars or
masses. Bowel sounds are present and normoactive in all four quadrants. Patient is continent and has had two
bowel movements. Had an abdominal ultrasound that shows ascites. Patient was previously on TPN but is now
on soft diet.
GENITOURINARY: Patient is continent. Patient reports normal urinary habits with no pain or trouble urinating.
Normal yellow clear urine noted.
EXTREMITIES/SKIN: Skin is expected color for ethnicity without lesions or rashes. Pink moist mucosa, dry
skin and lips. Skin is thin, warm and very dry, with some visible Ecchymosis with no edema. Capillary refill is
less than 2 seconds. Stage 1 pressure ulcer on coccyx. Patient has a PICC on his right arm and it is free from
any redness, swelling, or pain. IV site flushed readily with normal saline. No IV infusion currently running. The
dressing is secure, clean and intact. (patient pulled it out previously during his time in hospital) Grip and overall
strength was 3+. Patient has a normal range of motion.
What assessment data is relevant that must be recognized as clinically significant to the nurse?
➢ mental status and skin integrity
Rationale ADD SOURCE and EXPAND ON WHY :
II. Clinical Reasoning Begins…
1.
What is the most likely medical problem that your patient is presenting with?
➢ Patients most likely present with altered mental status (early onset dementia) since neutropenic
fever has resolved.
2.
What is the underlying cause /pathophysiology of this concern? ADD SOURCE
➢ DEMENTIA
3.
What is your primary nursing priority right now?
➢ The primary nursing priority is altered mental status with risk of falls.
4.
What nursing diagnostic statement will guide your plan of care?
➢ Patient is alert, oriented, confused (takes a long time to respond; AAOx3. Patient wasn’t sure
where he was.He is often confused with a tendency to forget. Patient is forgetful but responds
well to redirection.
5.
What interventions will you initiate based on this priority? REWORD AND EXPAND ON HIGHLIGHTED
SECTION
Frequent Assessment: Regularly assess the patient’s mental status and level of orientation.
Fall Precautions: Implement fall precautions to reduce the risk of falls.
When the patient is confused or forgetful, use redirection and provide reassurance.
frequently move patients due to stage 1 pressure ulcer due to lack of awareness and immobilization.
safety- patient constantly attempts to get out of bed although told many times not to so always be
watching patient and provide distraction techniques
Assist patient with meals for safety and preventing aspiration
6.
What is the worst possible complication to anticipate?REWORD AND EXPAND ON HIGHLIGHTED
SECTION
7.
The worst possible complication is injury and skin integrity (worsening of pressure ulcer) due to patients
forgetfulness
8.
What nursing assessment(s) will you need to identify and respond if this complication develops?
Medical Management: Rationale for Treatment & Expected Outcomes
Physician orders:
●
●
●
●
●
●
●
●
9.
Rationale: ADD SOURCE
Expected Outcome:
Medication
regimen
Fall risk
protocol
Elevate
head of
bed
Assist with
meals
Monitor
intake and
output
Soft dietnutrition
re-assessm
ent
Monitor
mental
status
Discharge
patient
Radiology/ Diagnotic Reports:
●
●
●
●
●
ECHO = EF= 65.8%
EKG = normal
Stool samples, occult blood, sputum culture, blood culture = all negative
Chest X-ray/ CT of chest = Pleural effusion
Lung scan= negative
●
●
Left Hip CT = Hematoma from biopsy performed
Ultrasound of abdomen = Ascites
What data above is relevant to this patient that must be recognized as clinically significant to the
nurse?
How do these radiology/ diagnostic findings relate to primary problem:
Lab Results:
CBC
WBC
HGB
PLTS
Neuts. %
Lymphs %
Normal Range
Current
8.7
8.3
379
76.0
7.0
Most Recent
7.8
8.3
380
73.0
8.0
Identify the relevant lab results to this patient and their clinical significance:REWORD AND EXPAND
ON HIGHLIGHTED SECTION
High neutrophils and low lymphocytes are relevant lab results to this patient.
Neutrophils are the body’s primary defense against infections. which is relevant due to his recent history of
neutropenic fever/sepsis. Stress of his current illness can lead to increased neutrophils.
With Patients history of chronic lymphoid leukemia (CLL) and B cell lymphoma often undergo chemotherapy or
radiation therapy as part of their treatment. These treatments can suppress the bone marrow’s production of
lymphocytes, leading to lymphocytopenia. Clinically, this can be significant as it may increase the patient’s
susceptibility to infection and immunocompromised state. The patient also has a history of neutropenia (low
neutrophil count) and thrombocytopenia (low platelet count)
Which labs when trended are showing improvement and/or reveal concerning potential
complications?REWORD AND EXPAND ON HIGHLIGHTED SECTION
The Wbcs are showing improvement considering he presented to hospital with 102 fever that indicates infection
high neutrophils and low lymphs are potential complications
Basic Metabolic panel
Sodium
Potassium
Glucose
Calcium
Magnesium
Lactate
BUN
Creatinine
Normal Range
135-145
3.5-5
70-100
9-10.5
1.3-2.1
Current
125
4.7
91
9.0
1.66
Most Recent
130
5.1
112
8.9
1.79
10-20
Male: 0.6-1.2
25.1
0.83
29.2
0.74
GFR
>60.00
>60.00
Identify the relevant lab results to this patient and their clinical significance: EXPAND ON INFORMATION
GIVEN
➢ The labs results of critical significant is the sodium, calcium, BUN, and GRF
Which labs when trended are showing improvement and/or reveal concerning potential complications?
➢ Potassium and glucose have improved by reducing from excess to the normal range
➢ Sodium, BUN, and GFR show potential complications because they are out of normal range.
UA
Color
Clarity
Sp. Grav
Protein
Glucose
Ketones
Blood
Nitrate
LET
RBC’s
WBC’s
Bacteria
Epithelial
Normal range
1.003 – 1.030
0 – 23
0 – 20
0 – 700
0 – 33
Current
Yellow
Clear
1.019
30
Negative
Negative
Trace
Positive
Most Recent
Yellow
Clear
1.019
30
Negative
Negative
Trace
Positive
6
22
1378
3
6
22
1378
3
Identify the relevant lab results to this patient and their clinical significance:
Which labs when trended are showing improvement and/or reveal concerning potential complications?
Liver Panel and GI labs
Albumin
Total bili
Alk Phos.
ALT
AST
Amylase
Lipase
Normal Range
Current
3.1
0.8
219
51
27
Most Recent
3.0
0.6
206
51
25
Identify the relevant lab results to this patient and their clinical significance:
Low albumin levels reveals Increased alkaline phosphatase reveals –
Which labs when trended are showing improvement and/or reveal concerning potential
complications?EXPAND on information provided
➢ Labs that are showing improvement is Albumin patient has recently gotten off TPN and is now
on a soft diet
Fluid & Electrolyte Application
9. Choose two of the most relevant abnormal labs for your patient and address the following:
Lab
Relevance
Value
Normal value
What caused
derangement?
Treatment
Nsg. Assessments/interventions
required:
What caused
derangement?
Treatment
Nsg. Assessments/interventions
required:
Critical value
High/Low
Lab
Relevance
Value
Normal value
Critical value
High/Low
III. Evaluation:
Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders
have been implemented that are listed under medical management.
Four hours later…
VS:
T: 98.6°F
P: 79 bmp
R: 20 breaths per minute
BP: 118/77
O2 sats: 96%
What VS data is relevant to this patient that must be recognized as clinically significant to the nurse?
All vitals within normal range
Nursing Assessment:
GENERAL APPEARANCE: Patient appears his stated age. Patient is alert, oriented, confused (takes a long
time to respond; AAOx3. Pigmentation matches genetic background, color tone even. Pink moist mucosa, dry
skin and lips. Patient is well groomed and appropriately dressed (although patient attempts to take off gown)
and appears clean.Stated dietary intake (soft diet) is adequate, the patient seems well nourished. Patient
sitting upright, watching television, no abnormalities detected.Some signs of distress or anxiety due to
dementia. Face is symmetrical with movement. Patient displays a normal affect. Patients’ speech is
appropriate, clear and understandable.
