Read through the CRT shown below then critique the clinical reasoning in it.
1. Are all the assessments "focused"? That is, do they relate to the problem with which they are associated? 2. Are the problem statements in order from most to least urgent? Are they articulated in 3 parts? (Problem statement, RT, Cause of problem, AEB, symptoms that cinch the deal and support your problem statement.) 3. Do the goals specifically relate to the problem statement with which they are associated? Are they written in a time context? Are they measureable (or binary... yes/no)? And are they reasonable? 4. The nursing actions (just like the rest of your clinical reasoning) should relate to the problem with which they are associated. Ideally, written as nursing "orders" (imperative verb form) not suggestions. They describe the means and methods of accomplishing the action. 5. The evaluation relates to the goal statement and explains if the goal was met (hooray!) or not (back to the drawing board.)
Back Story: Mrs. R
Mrs. R. is a fragile little woman who lives in a "retirement" home. She is normally pleasant to the staff and other residents and oriented for the most part. Yesterday the staff noticed that Mrs. R. was confused, dysarthric and lethargic. When they found they could not rouse her and keep her awake, they summoned paramedics to take her to the acute care facility. After several hours in the emergency room, Mrs. R. was admitted to a medical surgical unit.
Observations: Mrs. R. is a very elderly, thin little lady (when supine her abdomen is "scaphoid" with prominent iliac crests.) The patient is being settled into a "metabolic bed" so the nurse notes that Mrs. R's weight is 92 pounds. Her chart indicates that she is 5' 1" in height. This calculates out to a BMI of 17.4. She is oriented to self only (if that.) The nurse noted when she was put into her bed that she had been incontinent of a small amount of dark urine. She has brownish crusts adhering to her lips. She is edentulous and her mucous membranes are "tacky". Her hair is sparse and tangled, her skin is intact but dry. It "tents" everywhere the nurse tries it. Capillary refill is greater than 3 seconds and her fingers are cold.
Vital Signs: T= 99.6, P= 102 and regular, R= 24, BP= 108/52, %sat=98 on 2L oxygen.
Examination: The nurse auscultates Mrs. R's chest and finds pretty normal breath and heart sounds. While she's looking at the patient's chest, he observes that Mrs. R. does not have jugular vein distention while lying at a 45 degree angle. In fact, when the patient is supine the nurse can barely see the jugular veins fill. Mrs. R's bowel sounds are hypoactive in all 4 quadrants. On deep palpation of her thin abdomen, she groans a bit and the nurse feels what could be stool in the lower right quadrant.
Labs: (drawn in the ER)
Chemistries: Na+ 149, K+ 3.8, Cl- 115, HCO3- 18, BUN 25, Creatinine 2.2, Glucose 128, Mg2+ 1.5, PO4- 2.5, Albumin 2.9
Heme: Hgb 14, Hct 45, WBC 14,000 (90% neutrophils), platelets 207,000
Coags: were normal
Diagnostics:
Chest X-ray: Apart from some calcification at the aortic valve, Mrs. R's CXR is pretty clear
12 lead EKG: Sinus tachycardia with multifocal PAC's.
Observations: Mrs. R. is a very elderly, thin little lady (when supine her abdomen is "scaphoid" with prominent iliac crests.) The patient is being settled into a "metabolic bed" so the nurse notes that Mrs. R's weight is 92 pounds. Her chart indicates that she is 5' 1" in height. This calculates out to a BMI of 17.4. She is oriented to self only (if that.) The nurse noted when she was put into her bed that she had been incontinent of a small amount of dark urine. She has brownish crusts adhering to her lips. She is edentulous and her mucous membranes are "tacky". Her hair is sparse and tangled, her skin is intact but dry. It "tents" everywhere the nurse tries it. Capillary refill is greater than 3 seconds and her fingers are cold.
Vital Signs: T= 99.6, P= 102 and regular, R= 24, BP= 108/52, %sat=98 on 2L oxygen.
Examination: The nurse auscultates Mrs. R's chest and finds pretty normal breath and heart sounds. While she's looking at the patient's chest, he observes that Mrs. R. does not have jugular vein distention while lying at a 45 degree angle. In fact, when the patient is supine the nurse can barely see the jugular veins fill. Mrs. R's bowel sounds are hypoactive in all 4 quadrants. On deep palpation of her thin abdomen, she groans a bit and the nurse feels what could be stool in the lower right quadrant.
Labs: (drawn in the ER)
Chemistries: Na+ 149, K+ 3.8, Cl- 115, HCO3- 18, BUN 25, Creatinine 2.2, Glucose 128, Mg2+ 1.5, PO4- 2.5, Albumin 2.9
Heme: Hgb 14, Hct 45, WBC 14,000 (90% neutrophils), platelets 207,000
Coags: were normal
Diagnostics:
Chest X-ray: Apart from some calcification at the aortic valve, Mrs. R's CXR is pretty clear
12 lead EKG: Sinus tachycardia with multifocal PAC's.
Clinical Reasoning about Mrs. R.
Oxygenation: Does Mrs. R. have a problem with oxygenation? It may appear at first blush that she does not. After all her lungs are pretty clear and her %sats on just 2 liters of O2 are fine. But looks like Mrs. R. is hypovolemic. This requires her heart to beat faster to move a smaller amount of vascular volume around. She has a rapid heart beat and low blood pressure, plus almost no JVD when lying flat.
Fluid and Electrolytes: Mrs. R. is hypovolemic. An obvious fluid imbalance. But at the same time she is hypernatremic. An electrolyte imbalance. This indicates she has lost water in excess of salt sometime in the preceding days. The nurse has not been able to interview Mrs. R., but he is making a fairly safe assumption that Mrs. R. hasn't been drinking enough water. This is not uncommon in the elderly. The osmoreceptors in the hypothalamus usually prompts an individual to drink fluid (produces thirst), but this mechanism is not as active in the aging population. And though the nurse has not been able to ask the patient questions, nor interview the staff at the retirement home, he can imagine that as Mrs. R. became more debilitated, she was unable to provide herself with adequate amounts of fresh water, nor did the staff see to it that she drank enough.
Nutrition: The nurse's scrutiny of Mrs. R's body habitus is enough to raise strong suspicions that she is undernourished. These suspicions seem to be corroborated by Mrs. R's lab values that show a diminished serum albumin, magnesium and phosphorus, as well as her calculated BMI. The nurse reasons that if Mrs. R was debilitated and perhaps demented (he does not know the patient's baseline mentation with any certainty), she may not have a normal appetite and may not be eating the food presented to her. He also reasons that without teeth, Mrs. R. would not be able to masticate food which could further limit the food she is able to consume.
Elimination: Mrs. R. has been incontinent of urine. By exam the nurse strongly suspects that she may be constipated as well. The records that came with her from the home did not reference her last BM. If Mrs. R. had been increasingly fluid deficient for several days, then water would tend to leave the bowel lumen, making stool harder.
Rest and Restoration: Mrs. R. is unable to tell the nurse about her sleeping habits. Apart from some groaning when her abdomen was palpated deeply, she is also unable to indicate if she is having any pain.
Mobility: In the paperwork from the home, Mrs R was said to be confined to a wheel chair. Just on observation, the nurse decides Mrs. R may be too sick to sit up for any length of time and decides she should be on bed rest at least overnight. Because she is also confused, the nurse activates the bed alarm and raises 3 out of 4 side rails.
Safety: Mrs. R's condition includes the fact that several of the processes that would ordinarily help her maintain physiological stability are impaired. Most obviously her cortex is functioning poorly and cannot help Mrs. R. interpret and respond to her environment. The nurse notes that Mrs. R. was brought from the home with no glasses. He does not know if she is hard of hearing. These are important data for him to collect when possible since optimal function of special senses could help Mrs. R with cognition and orientation. A properly functioning immune system is essential for physiological stability, and it appears that Mrs. R may have issues with infection. She was slightly febrile when she was admitted to the unit, and her white count is quite high. Because the % of neutrophils in the CBC is similarly high, (a left shift), the chances are strong that Mrs. R. has a bacterial infection somewhere. (See below.)
