Putting the Pieces Together:

Clinical Assignment to Develop Clinical Reasoning

Part I. INITIAL Problem/Complication Data Collection

History of Present Problem:

83 year old female with a history of HTN, CHF, STEMI and PE/DVT came to the ED complaining of
weakness after getting up to use the restroom. Reports bone pain in lower extremities rated 8/10 and
difficulty walking. No shortness of breath or chest pain. Patient was lethargic but able to answer questions.

What data from the history is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT data from history: Rationale (pathophysiology):
1. Weakness, bone pain, difficulty Excess calcium in the blood is leached from bones which weakens them.
walking This causes bone pain, muscle weakness (MayoClinic).

2. CHF, HTN, STEMI Hypercalcemia is known to have effects on the heart and the vascular
system that are potentially life-threatening.The cardiovascular effects of
hypercalcemia include hypertension, left ventricular hypertrophy,
arrhythmias, vascular calcification, and a shortened QT interval on the
ECG (Karthikeyan et al., 2006, p. 28).

What is the relationship of your patient’s past medical history (PMH) and current medications?
PMH: Home Meds: Pharm. Classification: Expected Outcome:
1. HTN 1. Carvedilol 1.Beta Blocker 1. Decreased BP

2. CHF; MI 2. Enalaprlil; Losartan; 2. ACE Inhibitor; ARB; 2. Decreased BP and

Hydralazine Vasodilator improved heart function

3.PE/DVT 3. Aspirin; Xarelto 3. Blood thinners 3. Break up blood clots and

decreased reoccurrence

One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in
their life?
• Circle what PMH problem likely started FIRST.
• Underline what PMH problem(s) FOLLOWED as domino(s).

© 2013 Keith Rischer/www.KeithRN.com

What is the RELATIONSHIP between the clinical data that is RELEVANT and primary problem/nursing priority?
RELEVANT Clinical Data: Relationship to Primary Problem/Nursing Priority:
VS
BP: 166/56 BP: Hypercalcemia is known to cause cardiovascular problems such as HTN. Pt should
HR: 58 have BP checked when taking antihypertensives and blood thinners.
O2: 99%
RR: 18
TEMP: 99 F
Nursing Assessment: Hypercalcemia can cause bone pain with movement and muscle weakness. Pt with
Alert and oriented x3 hypercalcemia can also present lethargy. Pt should be checked for improvement in pain
and movement.
Delayed movements;
ambulation to chair with
assistance; grimacing with
movement

Lethargic

Lab INITIA CURREN High/Low/WNL? TREND: Improve/Worsening/Stable:

Test L T
Na+ 136 136 WNL STABLE

K+ 3.9 3.7 WNL STABLE

Mg+
Creat. 0.89 0.99 WNL STABLE

WBC 7.2 5.6 WNL STABLE

Neut. %
Hgb. 9.5 9.3 LOW WORSENING

P 2.1 2.0 LOW WORSENING

Ca 2+ 10.4 10.6 HIGH WORSENING

© 2013 Keith Rischer/www.KeithRN.com

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Choose the most RELEVANT/important abnormal lab value and complete:
Lab: Normal Why Relevant? Nursing Assessments/Interventions Required:
Value:
This lab value is 1. Continued monitoring and documentation of calcium lab
relevant because the value.
Ca 2+ 8.6 - 10.2 patient is being treated
Valu Critical for hypercalcemia. The 2. Assessment of pain and movement.
e: Value: initial and current lab
value shows signs that 3. Assessment of vital signs.
12 or more condition is worsening
10.4 which indicates plan of 4. Talk to provider about possibly changing medication.
care is not effective.
5. Reevaluate plan of care.

Radiology Reports:
What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Results: Clinical Significance:
CT Scan of Osseous 1. Excess calcium in the blood (hypercalcemia) is leaked from the bones. This leads to
structure: weakened bones.

Demineralization and 2. Pt is more susceptible to bone fractures and injury.

degenerative changes
3. Pt is at risk for fall which can lead to injury.

© 2013 Keith Rischer/www.KeithRN.com

 Clinical Reasoning Begins (when problem/complication developed)
1. What is the primary problem that your patient is most likely presenting with?

