©2018 Keith Rischer/www.KeithRN.com
SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Karen West is a 26-year-old single female who was admitted to the mental health unit this morning (0200) for a possible
overdose of pills following a fight with Steve, her boyfriend of six months. Steve shared that Karen flew into a rage when
he suggested that she “slow down” on her drinking at a party last night. She stormed out after throwing a drink at him.
When he arrived home an hour later Karen was breathing, but unresponsive with an open bottle of unknown pills on the
floor. Steve called 911, and she brought to the emergency department (ED).
In the ED, Karen began to awaken and stated that she remembers getting angry at her boyfriend at the party and thinks
she may have thrown a drink in his face. When she gets that angry, “Everything goes black.” She feels embarrassed at
what she did but is more upset that her boyfriend turned out to be “like everybody else. People always let you down. He
will probably leave me now, won’t he?” She remembers she couldn’t calm down after she got home and just kept taking
more and more pills hoping that would help. She states, “I wasn’t trying to kill myself.” There is a recent superficial cut
on her left thigh that is 4 cm in length. She admits that her life is getting out of control again and agreed to admit herself
voluntarily to a behavioral health unit, so she doesn’t “do something crazy.”
Personal/Social History:
Karen describes herself as someone who never feels content. She can feel deliriously happy at one point and then sad or
angry ten minutes later. She tries to put on a happy face for others, but almost always feels anxious. Even when things are
going well, she states that she feels like she is a fraud. She admits that sometimes the only way to feel better is to cut
herself. She revealed “old” razor blade cuts (scarring) to her inner thighs. She frequently drinks and uses marijuana to
calm down.
She was hospitalized once in her freshman year of college for depression and “cutting.” She saw a therapist for a few
weeks and started on an antidepressant, but the therapist was “awful,” and the medication made her gain weight, so she
quit both.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
Patient Care Begins:
P-Q-R-S-T Pain Assessment:
T: 99.0 F/37.2 C (oral) Provoking/Palliative: Provoked by movement of leg
P: 86 (regular)
Dull
R: 20 (regular) Region/Radiation: Left inner thigh
BP: 130/82
2/10
O2 sat: 98% room air
Continuous
© 2018 Keith Rischer/www.KeithRN.com
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:
RELEVANT Mental Status Exam Data: Clinical Significance:
GENERAL
Appears to be uncomfortable.
Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal
with palpation at radial/pedal/post-tibial landmarks, brisk cap refill
Alert & oriented to person, place, time, and situation (x4)
Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants
Voiding without difficulty, urine clear/yellow
Skin integrity intact except superficial 4 cm cut to left inner thigh. Multiple scars from previous
self-harm cutting
APPEARANCE: Disheveled with no body odor; appears younger than stated age.
MOTOR BEHAVIOR: Fidgeting in chair; wringing hands
Clear with normal rate and rhythm
MOOD/AFFECT: Reports feeling sad and remorseful for her behavior. Flat affect. Reports feeling anxiety
level of 8 out of 10.
THOUGHT PROCESS: Linear, logical
Currently reality-based thinking. No evidence of delusional thinking when assessed.
Some evidence of cognitive distortions
Denies hallucinations
INSIGHT/JUDGMENT: Insight fair – knows she needs some help now. Judgment: Fair to poor: Tends to think
about using maladaptive coping skills
Alert and orientated x4. Reports some memory issues around the events of previous night
Short term memory intact when tested. Long-term memory grossly intact – able to give an
accurate history
INTERACTIONS: Reports “people always let you down” so she doesn’t trust people
SUICIDAL/HOMICIDAL:
Self-Harm
Admits she could have died “by accident” from taking so many pills. Reports she thinks
about ending it all but denies a suicide plan. Feels so anxious that she thinks about cutting
herself while in the hospital to help herself calm down.
© 2018 Keith Rischer/www.KeithRN.com
Diagnostic Results:
Sodium (135–145) Potassium (3.5–5) Glucose (70–110) Creatinine (0.6–1.2)
138 4.8 99 1.0
140 4.5 88 1.1
WBC (4.5-11) Neutrophil (42-72%) Hgb (12-16) Platelets (150-450)
Current: 7.0 44 12.8 229
Prior: 8.9 58 13.2 298
Albumin (3.5–5.5 g/dL) Total Bili (0.1–1.0 mg/dL) ALT (8–20 U/L) AST (8–20 U/L)
Current: 3.9 0.8 38 34
Prior: 4.1 0.5 24 22
ETOH level Acetaminophen Aspirin
Current: 0.28 0.0 0.0
Prior: n/a n/a n/a
What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT
Diagnostic Data:
Clinical Significance: TREND:
Improve/Worsening/Stable:
© 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 medical plan of care. (Pharm. and Parenteral Therapies)
Care Provider Orders:
Voluntary admission to
behavioral health unit
CIWA every shift or as
indicated. Treat with Ativan
for symptoms of withdrawal
– score above 15
Close Observations for
positive suicide, self-harm or
violence ideation and if
patient is unable to contract
for safety per unit protocol
Milieu therapy
Fluoxetine 20 mg PO in AM
Topiramate 100 mg PO
every 12 hours
Olanzapine 2.5 mg PO every
6 hours PRN acute agitation
Lorazepam 1 mg PO every 4
hours PRN for ETOH
withdrawal symptoms
© 2018 Keith Rischer/www.KeithRN.com
Collaborative Care: Nursing
3. What is the nursing PRIORITY and plan of care? (Management of Care)
Nursing Interventions: Rationale: Expected Outcome:
4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?(Psychosocial Integrity)
Nursing Interventions: Rationale: Expected Outcome:
5. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as
a person? (Psychosocial Integrity/Basic Care and Comfort)
Current VS:
Quality:
Severity:
Timing:
Current Assessment:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Mental Status Examination:
APPEARANCE:
SPEECH:
THOUGHT CONTENT:
PERCEPTION:
COGNITION:
BMP:
Current:
Prior:
CBC:
LFT:
Misc:
ProblemRow1:
Nursing PRIORITY:
Rationale:
Expected Outcome:
Psychosocial Priorities: