Fluid Overload
NextGen SKINNY Reasoning
This study resource
was
Anthony Robinson, 67 years old
Primary Concept
Perfusion/Gas Exchange
Interrelated Concepts (In order of emphasis)
Clinical judgment
NCLEX Client Need Categories Covered in NCSBN Clinical Covered in
Case Study Judgment Model Case Study
Safe and Effective Care Environment Step 1: Recognize Cues
Management of Care Step 2: Analyze Cues
Safety and Infection Control Step 3: Prioritize Hypotheses
Health Promotion and Maintenance Step 4: Generate Solutions
Psychosocial Integrity Step 5: Take Action
Physiological Integrity Step 6: Evaluate Outcomes
Basic Care and Comfort
Pharmacological and
Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
https://www.coursehero.com/file/80563787/Post-Sim-Case-Studypdf/
, Present Problem:
You are the nurse caring for Anthony Robinson, a 67-year-old African American male patient with a history of heart
failure and iron deficiency anemia who was admitted to the medical floor from the emergency department earlier this
morning for low hemoglobin. Mr. Robinson’s initial hemoglobin was 6.2 and the primary care provider ordered 2 units of
packed red blood cells (PRBC). He received the first unit in the emergency department (ED) over 90 minutes and
tolerated well with no change in status.
Current Labs (ED):
Complete Blood Count (CBC)
WBC HGB Hct PLTs
7.5 6.2 34 154
Basic Metabolic Panel (BMP) + Mg
Na K Cl CO2 BUN Creat. Gluc Mg
143 3.5 110 26 16 1.1 132 1.8
The second unit was started after he arrived on the floor and is nearly 2/3 finished. You are rounding on your other
patients when Mr. Robinson presses his call light and states “I feel like I can’t catch my breath.” When you enter the
room, you see Mr. Robinson in bed breathing rapidly and he appears anxious.
1. What data from the present problem is RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
Recognizing a potential problem, you stop the
blood, allowing saline to infuse TKO, and
promptly collect a full set of VS before
contacting the primary care provider:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.2 F/36.8 C (oral) Provoking/Palliative:
P: 102 (regular) Quality: Denies
R: 28 (regular) Region/Radiation:
BP: 138/89 Severity:
O2 sat: 87% RA Timing:
https://www.coursehero.com/file/80563787/Post-Sim-Case-Studypdf/
NextGen SKINNY Reasoning
This study resource
was
Anthony Robinson, 67 years old
Primary Concept
Perfusion/Gas Exchange
Interrelated Concepts (In order of emphasis)
Clinical judgment
NCLEX Client Need Categories Covered in NCSBN Clinical Covered in
Case Study Judgment Model Case Study
Safe and Effective Care Environment Step 1: Recognize Cues
Management of Care Step 2: Analyze Cues
Safety and Infection Control Step 3: Prioritize Hypotheses
Health Promotion and Maintenance Step 4: Generate Solutions
Psychosocial Integrity Step 5: Take Action
Physiological Integrity Step 6: Evaluate Outcomes
Basic Care and Comfort
Pharmacological and
Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
https://www.coursehero.com/file/80563787/Post-Sim-Case-Studypdf/
, Present Problem:
You are the nurse caring for Anthony Robinson, a 67-year-old African American male patient with a history of heart
failure and iron deficiency anemia who was admitted to the medical floor from the emergency department earlier this
morning for low hemoglobin. Mr. Robinson’s initial hemoglobin was 6.2 and the primary care provider ordered 2 units of
packed red blood cells (PRBC). He received the first unit in the emergency department (ED) over 90 minutes and
tolerated well with no change in status.
Current Labs (ED):
Complete Blood Count (CBC)
WBC HGB Hct PLTs
7.5 6.2 34 154
Basic Metabolic Panel (BMP) + Mg
Na K Cl CO2 BUN Creat. Gluc Mg
143 3.5 110 26 16 1.1 132 1.8
The second unit was started after he arrived on the floor and is nearly 2/3 finished. You are rounding on your other
patients when Mr. Robinson presses his call light and states “I feel like I can’t catch my breath.” When you enter the
room, you see Mr. Robinson in bed breathing rapidly and he appears anxious.
1. What data from the present problem is RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
Recognizing a potential problem, you stop the
blood, allowing saline to infuse TKO, and
promptly collect a full set of VS before
contacting the primary care provider:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.2 F/36.8 C (oral) Provoking/Palliative:
P: 102 (regular) Quality: Denies
R: 28 (regular) Region/Radiation:
BP: 138/89 Severity:
O2 sat: 87% RA Timing:
https://www.coursehero.com/file/80563787/Post-Sim-Case-Studypdf/
