SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
JoAnn Smith is a 72-year-old woman who has a history of myocardial infarction (MI) four years ago and systolic heart
failure secondary to ischemic cardiomyopathy with a current ejection fraction (EF) of only 15%. She presents to the
emergency department (ED) for shortness of breath (SOB) the past three days. Her shortness of breath has progressed
from SOB with activity to becoming SOB at rest. The last two nights she had to sleep in her recliner chair to rest
comfortably upright. She is able to speak only in partial sentences and then has to take a breath when talking to the nurse.
She has noted increased swelling in her lower legs and has gained six pounds in the last three days. She is being
transferred from the ED to the cardiac step-down where you are the nurse assigned to care for her.
Personal/Social History:
JoAnn is a retired math teacher who is unable to maintain the level of activity she has been accustomed to because of the
progression of her heart failure the past two years. She has struggled with depression the past two years and has been
more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
 72-year-old
 Patient’s age matters in giving proper treatment, older population
have higher risk for coronary artery diseases (CAD)
 myocardial infarction (MI) four years
 Past diagnoses give an idea about the causes of the present
ago, systolic heart failure secondary to
findings, it also indicated that the heart was strained and how it
ischemic cardiomyopathy with a
causes more symptoms
current ejection fraction (EF) of only
15%
 shortness of breath (SOB) for three
 This symptom cannot be ignored since it has been going on for
days, SOB with activity to becoming
days and the SOB at rest is a sign of impaired gas exchange
SOB at rest, and when talking to the
nurse
 maintained upright to be able to sleep
 Patient would have difficulty breathing when supine, could
signify fluid buildup in the lungs
 increased swelling in lower legs and
 This could indicate edema, and heart complications
gained six pounds in the last 3 days
RELEVANT Data from Social History:
 Retired math teacher, unable to
maintain certain levels of activity
 Depression in the past two years
 Death of husband unexpectedly due to
MI
© 2018 Keith Rischer/www.KeithRN.com
Clinical Significance:
 The effects of her condition compromised her daily living


