John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and worsening nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has had a poor appetite the past month. He denies any ETOH (alcohol) intake the past week but admits to episodic binge drinking on most weekends.

© 2016 Keith Rischer/www.KeithRN.com
Cirrhosis
John Richards, 45 years old
Primary Concept
Nutrition
Interrelated Concepts (In order of emphasis)
1. Fluid and Electrolyte Balance
2. Perfusion
3. Cognition
4. Addiction
5. Clinical Judgment
6. Patient Education
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Cirrhosis
History of Present Problem:
John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and worsening
nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has had a poor appetite the
past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic binge drinking on most weekends.
John weighs 150 pounds (68.2 kg) and is 6’0″ (BMI 17.6). You are the nurse responsible for his care.
Personal/Social History:
John is single, has never married, and lives alone in his own apartment. He has struggled with heroin use/abuse in the past,
but has not used in the past two years. John is currently unemployed and has no health insurance. He was diagnosed with
hepatitis C ten years ago but has had minimal follow-up medical care since.
What data from the histories are RELEVANT and have 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?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
*Hepatitis C–past history of
IV drug abuse
*ETOH abuse x 25 years
Ibuprofen 600 mg PO prn
for headache
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her
life?
 Circle the PMH problem that likely started FIRST.
 Underline the PMH problem(s) FOLLOWED as domino(s).
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 100.5 F/38.1 C (oral) Provoking/Palliative: Nothing/nothing
P: 110 (regular) Quality: Ache
R: 20 Region/Radiation: RUQ/epigastric
BP: 128/88 Severity: 6/10
O2 sat: 95% RA Timing: Continuous
© 2016 Keith Rischer/www.KeithRN.com
Orthostatic BP’s:
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Rationale:
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Rationale:
Lab Results:
Position: HR: BP:
Lying 110 128/88
Standing 132 124/80
Current Assessment:
GENERAL
APPEARANCE:
Appears uncomfortable, body tense, occasional facial grimacing
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Pink, warm & dry,1+ pitting edema lower extremities, heart sounds regular–S1S2, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen distended, large–rounded–firm to touch, bowel sounds audible per auscultation in
all 4 quadrants
GU: Voiding without difficulty, urine clear/light orange, loss of pubic hair
SKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and
oral mucosa tacky dry, softball-sized ecchymosis on abdomen
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 12.8 9.5
Hgb (12–16 g/dL) 10.2 11.2
Platelets (150-450 x103/µl) 98 122
Neutrophil % (42–72) 88 75
Band forms (3–5%) 3 0
© 2016 Keith Rischer/www.KeithRN.com
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?
RELEVANT
Lab(s):
Clinical Significance: TREND:
Improve/Worsening/Stable:
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
PT/INR: 1.5 UP…worsening
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous:
Sodium (135–145 mEq/L) 135 138
Potassium (3.5–5.0 mEq/L) 3.5 3.8
Glucose (70–110 mg/dL) 78 88
BUN (7–25 mg/dl) 38 25
Creatinine (0.6–1.2 mg/dL) 1.5 1.1
Coags: Current: High/Low/WNL? Previous:
PT/INR (0.9–1.1 nmol/L) 1.5 1.2
Liver Function Test (LFT:) Current: High/Low/WNL? Previous:
Albumin (3.5–5.5 g/dL) 2.5 2.9
Total Bilirubin (0.1–1.0 mg/dL) 4.2 2.2
Alkaline Phosphatase
male: 38–126 U/l female: 70–230 U/l
285 155
ALT (8–20 U/L) 128 65
AST (8–20 U/L) 124 85
Misc. Labs:
Ammonia (11–35 mcg/dL) 35 28
© 2016 Keith Rischer/www.KeithRN.com
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required:
ALT
Value:
128
Critical Value:
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 primary problem?
Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome:
Establish peripheral IV
NS 0.9% bolus of 1000 mL
Ondansetron 4 mg IV every
4 hours PRN
Orthostatic BP
PRIORITY Setting: Which Orders Do You Implement First and Why?
(Remember your ABCs!)
Care Provider Orders: Order of Priority: Rationale:
1. Establish peripheral IV
2. NS 0.9% bolus of 1000
mL
3. Ondansetron 4 mg IV
every 4 hours PRN nausea
4. Orthostatic BP
© 2016 Keith Rischer/www.KeithRN.com
Medication Dosage Calculation:
Medication/Dose: Mechanism of Action: Volume/time frame to
Safely Administer:
Nursing Assessment/Considerations:
Ondansetron 4 mg
IV
4mg/2 mL vial IV Push:
Volume every 15 sec?
Collaborative Care: Nursing
3. What nursing priority (ies) 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:
5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
6. What is the worst possible/most likely complication to anticipate?
7. What nursing assessments will identify this complication EARLY if it develops?
8. What nursing interventions will you initiate if this complication develops?
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
10. How can the nurse address these psychosocial needs?
© 2016 Keith Rischer/www.KeithRN.com
Evaluation: Six Months Later…
John continues to drink ETOH on a daily basis and has not followed through with his discharge plan when he was
discharged from the hospital six months ago. John is now homeless and lives in a shelter. He was brought into the ED by
emergency medical services (EMS) because he was found wandering aimlessly in the neighborhood and was completely
disoriented.