Fluid and Electrolytes: Mrs. R. is hypovolemic. An obvious fluid imbalance. But at the same time she is hypernatremic. An electrolyte imbalance. This indicates she has lost water in excess of salt sometime in the preceding days. The nurse has not been able to interview Mrs. R., but he is making a fairly safe assumption that Mrs. R. hasn't been drinking enough water. This is not uncommon in the elderly. The osmoreceptors in the hypothalamus usually prompts an individual to drink fluid (produces thirst), but this mechanism is not as active in the aging population. And though the nurse has not been able to ask the patient questions, nor interview the staff at the retirement home, he can imagine that as Mrs. R. became more debilitated, she was unable to provide herself with adequate amounts of fresh water, nor did the staff see to it that she drank enough.
Nutrition: The nurse's scrutiny of Mrs. R's body habitus is enough to raise strong suspicions that she is undernourished. These suspicions seem to be corroborated by Mrs. R's lab values that show a diminished serum albumin, magnesium and phosphorus, as well as her calculated BMI. The nurse reasons that if Mrs. R was debilitated and perhaps demented (he does not know the patient's baseline mentation with any certainty), she may not have a normal appetite and may not be eating the food presented to her. He also reasons that without teeth, Mrs. R. would not be able to masticate food which could further limit the food she is able to consume.
Elimination: Mrs. R. has been incontinent of urine. By exam the nurse strongly suspects that she may be constipated as well. The records that came with her from the home did not reference her last BM. If Mrs. R. had been increasingly fluid deficient for several days, then water would tend to leave the bowel lumen, making stool harder.
Rest and Restoration: Mrs. R. is unable to tell the nurse about her sleeping habits. Apart from some groaning when her abdomen was palpated deeply, she is also unable to indicate if she is having any pain.
Mobility: In the paperwork from the home, Mrs R was said to be confined to a wheel chair. Just on observation, the nurse decides Mrs. R may be too sick to sit up for any length of time and decides she should be on bed rest at least overnight. Because she is also confused, the nurse activates the bed alarm and raises 3 out of 4 side rails.
Safety: Mrs. R's condition includes the fact that several of the processes that would ordinarily help her maintain physiological stability are impaired. Most obviously her cortex is functioning poorly and cannot help Mrs. R. interpret and respond to her environment. The nurse notes that Mrs. R. was brought from the home with no glasses. He does not know if she is hard of hearing. These are important data for him to collect when possible since optimal function of special senses could help Mrs. R with cognition and orientation. A properly functioning immune system is essential for physiological stability, and it appears that Mrs. R may have issues with infection. She was slightly febrile when she was admitted to the unit, and her white count is quite high. Because the % of neutrophils in the CBC is similarly high, (a left shift), the chances are strong that Mrs. R. has a bacterial infection somewhere. (See below.)
An Old Mnemonic: When a patient is febrile, where should you look first for the source of infection.
Answer: The 4 "W's"
The most likely source of infection (in order)
1. "Wind" (Pneumonia, atelectasis)
2. "Whiz" (UTI, urosepsis)
3. "Wound" (Surgical sites, any opening in the integument.)
4. "Walking" (Immobile patients... those not walking... are likely to form thrombi in deep veins. If the inflammation is extensive enough, it can cause fever.)
5. "Water" (Check all IV insertion sites for possible infection. Consider removing central lines)
1. "Wind" (Pneumonia, atelectasis)
2. "Whiz" (UTI, urosepsis)
3. "Wound" (Surgical sites, any opening in the integument.)
4. "Walking" (Immobile patients... those not walking... are likely to form thrombi in deep veins. If the inflammation is extensive enough, it can cause fever.)
5. "Water" (Check all IV insertion sites for possible infection. Consider removing central lines)