STUDENT NAME: _____________________ SKILLS INSTRUCTOR ___________________ DATE __________________

RN 62A: CASE STUDY FOR JOANN SMITH – PAD _______/20 pts

Part I: Recognizing RELEVANT Clinical Data 2 pts
1. 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:

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 98.4 F/36.9 C (oral) Provoking/Palliative:
P: 76 (reg) Quality: Denies
R: 16 (reg) Region/Radiation:
BP: 138/82 Severity:
O2 sat: 95% room air Timing:

2. What VS data are RELEVANT and must be recognized as clinically significant by the nurse? 1 pt
RELEVANT VS Data: Clinical Significance:

© 2018 Keith Rischer/www.KeithRN.com

This case study has 4 pages
STUDENT NAME: _____________________ SKILLS INSTRUCTOR ___________________ DATE __________________

Current Assessment:
GENERAL Resting comfortably, body relaxed, appears in no acute distress
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory
effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular-S1S2, pedal/post tibial pulses strong in
left foot, unable to palpate right foot pedal and post tibial pulses manually. Able to Doppler
pulses in right foot. Right foot is cool, pale in color in comparison to
the left foot, cap refill is brisk in left foot but 3-4 seconds in right foot
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, skin turgor elastic, no tenting present, there is little hair growth on
right leg while the left leg has normal density of hair growth
3. What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? 2 pts
RELEVANT Assessment Data: Clinical Significance:

Diagnostic Results:
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 139 3.9 275 2.4
Most Recent: 141 4.5 195 2.2

Complete Blood Count (CBC)

WBC % Neuts HGB PLTs HGB A1c
Current: 8.8 70 12.9 189 9.9
Most Recent: 9.5 75 13.5 199 7.9

Lipid Panel
LDL HDL Total Cholesterol Triglycerides
Current: 240 29 290 384
Most Recent: 205 30 268 315

4. What data must be interpreted as clinically significant by the nurse? 2.5 pts(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Clinical Significance: TREND:
Diagnostic Data: Improve/Worsening/Stable:

© 2018 Keith Rischer/www.KeithRN.com

This case study has 4 pages
STUDENT NAME: _____________________ SKILLS INSTRUCTOR ___________________ DATE __________________

Part II: Put it All Together to THINK Like a Nurse!

5. After interpreting relevant clinical data, what is the primary problem? 2 pts
(Management of Care/Physiologic Adaptation)
Problem: Pathophysiology in OWN Words:

Collaborative Care: Medical Management 3.5 pts (0.5 pt each item)

6. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Medical Management: Rationale: Expected Outcome:
Basic metabolic panel
(BMP)

Complete cell count (CBC)

Hemoglobin A1c

Lipid profile

Urine analysis (UA)

Heparin IV drip per

therapeutic protocol
(4,200 unit IV bolus/1150
unit IV continuous drip)

Bilateral femoral angiogram

Collaborative Care: Nursing

7. What nursing priority (ies) will guide your plan of care? 2 pts (Management of Care)
Nursing PRIORITY:
PRIORITY Nursing Interventions: Rationale: Expected Outcome:

© 2018 Keith Rischer/www.KeithRN.com

This case study has 4 pages
STUDENT NAME: _____________________ SKILLS INSTRUCTOR ___________________ DATE __________________

8. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? 3 pts
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

CARING/COMFORT:
How can you engage and show that
this pt. matters to you?

Physical comfort measures:

EMOTIONAL SUPPORT:
Principles to develop a therapeutic
relationship

SPIRITUAL CARE/SUPPORT:

9. What educational/discharge priorities need to be addressed to promote health and wellness for this patient
and/or family? 2 pts (Health Promotion and Maintenance)

© 2018 Keith Rischer/www.KeithRN.com

This case study has 4 pages