The primary care provider in the ED orders the following labs: CBC, BMP, LFT, and INR.
1. What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data: Rationale:
RELEVANT Assessment Data: Rationale:
Compare & Contrast: Last Nursing Assessment 6 Months Ago:
Emphasize that the nurse should look back at previous admissions, especially admission H&P, consultation H&P,
discharge summary, and labs/diagnostics as time allows. Discharge summary may be most important if time is of the
essence. An essential component of clinical reasoning is TRENDING clinical data. This TREND can be established from
most recent documentation in the medical record that could be hours, days or even months ago. This data is still relevant
and needed to establish this trend!
Current VS: Current PQRST:
T: 99.5 F/37.5 C (oral) Provoking/Palliative: DENIES
P: 118 (reg) Quality:
R: 22 (reg) Region/Radiation:
BP: 88/50 Severity:
O2 sat: 94% room air Timing:
Current
Assessment:
GENERAL
APPEARANCE:
Disheveled, clothing dirty, has strong body odor, appears unkempt, does not smell of ETOH
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Jaundiced, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Confused and disoriented to person, place, time, and situation (x4)
GI: Abdomen protuberant–distended, bowel sounds audible per auscultation in all 4 quadrants
GU: Voiding without difficulty, urine clear/orange
SKIN: Skin integrity intact, skin is yellow/jaundiced in color with yellow sclera
© 2016 Keith Rischer/www.KeithRN.com
2. Compare the current nursing assessment with his last assessment above. What has changed most
dramatically from his last assessment six months ago that is clinically significant?
3. Has his status improved or not as expected to this point?

Lab 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:
Last Nursing Assessment 6 Months Ago:
GENERAL
APPEARANCE:
Appears uncomfortable, restless
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation
at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen large–rounded–firm to touch, bowel sounds audible per auscultation in all 4
quadrants
GU: Voiding without difficulty, urine clear/light orange
SKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips
and oral mucosa tacky dry
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 6.9 12.8
Hgb (12–16 g/dL) 8.9 10.2
Platelets (150-450 x103/µl) 47 98
Neutrophil % (42–72) 68 88
Band forms (3–5%) 3 3
Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous:
Sodium (135–145 mEq/L) 127 135
Potassium (3.5–5.0 mEq/L) 2.8 3.5
Glucose (70–110 mg/dL) 74 78
BUN (7–25 mg/dl) 55 38
Creatinine (0.6–1.2 mg/dL) 1.8 1.5
© 2016 Keith Rischer/www.KeithRN.com
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Coags: Current: High/Low/WNL? Previous:
PT/INR (0.9–1.1 nmol/L) 2.6 1.5
Liver Function Test (LFT:) Current: High/Low/WNL? Previous:
Albumin (3.5–5.5 g/dL) 2.2 2.5
Total Bilirubin (0.1–1.0 mg/dL) 7.2 4.2
Alkaline Phosphatase
male: 38–126 U/l female: 70–230 U/l
140 285
ALT (8–20 U/L) 59 128
AST (8–20 U/L) 62 124
Misc. Labs:
Ammonia (11–35 mcg/dL) 78 30
© 2016 Keith Rischer/www.KeithRN.com
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required:
Ammonia
Value:
78
Critical Value:
Medical Management: Rationale for Treatment & Expected Outcomes
Care Provider Orders: Rationale: Expected Outcome:
Lactulose 200 g/300 mL
rectal x1 NOW
Banana bag (thiamine 100
mg-folic acid 1 mgmultivitamin 10 mL) in 1000
mL of 0.9% NS over 2 hours
Potassium Chloride 10 mEq
IVPB (x4) each dose over 1
hour. Recheck potassium per
hospital protocol
Transfer to ICU
4. Does your nursing priority or plan of care need to be modified in any way after this evaluation and assessment of all
clinical data including labs?
5. Based on your current evaluation, and assessment of all clinical data, what are your nursing priorities and plan of
care?
John is going to be admitted to ICU. Effective and concise handoffs are essential to excellent
care and if not done well can adversely impact the care of this patient. You have done an
excellent job to this point, now finish strong and give the following SBAR report to the nurse
who will be caring for this patient:
© 2016 Keith Rischer/www.KeithRN.com
Situation:
Name/age:
BRIEF summary of primary problem:
Day of admission/post-op #:
Background:
Primary problem/diagnosis:
RELEVANT past medical history:
RELEVANT background data:
Assessment:
Current vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
TREND of any abnormal clinical data (stable-increasing/decreasing):
How have you advanced the plan of care?
Patient response:
INTERPRETATION of current clinical status (stable/unstable/worsening):
Recommendation:
Suggestions to advance plan of care:
© 2016 Keith Rischer/www.KeithRN.com
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?
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
2. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person?
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
2. How can I use what has been learned from this scenario to improve patient care in the future?