CS1/2

Rapid Reasoning Mr. Schmidt, virtual case study Module 5

1. What VS & assessment data is RELEVANT that must be recognized as clinically significant

to the nurse?  

Relevant: VS/assessment data	Relationship to primary medical problem-

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

Relevant: diagnostic results-	Relationship to primary medical problem-

3. What is the medical problem that your patient is most likely presenting with?  

4. What is the underlying cause/pathophysiology of this concern?  

5. Based on the data you collected, what is your primary concern right now? 

6. What interventions will you initiate based on this primary concern? (start with A-B-C

priorities)  

7. What body system will you mostly thoroughly assess based on the patient’s chief complain

and primary/priority concern>  

8. What is the worst possible complication to anticipate?  

  

9. What nursing assessments will you need to initiate to identify and respond to quickly if this

complication develops? 

10. What is the relationship between the following physician orders / medication orders and your patients primary medical problem?  

Physician order-	How it will help resolve primary problems

Mr. Schmidt is a 62-year-old man who had 3 vessel CABG 2 days ago. He was transferred to the cardiac telemetry floor yesterday and is currently progressing per his plan of care for discharge tomorrow. He had his chest tubes removed yesterday and his pain is controlled 3/10 with Norco 325mg/5mg. He was last reported to be in NSR pulse in the 80’s and vitals stable for this patient. Assessment is WNL except for diminished breath sounds bilaterally and 2+ pitting edema to bilateral lower extremities up to the mid-calf area. His weight is up 4.8kg from surgery.

You enter his room to teach him about the medications he will continue at discharge such as a loop diuretic, a statin, and an ace-inhibitor and inform him of the necessity to participate in phase 1 cardiac rehabilitation. He is up in the chair upon entering room when he states his “chest feels jumpy”, he complains of being lightheaded and dizzy and his heart is racing. You notice that he is pale, anxious compared to last seen and slightly diaphoretic.

*Students will complete the Rapid Reasoning Activity Sheet

*Students will revise the current plan of care based on Mr. Schmidt’s current status.

*Create 3 priority nursing diagnoses- diagnosis must have 3 parts each

*Each diagnosis will have 2 goals

* Identify 6 interventions for each goal identified (3 assessments & 3 teachable points.