Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
• Fluid and Electrolyte Balance
• Cellular Regulation
• Immunity
• Stress
• Clinical Judgment
NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study
Safe and Effe...
Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
• Fluid and Electrolyte Balance
• Cellular Regulation
• Immunity
• Stress
• Clinical Judgment
NCLEX Client Need Categories Percentage of Items from Covered in
Each Case Study
Category/Subcategory
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%
SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Jan Leisner is a 50-year-old Caucasian woman who has been healthy with no previous medical history. One year ago, she
noted a small palpable lump in her right breast about the size of an almond. Because she has been healthy, she assumed it
was nothing and ignored it. Over the last month she has noted that this lump has been increasing in size. Her
mammogram confirmed a 5 cm mass. An ultrasound biopsy confirmed the presence of cancer cells in the tumor as well as
in three of her lymph nodes most proximal to the tumor. An MRI scan that followed revealed a 1 cm tumor on her lumbar
spine. She is not a surgical candidate at this time, so an implanted venous access device (VAD) will be placed later this
afternoon so that chemotherapy can be started as soon as possible. You are the nurse responsible for her care on the
oncology unit of a community hospital.
Personal/Social History:
Jan has four children under the age of 17. She has no personal or family history of breast cancer. She has never smoked
and lives with her husband in a suburban community. She works part-time as a substitute teacher. Jan is a devout
Christian who has a strong faith and trust in God. She also believes in the power of prayer and believes that God can heal
her. She chose to have a mammogram just before her husband’s insurance plan expired because he just lost his job.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
One year ago she noted a small palpable lump Any lump in the breast area has the potential to be cancerous and
in her right breast about the size of an needs to be followed up. The majority of breast masses are
almond. benign, 10% are cancerous…Irregular fixed masses are
suspicious for malignancy [Epocrates, 2015].
A rapidly growing lump is a clinical RED FLAG, a cause for
Over the last month she has noted that this concern, and must not be ignored! Though denial is a
lump has been increasing in size. Her common coping mechanism, in this context it could be deadly!
mammogram confirmed a 5 cm mass.
Cancer that has progressed to lymph nodes is a clinical RED FLAG
This biopsy confirmed the presence of that increases the likelihood of metastasis. Finding cancer cells in
the lymph nodes is stage III because of their close proximity to the
cancer cells in the tumor as well as in three primary tumor.
of her lymph nodes most proximal to the
tumor. Metastasis from the primary site to a distant location meets the
criteria for stage IV. This is the worst possible staging and makes
The MRI scan revealed a 1 cm tumor on this a terminal diagnosis.
her lumbar spine.
RELEVANT Data from Social History: Clinical Significance:
Jan has 4 children under the age of 17. She is a mother with children whom she wants to see grow up. This
complicates this scenario for both Jan and the nurse. The stakes are
high, but the nurse can make a difference by choosing to ENGAGE in
her experience and make the “art” of nursing a priority to support
her holistically.
With any serious illness, but especially a terminal illness such as
Jan is a Christian who has a strong faith and cancer, to provide true holistic care, the nurse must be willing to
trust in God who also believes in the power gently “go there” when appropriate and establish a trust
of prayer and believes that God can heal her. relationship. I have found that any one of the following spiritual
assessment questions can guide the nurse to support this patient’s
spiritual needs:
□ “What is your source of strength, peace, and hope in
this illness?
• “Are you connected with a faith community?”
• “How has this illness affected your faith?”
• “What can I do to support your faith?”
She chose to have a mammogram before her A lack of insurance also complicates this scenario! Social services
husband’s insurance plan expired because must be consulted to see what state/federal health programs for which
he just lost his job. she may be eligible.
Five Weeks Later…
Jan is promptly started on chemotherapy of Cytoxan and Adriamycin every three weeks for the next three months. Two
weeks after her first chemotherapy treatment she experiences persistent nausea and vomiting, and has been unable to keep
anything down the past 24 hours. She has fatigue so severe she has been unable to move off the couch for the past three
days, and has experienced night sweats with a fever last night. After contacting her oncologist, he arranges to have Jan
admitted directly to the med/surg floor where you will be the nurse responsible for her care.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 101.5 F/38.6 C (oral) Provoking/Palliative: Eating/nothing
P: 110 (regular) Quality: Sharp, ache
R: 20 Region/Radiation: Mouth/tongue
BP: 96/40 Severity: 5/10
O2 sat: 98% room air Timing: Persistent the past 3 days
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
T: 101.5 F/38.6 C (oral) Fever in the context of likely neutropenia after chemotherapy has been
started is a clinical RED FLAG! Further lab tests are needed to identify
the source. The nurse will need to situate this knowledge to identify and
anticipate current care priorities.
P: 110 (regular) WHY is her heart rate elevated?
Elevated HR could reflect increased metabolic needs driven by fever; she
likely has an infection. This has a RELATIONSHIP to fluid volume deficit
that will also cause tachycardia. Bring back pathology….CO=SVxHR
and
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