LVN VN39 Skinny Reasoning Case Study Parts 1 and 2. A Graded.

Part I: Recognizing RELEVANT Clinical Data History of Present Problem: JoAnn Smith is a 68-year-old woman who presents to the emergency department (ED) after having three days of progressive weakness. She denies chest pain but admits to shortness of breath (SOB) that increases with activity. She also has epigastric pain with nausea that has been intermittent for 20-30 minutes over the last three days. She reports that her epigastric pain has gotten worse and is now radiating into her neck. Her husband called 9-1-1 and she was transported to the hospital by emergency medical services (EMS). Personal/Social History: JoAnn is a recently retired math teacher who continues to substitute teach part-time. She is physically active and lives independently with her spouse in her own home. She has smoked 1 pack per day the past 40 years. JoAnn appears anxious and immediately asks repeatedly for her husband upon arrival. 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: Progressive weakness for 3 days Denies chest pain Complains of SOB that worsen with activity Intermittent and worsening epigastric pain with nausea for 3 days Reports that pain radiates to neck This are classic signs and symptoms of angina. RELEVANT Data from Social History: Clinical Significance: She is physically active Lives at home with spouse Smoked 1 pack a day for 40 years Patient is anxious The signs and symptoms reposted by patient might indicate acute coronary syndrome. Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.2 F/37.3 C (oral) Provoking/Palliative: Nothing/Nothing P: 128 (regular) Quality: Ache R: 24 (regular) Region/Radiation: Left arm that radiates into neck BP: 108/58 Severity: 5/10 O2 sat: 99% room air Timing: Intermittent-20-30" at a time What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Temp: 99.2 Pulse: 128 Resp: 24 Pain: 5/10, ache, left ate that radiates into neck, intermittent for 20-30 minutes at the time. Low grade fever Tachycardia (indicates pain) Tachypnea (indicates pain and/or poor oxygenation) Patient is showing sings of angina