did you know that case studies remain one of the most powerful tools an educator has to teach a practice based profession such as nursing today I will share a skinny reasoning case study on COPD pneumonia that is brief and can be completed in just 15 to 20 minutes and emphasizes both critical thinking and clinical reasoning so students are better prepared for practice and the unclicks so let's get started Joan Walker is an 84 year old female who has had a productive cough of green phlegm that started four days ago that persists she was started three days ago on prednisone 40 milligrams daily and as if from ice and 250 milligrams daily for five days by her primary physician though she has had intermittent chills she had a fever last night of a hundred and two degrees she has had more difficulty breathing during the night and has been using her albuterol inhaler every one to two hours with no improvements so she called 911 see department where you are the nurse who will be responsible for her care now again a key tenant of clinical reason is the ability to recognize relevant clinical data step-by-step as we work through this scenario so as the nurse in the emergency department gets this initial scenario in this initial report what's relevant and why well as we look at this she's 84 years old Joan is old therefore she is at higher risk and is a right patient who could develop a problem or complication she's had green phlegm what is the significance of color to phlegm versus clear or white dead neutrophils she has an infection yellow or green or anything in between is always a red flag that needs to gain be recognized as relevant by the nurse she was started on prednisone as if from mysen the nurse was understand what are these drugs doing one is decreasing inflammation she's got the history of COPD is that relationship between COPD as as it relates to inflammation and breathing she's also had intermittent chills and a fever of a hundred and two degrees this contextualizes the importance of the inflammatory response and recognizing that there is something cooking and it's not dinner so now she's been more short of breath using her albuterol inhaler every 1 to 2 hours with no improvement so she called 9-1-1 all of that data is definitely recognizing or stating there is a problem in the nurse needs to recognize this is a very high risk critical patient so let's move on the nurse collects the first set of vital signs the temp is 103 point two the pulse is 110 her respiratory rate is thirty her blood pressure is 178 over 96 and her o2 SATs are 86% on 6 liters per nasal canula and again step back what is relevant and why is it significant well we have got again our febrile response has even higher we have got a full-blown inflammatory response most likely due to an infection her pulse is 110 her rate is 30 those first three vital signs criteria are the components of sirs criteria recognize that there is a systemic inflammatory response that is more than just a simple pneumonia she's likely septic blood pressure is high though at this point in time and is not trending low as we would expect with septic shock in a row 2 SATs 86% yes 92% or greater 90% with a history of COPD or pneumonia that's too low six liters can we go to 8 or 10 nasal cannula no the nurse needs to recognize we basically need to go to an alternative oxygen delivery system such as a face mask or a high-flow nasal cannula let's now go to the nursing assessment her general appearance she's anxious and distressed barrel chest present her respirations she's dispute with accessory muscle use her breath sounds are diminished bilaterally with anterior posterior expert ory wheezing she's pale hot and drying she's got equal with pulses bilaterally she's alert and oriented times form her abdomens soft non-tender avoiding without difficulty you're in clear yellow skin integrity intact and again what's relevant and why in this physical assessment a very brief head to toe in the context of this patient she's got the barrel chest what does that signify she has chronic COPD she's using her accessory muscles what's the significance of retractions the nurse must recognize that's always a patient who is struggling and in distress their diet thereby if they're she's diminished and she's got expert ory wheezing what is that signifying and what's the physiological significance of wheezing again narrowed bronchioles causing that whistling she's tight and she needs to be opened up so let's go to the next we get some laps and here's our diagnostic data her basic metabolic panel her sodium is 138 K is 3.9 her glucose is 112 her creati swoon point 2 compared to her most recent there's not a trend again a key component of clinical reasoning where's our trend where's our trajectory going comparing the most recent whether it was a week ago a month ago or a year ago or just four hours ago if they're in the acute care setting or any care setting no problems their white count let's look at our CBC white count is currently 14.5 haemoglobin 13.3 platelets 217 92% neutrophils with five bands again look at her most recent look at where our trends going our white count is too high and contextualizing that we have a full-blown inflammatory response with an aggressive neutrophil count percentage of 92% again that's high she's left shifting with positive bands which are immature neutrophils all of these aspects of the of the significance in a white blood count need to be recognized by the nurse let's look at her lactate 3.2 normal is less than 2.2 what's the significance of lactate well when your students know their physiology they can go back and say what is the what is what happens when you have a cells that are not getting enough oxygen we call that lactic acidosis or anaerobic metabolism therefore when you have perfusion issues you have a lactate that's going to be elevated that's why lactate needs to be recognized as a red flag anytime it's present but when it's elevated again we have a problem let's look at our ABG's her pH is seven point two five her piece co2 is 68 her po2 is 52 her bike harvest 36 and her o2 SATs are 84% we need to look at each aspect of what's taking place here why is she acidotic well let's look at her co2 she's definitely driving that down she's got respiratory acidosis but she's also hypoxic 52% is too low 80 to 100 is normal if you