© 2018 Keith Rischer/www.KeithRN.com SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted to the pediatric unit of the hospital from the walk-in clinic with an acute asthma exacerbation. Jared started complaining of increased chest tightness and shortness of breath one day prior to admission. He has been at 50 percent of his personal best measurement for his peak expiratory flow (PEF) meter reading which did not improve with the use of albuterol metered dose inhaler (MDI) (per his written asthma management plan). In the walk-in clinic Jared is alert, speaking in short sentences due to breathlessness at rest. He has coarse expiratory wheezes throughout both lung fields with decreased breath sounds at the right base. His oxygen saturation on room air is 90%. His color is ashen and he has dark circles under his eyes. He is sitting upright and using his accessory chest muscles to breath and has moderate intercostal and substernal retractions. He is complaining of tightness in his chest. Jared was diagnosed with asthma at age 6 years and has three prior hospitalizations for asthma with one admission to the pediatric intensive care unit. He has never had to be intubated with these episodes. Personal/Social History: He is accompanied by his mother and 16-year-old sister. Jared lives with his mother, maternal grandmother, and sister in an older housing development in the inner city. He is in the 5th grade and a good student despite two to three absences per school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of friends at school and likes his teacher, Mr. Bates, who is also his soccer coach. Both Jared and his mother deny tobacco smoke at home. What data from the histories are important and RELEVANT; therefore it has 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: 99.9 F/37.7 C (oral) Provoking/Palliative: Worsens when tries to take a deep breath. Feels better when allowed to sit upright on gurney P: 120 (regular) Quality: Tightness R: 30 (regular) Region/Radiation: Across anterior chest BP: 114/78 Severity: 8/10 O2 sat: 90% on room air Timing: Constant End Tidal CO2: 30 © 2018 Keith Rischer/www.KeithRN.com What VS data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: What assessment data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: Diagnostic Results: Basic Metabolic Panel ...

1. © 2018 Keith Rischer/www.KeithRN.com
SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Jared Johnson is a 10 year-old African-American boy with a
history of moderate persistent asthma. He is being admitted
to the pediatric unit of the hospital from the walk-in clinic with
an acute asthma exacerbation. Jared started complaining
of increased chest tightness and shortness of breath one day
prior to admission. He has been at 50 percent of his personal
best measurement for his peak expiratory flow (PEF) meter
reading which did not improve with the use of albuterol
metered dose inhaler (MDI) (per his written asthma management
plan).
In the walk-in clinic Jared is alert, speaking in short
sentences due to breathlessness at rest. He has coarse expiratory
wheezes throughout both lung fields with decreased breath
sounds at the right base. His oxygen saturation on room air is
90%. His color is ashen and he has dark circles under his eyes.
He is sitting upright and using his accessory chest muscles

2. to breath and has moderate intercostal and substernal
retractions. He is complaining of tightness in his chest. Jared
was
diagnosed with asthma at age 6 years and has three prior
hospitalizations for asthma with one admission to the pediatric
intensive care unit. He has never had to be intubated with these
episodes.
Personal/Social History:
He is accompanied by his mother and 16-year-old sister. Jared
lives with his mother, maternal grandmother, and sister in
an older housing development in the inner city. He is in the 5th
grade and a good student despite two to three absences per
school year for his asthma. He likes to ride his bike and is the
goalie on the soccer team. He says that he has lots of
friends at school and likes his teacher, Mr. Bates, who is also
his soccer coach. Both Jared and his mother deny tobacco
smoke at home.
What data from the histories are important and RELEVANT;
therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:

3. RELEVANT Data from Social History: Clinical Significance:
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.9 F/37.7 C (oral) Provoking/Palliative: Worsens when
tries to take a deep breath. Feels better when
allowed to sit upright on gurney
P: 120 (regular) Quality: Tightness
R: 30 (regular) Region/Radiation: Across anterior chest
BP: 114/78 Severity: 8/10
O2 sat:
90% on room air
Timing: Constant

4. End Tidal CO2: 30
© 2018 Keith Rischer/www.KeithRN.com
What VS data are RELEVANT and must be recognized as
clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
What assessment data are RELEVANT and must be recognized
as clinically significant to the nurse?
RELEVANT Assessment Data: Clinical Significance:
Diagnostic Results:
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.

5. Current: 138 3.7 80 0.6
Complete Blood Count (CBC)
WBC % Neuts HGB PLTs
Current: 10.0 55 14.1 350
Radiology:
Chest x-ray
Hyper-expansion of airways with otherwise clear lung fields.
What data must be interpreted as clinically significant by the
nurse? (Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT
Diagnostic Data:
Clinical Significance:

6. Current Assessment:
GENERAL
APPEARANCE:
Ashen, anxious appearing, moderate respiratory distress. Sitting
upright on gurney.
Only able to talk in short sentences due to breathlessness. Has
intercostal and sub-
sternal retractions with increased respiratory rate, using
accessory muscles to
breathe (sternocleidomastoid muscles).
RESP: Breath sounds with inspiratory and expiratory wheezing
and prolonged expiration.
Has tight-sounding non-productive cough, decreased breath
sounds in right base
CARDIAC: Pale, warm & moist at forehead, no edema, heart
sounds regular with no abnormal
beats, pulses strong, equal with palpation at radial/pedal/post-
tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation
(x4)
GI: Abdomen soft/non-tender, bowel sounds audible per
auscultation in all four

7. quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, moist on forehead
© 2018 Keith Rischer/www.KeithRN.com
Part II: Put it All Together to THINK Like a Nurse!
1. After interpreting relevant clinical data, what is the primary
problem?
(Management of Care/Physiologic Adaptation)
Problem: Pathophysiology in OWN Words:
Collaborative Care: Medical Management
2. State the rationale and expected outcomes for the medi cal
plan of care. (Pharm. and Parenteral Therapies)
Medical Management: Rationale: Expected Outcome:
Vital signs every 1 hour and
as needed

8. Continuous oxygen
saturation monitoring
Continuous end tidal CO2
monitoring
Start peripheral IV then
saline lock
O2 to keep saturations >93%
Albuterol 2.5 mg and
ipratropium bromide 0.25
mg via face mask nebulizer
every 20 minutes as needed
for respiratory distress

9. Methylprednisolone IV
loading dose 2mg/kg then
start Methylprednisolone IV
0.5 mg/kg every 6 hours for
48 hours
Diet as tolerated
© 2018 Keith Rischer/www.KeithRN.com
Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care?
(Management of Care)
Nursing PRIORITY:
PRIORITY Nursing Interventions: Rationale: Expected
Outcome:

10. 4. What psychosocial/holistic care PRIORITIES need to be
addressed for this patient? (Psychosocial Integrity)
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:

11. EMOTIONAL SUPPORT:
Principles to develop a therapeutic
relationship
SPIRITUAL CARE/SUPPORT:
5. What educational/discharge priorities need to be addressed to
promote health and wellness for this patient and/or
family? (Health Promotion and Maintenance)
RELEVANT Data from Present ProblemRow1: Clinical
SignificanceRow1: RELEVANT Data from Social HistoryRow1:
Clinical SignificanceRow1_2: Current VS: PQRST Pain
Assessment 5th VS: T 999 F377 C oral: ProvokingPalliative: P
120 regular: Quality: Tightness: R 30 regular: Across anterior
chest: BP 11478: Severity: 810: O2 sat 90 on room air:
TimingEnd Tidal CO2 30: ConstantEnd Tidal CO2 30:
RELEVANT VS DataRow1: Clinical SignificanceRow1_3:

12. Current Assessment: GENERAL APPEARANCE: RESP:
CARDIAC: NEURO: GI: Abdomen softnontender bowel sounds
audible per auscultation in all four: GU: SKIN: Skin integrity
intact moist on forehead: RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_4: Basic Metabolic Panel
BMPRow1: Creat: Current: 06: Complete Blood Count
CBCRow1: PLTs: Current_2: 350: 100: Hyperexpansion of
airways with otherwise clear lung fields: RELEVANT
Diagnostic DataRow1: Clinical SignificanceRow1_5:
ProblemRow1: Pathophysiology in OWN WordsRow1:
RationaleVital signs every 1 hour and as needed Continuous
oxygen saturation monitoring Continuous end tidal CO2
monitoring Start peripheral IV then saline lock O2 to keep
saturations 93 Albuterol 25 mg and ipratropium bromide 025
mg via face mask nebulizer every 20 minutes as needed for
respiratory distress Methylprednisolone IV loading dose 2mgkg
then start Methylprednisolone IV 05 mgkg every 6 hours for 48
hours Diet as tolerated: Expected OutcomeVital signs every 1
hour and as needed Continuous oxygen saturation monitoring
Continuous end tidal CO2 monitoring Start peripheral IV then
saline lock O2 to keep saturations 93 Albuterol 25 mg and
ipratropium bromide 025 mg via face mask nebulizer every 20
minutes as needed for respiratory distress Methylprednisolone
IV loading dose 2mgkg then start Methylprednisolone IV 05
mgkg every 6 hours for 48 hours Diet as tolerated: Nursing
PRIORITY: PRIORITY Nursing InterventionsRow1:
RationaleRow1: Expected OutcomeRow1: Psychosocial
PRIORITIES: RationaleCARINGCOMFORT How can you
engage and show that this pt matters to you Physical comfort
measures: Expected OutcomeCARINGCOMFORT How can you
engage and show that this pt matters to you Physical comfort
measures: RationaleEMOTIONAL SUPPORT Principles to
develop a therapeutic relationship: Expected
OutcomeEMOTIONAL SUPPORT Principles to develop a
therapeutic relationship: RationaleSPIRITUAL

13. CARESUPPORT: Expected OutcomeSPIRITUAL
CARESUPPORT: Answer5: