Step #1: THINK Like a Nurse by Recognizing RELEVANCE and
PRIORITIES
Four Principles of Clinical Reasoning:
1. Identify and interpret RELEVANT clinical data.
2. TREND relevant clinical data to determine current status (stable vs. unstable).
3. Grasp the “essence” of the current clinical situation.
4. Determine nursing PRIORITY and plan of care.
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.
What data from the PRESENT PROBLEM are RELEVANT and must be interpreted as clinically significant by the
nurse?
RELEVANT Data from Present Problem: Clinical Significance:
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:
© 2016 Keith Rischer/www.KeithRN.com
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:
Cardiac Telemetry Strip:
Interpretation:
Clinical Significance:
Radiology Reports: Chest x-ray
What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Results:
Clinical Significance:
Bilateral diffuse
pulmonary infiltrates
consistent with
pulmonary edema
© 2016 Keith Rischer/www.KeithRN.com
Lab Results:
Complete Blood Count (CBC):
WBC (4.5-11.0 mm 3)
Hgb (12-16 g/dL)
Platelets (150-450x 103/µl)
Neutrophil % (42-72)
Current:
4.8
12.9
228
68
High/Low/WNL?
Previous:
5.8
13.2
202
65
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
Basic Metabolic Panel (BMP):
Sodium (135-145 mEq/L)
Potassium (3.5-5.0 mEq/L)
Glucose (70-110 mg/dL)
Calcium (8.4-10.2 mg/dL)
Creatinine (0.6-1.2 mg/dL)
Current:
133
4.9
105
8.8
2.9
TREND:
Improve/Worsening/Stable:
High/Low/WNL?
Previous:
138
4.2
118
9.5
2.2
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT
Lab(s):
Clinical Significance:
Misc. Chemistries:
Magnesium (1.6-2.0 mEq/L)
PT/INR (0.9-1.1 nmol/L)
Current:
1.9
2.5
TREND: Improve/Worsening/Stable:
High/Low/WNL?
Previous:
1.8
2.4
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
Cardiac Labs:
Troponin (<0.05 ng/mL)
BNP (B-natriuretic Peptide) (<100 ng/L)
© 2016 Keith Rischer/www.KeithRN.com
Current:
0.10
1855
High/Low/WNL?
Previous:
0.12
155
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
Put it All Together to THINK Like a Nurse!
1. What is the primary problem that your patient is most likely presenting?
2. What nursing PRIORITY (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
3. What interventions will you initiate based on this PRIORITY?
Nursing Interventions:
Rationale:
Expected Outcome:
4. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family?
© 2016 Keith Rischer/www.KeithRN.com