Depression could affect her motivation to live
Losing a loved one could add to her depression especially that the
reason of death is the same as her condition
Patient Care Begins:
Current VS:
T: 98.6 F/37.0 C (oral)
P: 92 (irregular)
R: 26 (regular)
BP: 162/54 MAP: 90
O2 sat: 90% (6 liters n/c)
P-Q-R-S-T Pain Assessment (5th VS):
Provoking/Palliative:
Denies Pain
Quality:
Region/Radiation:
Severity:
Timing:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data:
Clinical Significance:
 Pulse of 92 (irregular)
 Normal count, but irregular – could indicate arrythmia
 Respiration of 26 (regular)
 It is good that it is regular, but it is more than the normal of 20, this
could indicate tachypnea
 BP: 162/54 MAP: 90
 Systolic pressure is elevated
 O2 sat: 90% (6 liters n/c)
 Oxygen saturation is relatively low even with oxygen support
(normal: 95% - 100%)
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Appears anxious, restless
Breath sounds have coarse crackles scattered throughout both lung fields ant/post, labored
respiratory effort, patient sitting upright
Rhythm: atrial fibrillation, pale, cool to the touch, pulses palpable throughout, 3+ pitting
edema lower extremities from knees down bilaterally, S3 gallop, irregular, no jugular venous
distention (JVD) noted
Alert and oriented to person, place, time, and situation (x4)
Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
Voiding without difficulty, urine clear/yellow
Skin integrity intact, skin turgor elastic, no tenting present
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
 Appears anxious, restless
 The patient is not comfortable, needs further assessment
 Coarse crackles in breath sounds
 This could indicate excessive fluid in the lungs, would check for
pulmonary edema, aspirates, other related diseases
 Atrial fibrillation, pale, cool to
 Heart complications, irregular heartbeat, edema, heart murmur,
touch, 3+ pitting edema bilaterally
insufficient blood supply to the body evidenced by pallor and cool to
in lower extremities, S3 gallop,
touch
irregular
© 2018 Keith Rischer/www.KeithRN.com
Cardiac Telemetry Strip:
Interpretation:
Rhythm: Irregular
Irregular R-R intervals
P waves: not definitive, only flutter waves/saw-tooth appearance
Clinical Significance:
Atrial fibrillation – multiple rapid impulses from many foci depolarize in the atria in a totally disorganized manner at a rate
of 350 – 600 times per minute; the atria quiver, which can lead to the formation of thrombi (Silvestri & Silvestri. 2020, p.
702).
Note: Answers on this part was based on how I compared it to some examples on the internet and on Saunders Comprehensive
Review for the NCLEX-RN Examination (2020)
© 2018 Keith Rischer/www.KeithRN.com
Diagnostic Results:
Current:
Most Recent:
Na
133
138
Current:
Most Recent:
WBC
4.8
5.8
Current:
Most Recent:
Radiology:
Chest x-ray
Trop.
0.10
0.12
Basic Metabolic Panel (BMP)
K
Gluc.
4.9
105
4.2
118
Creat.
2.9
2.2
Complete Blood Count (CBC)
% Neuts
HGB
68
12.9
65
13.2
PLTs
228
202
BNP
1855
155
Cardiac
Mg
1.9
1.8
PT/INR
2.5
2.4
Bilateral diffuse pulmonary infiltrates consistent with pulmonary edema
What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT
Clinical Significance:
TREND:
Diagnostic Data:
Improve/Worsening/Stable:
Sodium, mL/dL:
Worsening
 hyponatremia
 138 to 133
Stable/Improving but still high
Glucose, mmol/L:
 hyperglycemia
 118 to 105
Worsening
Creatinine, mg/dL:
 impaired kidney function
 2.2 to 2.9
Improving but still high
Troponin, ng/mL:
 high, heart problem
 0.12 to 0.10
Worsening
BNP, pg/mL:
 heart failure
 155 to 1855
Stable
PT/INR:
 above normal, but therapeutic range if taking
 2.4 to 2.5
anticoagulants
Chest x-ray
Worsening
 Bilateral
 this finding supported the patient’s symptoms of SOB
diffuse
and difficulty sleeping in supine position
pulmonary
infiltrates
consistent with
pulmonary
edema
© 2018 Keith Rischer/www.KeithRN.com
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:
Heart Failure
Pathophysiology in OWN Words:
Based on the current findings, the patient is experiencing heart failure. The heart keeps our
systemic circulation going, but if it is strained or if it is not doing its job, certain complications
occur. It could lead to pulmonary problems, like fluid buildup in the lungs and pulmonary
edema causing difficulty in breathing. Another complication would be the fluid build up in the
other parts of the body especially in the lower extremities by the presence of edema, the
swelling and increased weight at a short time. This could impair the mobility of the patient
affecting their daily activities.
Collaborative Care: Medical Management
2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Medical Management:
Titrate oxygen to keep O2
sat >92%
Rationale:
 Keeping the oxygen saturation up is the most
important since it is related to breathing
Furosemide 40 mg IV push

Furosemide is a loop diuretic that helps in fluid
retention
Nitroglycerin IV drip: titrate
to keep SBP <130

Nitroglycerin helps with chest pain, it relaxes the
vascular smooth muscle causing vasodilation
lowering the systolic BP (US FDA, 2010)
Strict I&O

Monitoring the intake and output of the patient is
important to assess for fluid retention
Fluid restriction of 2000 mL
PO daily