Patient most likely presented with muscle weakness due to hypercalcemia.

2. What nursing priority will guide your plan of care?

The nursing priority to guide my plan of care is muscle weakness due to hypercalcemia. The patient is at risk
for falls, bone fractures and other injuries.

3. What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:

1. Administer prescribed medications. Medications can help to decrease calcium levels Decreased calcium
in blood (MayoClinic). levels will help reduce
muscle weakness .

2. Reinforce techniques of therapeutic exercise ROM and muscle strengthening within a The patient will
taught by physical therapist. prescribed regimen will promote muscle effectively perform
function and increase physical stamina exercises, move
(Gulanick & Myers, 2007, p. 749). purposefully and
perform self care
exercises.

3. Assist patient with ambulation. Assistance encourages patient to move. The patient will
eventually ambulate
independently.

4. What body system(s) will you most thoroughly assess based on the primary/priority concern?
Musculoskeletal, Cardiovascular

5. What is the worst possible/most likely complication to anticipate?

Osteoporosis

6. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

• Test for muscle strength

• Measure height
• Labs: serum calcium, 24hr urine calcium

© 2013 Keith Rischer/www.KeithRN.com

Medical Management: Rationale for Treatment & Expected Outcomes
Choose at least 3-5 Physician orders (new medications/treatments/labs) written that are most relevant to your
patient when they first experienced their change in status
Care Provider Orders: Rationale: Expected Outcome:
1. Administer: potassium Use of IV phosphate is effective in lowering serum Serum calcium will be lowered.
phosphate IVPB calcium levels ( Medscape, 2018).

2. Administer: carvedilol Beta blockers are used to decrease BP. BP will be decreased.

3. Low calcium diet / This will decrease serum calcium level. There will be a decrease in
monitor nutrition labs serum calcium.

© 2013 Keith Rischer/www.KeithRN.com

Part II: CURRENT Status
th
Current VS: WILDA Pain Assessment (5 VS):
T: (oral) 97.9 F Words: “ I’m not in any pain right now. But usually feel pain in my legs”.

P: (regular) 58 Intensity: N/A

R: (regular) 18 Location: N/A
BP: 145/50 Duration: N/A
O2 sat: 99% Aggravate: N/A
Alleviate:

What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Rationale:

BP: BP: Hypercalcemia is known to cause cardiovascular problems such as HTN. Pt should have
BP checked when taking antihypertensives and blood thinners.
145/50

Student Nursing Assessment:

CV Resp Neuro GI GU Skin/ Musculo
Pain
Heart Tones: Breath sounds: a/o to: BS: Normal Urine color: Incision: Strength: Weak
Normal Normal person: Yes N/A None
place: Yes Abd: Round Tol. to activity:
Color: time: Yes Clarity: N/A
Resp: 18 situation: Yes Appetite: Dry/moist: Low
Temp: 97.9 F Decreased Foley: None Smooth and
O2: 99% moist Fall risk? Yes
LOC: Fair
Pulses: 58 Flatus: None
IS volume: I/O:N/A
Integrity:
Edema: Intact
Minimal bipedal BM: 2x/day

Braden: N/A
Tele:
Drains: IV
right arm

© 2013 Keith Rischer/www.KeithRN.com

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

RELEVANT Assessment Data: Rationale:

1. Strength: Weak Patient is a fall risk and still weak. She will need assistance with ambulation.

© 2013 Keith Rischer/www.KeithRN.com

 II. Current Clinical Reasoning Begins
1. What nursing priority will guide your plan of care?
Weakness

2. What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:

1. Talk to the provider about changing Medications can help to decrease calcium levels Decreased calcium
medication and administer as prescribed. in blood (MayoClinic). The provider should be levels will help reduce
notified of continuous weakness. muscle weakness .

2. Reinforce techniques of therapeutic exercise The patient will

taught by physical therapist. ROM and muscle strengthening within a effectively perform
prescribed regimen will promote muscle exercises, move
function and increase physical stamina purposefully and
(Gulanick & Myers, 2007, p. 749). perform self care
exercises.

