Acute Delirium
UNFOLDING Reasoning
John Kelly, 77 years old
Primary Concept
Cognition
Interrelated Concepts (In order of emphasis)
• Stress
• Coping
• Clinical Judgment
• Patient Education
• Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
✓ Management of Care 17-23% ✓
✓ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12% ✓
Physiological Integrity
✓ Basic Care and Comfort 6-12% ✓
✓ Pharmacological and Parenteral Therapies 12-18% ✓
✓ Reduction of Risk Potential 9-15% ✓
✓ Physiological Adaptation 11-17% ✓
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, UNFOLDING Clinical Reasoning Case Study
History of Present Problem:
John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure
who had a right total hip arthroplasty and is post-operative day one. Since surgery he has been on path, resting
comfortably and his pain has been controlled with oxycodone 5 mg PO. When the nurse enters the room to do his
morning assessment, John is agitated, combative and resistive to staff. He pulled out his Foley urinary catheter, his IV
catheter and removed his surgical dressing. His legs are swung over the side rails and is trying to get out of bed. John
does not know where he is and oriented to self only. He insists that he is at home and yells out, “You get the hell out of
my home or I am going to call the police!” His wife is visibly upset and states that she has never seen him behave like
this before. With tears in her eyes she asks you, “What is happening to my husband! Please do something to help him!”
Personal/Social History:
John is a retired high school math teacher who lives at home with his wife and lives independently. He is active at the
senior center where he attends social activities 3-4 times a week. He attends Catholic Mass every Sunday with his wife.
He is a nonsmoker and has a glass of wine 2-3 times a week with dinner.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
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:
T: 99.1 F/37.3 C (oral) Provoking/Palliative: Pain in his right hip but unable to give details
P: 102 (regular) Quality: Tenderness to palpation over incision site
R: 18 (regular) Region/Radiation: Right hip
BP: 155/65 Severity: Unable to verbalize due to confusion, tenderness to palpation but
does not appear to be in acute discomfort based on assessment
O2 sat: 95% room air Timing: Unable to verbalize
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
UNFOLDING Reasoning
John Kelly, 77 years old
Primary Concept
Cognition
Interrelated Concepts (In order of emphasis)
• Stress
• Coping
• Clinical Judgment
• Patient Education
• Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
✓ Management of Care 17-23% ✓
✓ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12% ✓
Physiological Integrity
✓ Basic Care and Comfort 6-12% ✓
✓ Pharmacological and Parenteral Therapies 12-18% ✓
✓ Reduction of Risk Potential 9-15% ✓
✓ Physiological Adaptation 11-17% ✓
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, UNFOLDING Clinical Reasoning Case Study
History of Present Problem:
John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure
who had a right total hip arthroplasty and is post-operative day one. Since surgery he has been on path, resting
comfortably and his pain has been controlled with oxycodone 5 mg PO. When the nurse enters the room to do his
morning assessment, John is agitated, combative and resistive to staff. He pulled out his Foley urinary catheter, his IV
catheter and removed his surgical dressing. His legs are swung over the side rails and is trying to get out of bed. John
does not know where he is and oriented to self only. He insists that he is at home and yells out, “You get the hell out of
my home or I am going to call the police!” His wife is visibly upset and states that she has never seen him behave like
this before. With tears in her eyes she asks you, “What is happening to my husband! Please do something to help him!”
Personal/Social History:
John is a retired high school math teacher who lives at home with his wife and lives independently. He is active at the
senior center where he attends social activities 3-4 times a week. He attends Catholic Mass every Sunday with his wife.
He is a nonsmoker and has a glass of wine 2-3 times a week with dinner.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
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:
T: 99.1 F/37.3 C (oral) Provoking/Palliative: Pain in his right hip but unable to give details
P: 102 (regular) Quality: Tenderness to palpation over incision site
R: 18 (regular) Region/Radiation: Right hip
BP: 155/65 Severity: Unable to verbalize due to confusion, tenderness to palpation but
does not appear to be in acute discomfort based on assessment
O2 sat: 95% room air Timing: Unable to verbalize
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