NEUROLOGIC: Patient is alert, oriented, confused (takes a long time to respond; AAOx3. Patient wasn’t sure
where he was. Patient is forgetful but responds well to redirection. No pain: noted 0 on a 0-10 pain scale. The
strength test is 3+. Pupils are equal, round and reactive to light and accommodation (PERRLA)
RESPIRATORY: Respiratory rate is 21 breaths/minute, symmetric chest expansion bilaterally. Breathing
pattern is regular and even. Exhibiting unlabored breathing. Lung sounds clear bilaterally in all lobes anteriorly
and posteriorly.No adventitious lung sounds noted. SpO2 saturation 97% of room air.
CARDIAC: The patient’s BP is 122/77 mm/Hg taken on the left arm, sitting – within normal range. Pulse is 91
bmp. S1 and S2 normal, no S3, S4 sounds or murmurs noted. Capillary refill is less than two seconds. Pulses
(radial, dorsalis pedis, and posterior tibial) are present +2 regular and equal bilaterally.
ABDOMEN/GI: Abdomen is flat, symmetric, and non-tender without distention. No visible lesions, scars or
masses. Bowel sounds are present and normoactive in all four quadrants. Patient is continent and has had two
bowel movements. Had an abdominal ultrasound that shows ascites. Patient was previously on TPN but is now
on soft diet.
GENITOURINARY: Patient is continent. Patient reports normal urinary habits with no pain or trouble urinating.
Normal yellow clear urine noted.
EXTREMITIES/SKIN: Skin is expected color for ethnicity without lesions or rashes. Skin is thin, warm and very
dry, with some visible Ecchymosis with no edema. Capillary refill is less than 2 seconds. stage 1 pressure ulcer
on coccyx. Patient has a PICC on his right arm and it is free from any redness, swelling, or pain.Iv site flushed
readily with normal saline. No IV infusion currently running. The dressing is secure, clean and intact. (patient
pulled it out previously during his time in hospital) Grip and overall strength was 3+. Patient has a normal range
of motion.
What assessment data is relevant to this patient that must be recognized as clinically significant to the
nurse?
➢ The patient’s mental status and skin integrity (thin, dry weak)
Rationale ADD SOURCE AND EXPAND ON WHY IT IS CLINICALLY SIGNIIFCANT:
1.
Has the status of the patient improved or not as expected to this point?
➢ yes, the status of the patient improved as expected at this point. Patient no longer has fever or infection
he is medically stable. Patient is now with his wife louis and is anticipating discharge to daughters of
israel sub acute rehab center.
2.
What data supports this evaluation assessment?
➢ The fever has reduced from 102 F to 96.8 F. Having a familiar and supportive presence like his spouse
provided comfort and familiarity which positively impacted W.F. As well as Reevaluating and constantly
reorienting the patient it has helped maintain their cognitive functioning and reduce confusion.
3.
Based on this assessment data, now what will be your nursing priorities and current plan of
care?
➢ Based on this assessment data the nursing priorities would be Mental status evaluation, tissue
perfusion due to history of DVT and PE. Skin integrity due to limited mobility and altered mental
status if the patient forgets to reposition, or is incontinent, as well as his current stage 1
pressure ulcer. The current plan of care is to transport patients to rehabilitation centers for care
and full recovery.
Your knowledge and application of the pathophys. of
have allowed you to make a series
of needed assessments and judgements that have facilitated the treatment and care of your patient. You have
made a difference at the bedside! But in order to proceed with the needed transfer you need a provider’s order.
What will you concisely state to update the provider at this time: CALL PROVIDER TO TRANSFER NURSE
TO PROVIDER
(QSEN-Teamwork & Collaboration/Safety)
Situation:
Background:
Assessment:
Recommendation:
Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the
care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR
report to the incoming nurse who will be caring for this patient: NURSE TO NURSE HAND OFF
(QSEN-Teamwork & Collaboration/Safety)
Situation:
Background:
Assessment:
Recommendation:
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