NR 341 Rapid Reasoning Case Study-Student

11 July 2024

Rapid Reasoning Case Study-Student

I. Data Collection

History of Present Problem:

  • Details about the current illness or medical condition of the patient should be documented here.

Personal/Social History:

  • Important social and personal background information relevant to the patient’s condition should be noted here.

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?

  • RELEVANT Data from Present Problem: Clinical Significance:
  • RELEVANT Data from Social History: Clinical Significance:

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

  • PMH: Home Meds:

Lab/Diagnostic Results:

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

  • RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

II. Patient Care Begins:

Current VS:

  • T:
  • P:
  • R:
  • BP:
  • O2 sat:

WILDA Pain Scale (5th VS):

  • Words:
  • Intensity:
  • Location:
  • Duration:
  • Aggravate:
  • Alleviate:

What VS data is RELEVANT that must be recognized as clinically significant?

  • RELEVANT VS Data: Clinical Significance:

Current Assessment:

  • GENERAL APPEARANCE: Resting comfortably, appears in no acute distress.
  • RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort.
  • CARDIAC: Pink, warm & dry, 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/nontender, bowel sounds audible per auscultation in all four quadrants.
  • GU: Voiding without difficulty, urine clear/yellow.
  • SKIN: Skin integrity intact.

What assessment data is RELEVANT that must be recognized as clinically significant?

  • RELEVANT Assessment Data: Clinical Significance:

III. Clinical Reasoning Begins…

  1. What is the primary problem that your patient is most likely presenting with?
  2. What is the underlying cause/pathophysiology of this concern?
  3. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)
  4. What interventions will you initiate based on this priority?
  • Nursing Interventions: Rationale: Expected Outcome:
  1. What body system(s) will you most thoroughly assess based on the primary/priority concern?
  2. What is the worst possible/worst possible complication to anticipate?
  3. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

Medical Management:

  • Care Provider Orders: Rationale: Expected Outcome:

PRIORITY Setting: Which Orders Do You Implement First and Why?

  • Care Provider Orders: Order of Priority: Rationale:

Medication Dosage Calculation:

  • Medication/Dose:
  • Mechanism of Action:
  • Volume/time frame to Safely Administer:
  • Nursing Assessment/Considerations:
  • Normal Range: (high/low/avg?)
  • Hourly rate IVPB:
  • IV Push Rate Every 15-30 Seconds:

Educational/Discharge Priorities:

  • What educational/discharge priorities have you identified and how will you address them?

End-of-Shift SBAR Report:

  • Situation:
  • Background:
  • Assessment:
  • Recommendation:

Caring & the “Art” of Nursing

  1. What is the patient likely experiencing/feeling right now in this situation?
  2. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person?