Oral fluid restriction lessens the fluid load in the
body
Low sodium diet

Low sodium diet lowers blood pressure. Increased
sodium increases the fluid that comes with it
causes hypervolemia that could result to high
blood pressure
© 2018 Keith Rischer/www.KeithRN.com
Expected Outcome:
 Patient maintains O2 sat
>92% during the shift
 Patient’s edema gets
reduced from 3+ to 2+
during the shift
 Patient will have less
complaints of chest pain,
SBP <130 for the whole
shift
 During the shift, patient
would have close to equal
I&O
 Patient will not have an
abrupt increase in weight
and swelling has reduced
for the whole stay in the
facility
 During the shift, patient
adheres to strict low
sodium diet and maintains
a normal BP range.
Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (Management of Care)
Ensure adequate oxygen supply and improve breathing, affected
Nursing PRIORITY:
breathing caused by pulmonary edema, and mobility caused by swelling
in lower extremities
Restricted fluid intake and diet
PRIORITY Nursing Interventions: Rationale:
Expected Outcome:
The nurse will monitor oxygen
saturation, weight, and I&O closely
The nurse will demonstrate some
effective breathing techniques and will
ask for a return demonstration.
The nurse will educate the patient and
the family about I&O, and the
importance of proper diet for the patient.
The nurse will demonstrate and provide
the patient a walker, crutches, canes, or
any ambulatory devices that could help
in her mobility.
© 2018 Keith Rischer/www.KeithRN.com
The patient has fluid retention, so the nurse
should watch out for any sudden increase in
weight, deficiencies in I&O, and the pulmonary
edema causes the impaired gas exchange of the
patient
The patient maintains
normal oxygen
saturation, will not
have a sudden increase
in weight, and will
have normal I&O
during her stay in the
facility.
Proper breathing techniques can help the patient
maximize her breathing and a teach back method
is a good way to determine if the patient
understood the teaching.
By the end of the shift,
the patient can perform
effective breathing.
The patient is on strict diet, so it would be also
important for the family to know and adjust to
what the patient needs.
The patient will be
able to adhere to the
diet until her blood
pressure becomes
normal.
Ambulatory devices assist patients in walking
and in physical therapy.
The patient will be
able to effectively use
the ambulatory devices
by the end of my shift.
4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES:
PRIORITY Nursing Interventions:
Depression and recently widowed, less ability to perform activities of the
daily living
Rationale:
Expected Outcome:
CARING/COMFORT:
How can you engage and show that this
pt. matters to you?
I would validate the patient’s feelings, I
would provide her with a safe space
where she can freely express her
feelings, I would recognize her
depression, and I would support her in
her grief. I would listen and at the same
time respect her privacy.
Validating the patient’s feelings and providing
her a safe space are ways to show respect for the
patient and it is important to empathize with her.
Patient will be
comfortable in telling
me about her worries
during my shift.
Having a support system could greatly help the
patient face her current challenges, and they
would be there for her to guide her in her
treatment.
The family members
will be able to
effectively comfort
the patient by the end
of my shift.
Grieving is a process, and it takes time to accept
a loved one’s death. She is also going through
hardships herself, so it would be beneficial for
her to validate her feelings.
Patient will be able to
express her grief and
sadness to me before
the shift ends.
It helps the patient to respect their beliefs. The
patient could seek comfort through her beliefs
and believing in her faith with people who
understand her could be good for her well-being.
Patient will trust and
verbally tell me
during her shift about
her beliefs.
Physical comfort measures:
I would invite some members of the
family and educate them on how to
comfort the patient. Ask them to bring
some comfort food (within the diet) for
the patient, and if she has any hobbies,
ask the family to bring it with them so
she has something to do while getting
treatment.
EMOTIONAL SUPPORT:
Principles to develop a therapeutic
relationship
I would let the patient feel and know
that she is not alone. I would also let
her grieve, give her some space and
time to mourn.
SPIRITUAL CARE/SUPPORT:
If the patient observes some rituals, I
would allow the patient to invite people
who observe the same belief or invite
their leader to perform rituals that she
would need.
© 2018 Keith Rischer/www.KeithRN.com
5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or
family? (Health Promotion and Maintenance)
Important education and discharge information that the patient and the family should know:
Intake and output, fluid restriction, proper diet (with sodium restriction), medication information, administration, and
adherence (example: diuretics should be taken in the morning, side effects, and other contraindications, should not miss a
dose), importance of a support system for the patient, ambulatory devices
© 2018 Keith Rischer/www.KeithRN.com
References
Silvestri, L. & Silvestri, A. (2020). Saunders Comprehensive Review for the NCLEX-RN Examination 8th edition. Elsevier, Inc.
US Food and Drug Administration (2010). Nitrostat. Accessdata FDA.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021134s004lbl.pdf
© 2018 Keith Rischer/www.KeithRN.com