3. Assist patient with ambulation. The patient will

Assistance encourages patient to move. eventually ambulate
independently.

3. What body system(s) will you most thoroughly assess based on the primary/priority concern?
Musculoskeletal
4. What is the worst possible/most likely complication to anticipate?
Osteoporosis

5. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

• Test for muscle strength

• Measure height
• Labs: serum calcium, 24hr urine calcium

© 2013 Keith Rischer/www.KeithRN.com

CURRENT Medical Management: Rationale for Treatment & Expected Outcomes
Choose at least 3-5 Physician orders (new medications/treatments/labs) written that are most relevant to your patient from the last 24
hours (yesterday & today)…Go to primary physicians progress note today/yesterday
Care Provider Orders: Rationale: Expected Outcome:
1. Administer: potassium Use of IV phosphate is effective in lowering serum Serum calcium will be lowered.
phosphate IVPB calcium levels ( Medscape, 2018).

2. Administer: carvedilol Beta blockers are used to decrease BP. BP will be decreased.

3. Low calcium diet / This will decrease serum calcium level. There will be a decrease in
monitor nutrition labs serum calcium.

© 2013 Keith Rischer/www.KeithRN.com

 III. Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with their medical condition
to prevent future readmission with the same problem?

The most important discharge information will be to avoid foods high in calcium such as leafy greens, cheese,
etc. Perform mild exercises such as walking so that the body is not immobile for long periods of time. Take all
medication as prescribed. Report any signs of weakness.

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

Ask the patient to perform therapeutic exercises learned in physical therapy. Ask the patient to describe a meal
they will eat at home. Ask the patient about the medications they are taking and its purpose.

3. What modifications will you need to make related to your teaching methods based on the patient’s age,,
culture, and level of health literacy?

Giving the patient a paper with this information will increase effectiveness as they can always refer back to this
paper.

VII. Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?

The patient most likely feels helpless and like a burden given that she is weak and requires assistance to move.

2. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a
person?

I can check in on my patient and cater to her psychosocial needs by asking how she feels. I can also offer to do
things for her so that she does not have to ask. 


© 2013 Keith Rischer/www.KeithRN.com

 Quality & Safety Education for Nurses: QSEN Competencies
What is QSEN and why is it relevant to the professional nurse? (go to: www.qsen.org)
Answer the following questions in your own words based on your application of QSEN competencies from the website

Patient Centered Care

How can you ensure and assess the effectiveness of communication with the patient and family?
(QSEN-Patient Centered Care)

I can do this by asking the patient and family questions after speaking with them. I can also have them demonstrate
information given to them.

How can you ensure that your patient is an active partner while under your care and promote self-care once they are
discharged? (QSEN-Patient Centered Care)

I can do this by correctly assessing my patient to see if they are adhering to the task given to them. I can also assess
effectiveness of the task. To promote self-care I would emphasize the importance of adhering to all task and if needed have
the patient come in for follow ups.

Teamwork & Collaboration

What can you do to facilitate safe and effective update/report to the physician or oncoming nurse?
(QSEN-Teamwork and Collaboration)

I can check to see if all information I obtain is accurate and document it. I can also give handoff reports at the
bedside.

Informatics
What medical electronic data bases are available in your clinical setting that would be a resource if needed to obtain
needed information on a medication you have not given before or an illness/surgery you have never seen before?
(QSEN-Informatics)

The hospital uses the AllScripts system which allows nurses to receive information on medications they are going to
administer.

Safety/Quality Improvement
What would you as the nurse do if you almost gave the wrong dose of one of the ordered medications because of a
similarity in the label provided by pharmacy to another drug? (Use this institution’s policy)
(QSEN-Safety/Quality Improvement)

I would contact the HCP immediately and determine how and if the mistake can be reversed. I would then ensure to
document the situation.

© 2013 Keith Rischer/www.KeithRN.com

Evidence Based Practice
As a new nurse, what resources could you utilize to provide current, evidence based and individualized care
planning based on the needs of this patient? (QSEN-Evidence Based Practice)

The resources I can utilize is nursing databases that have past and current articles on research studies conducted in
nursing.

© 2013 Keith Rischer/www.KeithRN.com