5 Rights of Clinical Reasoning PDF

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Adult Health 2 nursing school case study assignments...

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THINK Like a Nurse

The FIVE Rights of Clinical Reasoning 1. RIGHT Cues. Identify and recognize what clinical data is relevant or most important. 2. RIGHT Patient. Is your patient high risk for a change in status due to age or being susceptible to infection? 3. RIGHT Time. EARLY recognition of worst possible/most likely complication. 4. RIGHT Action. Once a problem is identified, what nursing interventions must be initiated? 5. RIGHT Reason. Rationale for implementing nursing interventions when a problem is recognized.

1. RIGHT CUES. What clinical data (VS, assessment, labs) did you collect that is relevant or most important? RELEVANT Data:

Clinical Significance:

Increased HR, BP, RR Decreased O2 Sat on RA Hgb 6.2 Hct 34

The body is compensating for the fluid overload. The heart is working harder. The O2 sat is low because there's all this fluid depleting oxygenation to the tissues, and fluid build up in the lungs. Because of all this fluid, the concentration is diluted. This dilution causes the Hct to decrease and Hgb is attached to the Hct. Hgb is also effected by the lack of oxygenation to the tissues.

2. RIGHT PATIENT. Is your patient high risk for a change in status because of age or being a susceptible host?

He is high risk because of age and PMHx of CHF

What is the worst possible/most likely complication(s) to anticipate based on the primary problem of your patient? 3. RIGHT TIME. What nursing assessments will identify this complication EARLY if it develops? 4. RIGHT ACTION. What nursing interventions will you initiate if this complication develops? 5. RIGHT REASON. What is the rationale for the interventions you identified? How will they make a difference? 3. Assessments to Identify EARLY:

4. Interventions to Rescue:

5. Rationale:

Crackles in the lungs Increased RR, SOB, dyspnea Edema

Raise HOB, give O2, give diuretic, restrict fluids

We want to raise the HOB and give O2 to maintain breathing (ABCs). We want to then give the diuretics because this will hopefully alleviate the rest of the Sx. We then want to restrict fluids until the pt is completely stabilized.

© 2016 Keith Rischer/www.KeithRN.com Adapted from: Levett-Jones, T., Hoffman, K., Dempsey, J., Yeun-Sim Jeong, S., Noble, D., Norton, C. Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today...