know you're a bee gees and o2 sad is again 84% bike harvest 36 that's way high why well the nurse can make a judgement knowing that she's a COPD er she's got chronic co2 retention therefore her kidneys are compensating with the bicarb I can these key constructs need to be deeply understood by our students who will soon be nurses and now let's look at the chest x-ray left lower lobe infiltrate hypoventilation present in both lung fields and again that's confirming an infiltrate consistent with pneumonia now again do we need a next way to tell us she has pneumonia in his gut respiratory distress no we've interpreted the data using Christine Tanner's model of clinical judgment we've interpreted correctly as a thinking nurse and we have a problem that's pneumonia the x-ray is just confirming that so that's the first half of skinny reasoning it's asking what's relevant and why and that's a key construct of clinical reasoning so now let's go deeper and we're just gonna ask five simple questions that will can that will grasp the essence of clinical reasoning and making it practical question number one after interpreting relevant clinical data what is the primary problem and then state the pathophysiology this problem in your own words what's obvious we have pneumonia is present but do we have something more than pneumonia yes we need to recognize pneumonia superimposed with with a patient who meets sirs criteria or that systemic inflammatory response syndrome that is a problem that could deteriorate quickly if we're not anticipating and being proactive with our thinking secondly state the rationale and expected outcomes for the medical plan of care and again the nurse must understand the physician and the medical model and why would they order these medications like a duo Neb of albuterol a petra PM nebulizer establish the peripheral IV lorazepam one milligram methylprednisolone IV push to levofloxacin 750 milligrams as well as tylenol a thousand milligrams we want our students to know the mechanism of action how is they'll beautiful albuterol in a Patra PM nebulize you're gonna benefit this patient again the nurse must understand beta-2 agonist that it's going to dilate by addressing the sympathetic nervous system and therefore improve oxygenation could be a bronchodilator as we do that beta beta 2 stimulation and therefore just working through that we want our students to know the mek of action of every aspect of these medications and that let's go to the nursing priority question number three what nursing priority will guide your plan of care and this is where we need to give our students the flexibility to say Nanda when it fits and state the essence of which is again a construct of clinical reasoning when it does not now I can go with Nanda in this pair in this context of impaired gas exchange clearly as well as respiratory distress but we also have some other issues related to sepsis and looking at those aspects but in essence we have an oxygenation issue and therefore we want to use that as our primary focus the ABCs are always relevant and so we have a B priority but that sepsis is also a not currently a B priority but it's going to be at best AC priority but again they are dovetailing we need to have both of those on our radar and then the interventions that we're going to do to manage oxygenation well this can be increased our oxygenation flow whether it's gonna be sitting that patient upright administering those medications like the do own AB all of that's part of the nurses plan of care then we go to four psychosocial and holistic care priorities that need to be addressed and again we want our nurses to not only think like a nurse but to care like a nurse so we want them to see the big picture of the art of nurse you didn't say what is this patient going through if you couldn't breathe how would you feel will you be anxious would you feel like you might be stressed inning and and and just how would you want to be comforted again using touch and other aspects of communicating caring we need to be very intentional we need to address these aspects of the art of Nursing even Spiritual Care in the context of a patient who is in distress she's not currently dying but she may want that to provide additional comfort if that's important to her and finally what educational and discharge priorities need to be addressed to promote health and wellness for this patient and our family and we're not going to be addressing this right now in the emergency department with a patient with a B C priority but when this patient gets admitted and is on the floor and it's now day two or day three and is gonna go home in the next one to two days this must be on our radar as nurses and be very intentional to help communicate what that patient needs to know regarding education but I would also go on to say that if you're in the emergency department or any acute care setting that you've got a critical patient or potential teach them as you're communicating to them what you're doing why you're doing it why we're giving this nebulizer why we're giving this IV and all that we're doing that's gonna communicate caring it's also going to provide comfort so never just remember there's a patient there who's very stressed and anxious don't ignore that but always be teaching everything the nurse does and that truly is the essence of providing that holistic care that's gonna make our patients be comfortable and feel that feel cared for what did you think I think that you can do this and you can do this in your classroom but as you look at this what is your go-to strategy to help your students understand important content in your classroom I'd like to hear what you do supposed to comment on this video and let others learn from your journey but if you're looking for additional tools to rock active learning in your classroom I have an all-inclusive membership site just for nurse educators that provides access to my entire vault of over 200 clinical reasoning case studies and over 50 topics and much more click the link in the description to learn more finally like this video and share with someone who would benefit and appreciate it if you haven't already subscribed to this YouTube channel and be the first in line to get fresh content that will help your students be prepared not only for the NCLEX but clinical practice