Altered Mental Status: Clinical Reasoning Activity

Altered Mental Status
Clinical Reasoning Activity
Marge Goetz, 82 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
 Clinical judgment
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
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% 
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com All Rights reserved.

Part I: Present Problem:
Marge Goetz is an 82-year-old Caucasian female with a history of hypertension, diabetes type II and heart failure with a
current history of heart failure exacerbation who was admitted to transitional care after being discharged from cardiac
telemetry. She lives alone and requires further occupational and physical therapy to regain her strength so she can return
to independent living if possible.
She has not had a bowel movement in three days. She is on daily Metamucil, docusate, and bisacodyl 2 tabs PO BID.
After trying to have a bowel movement on the commode she insists that the nurse assesses her for an impaction. Marge is
standing up straddling the toilet using the walker to brace herself. The nurse lubricates her finger and uses digital
stimulation to remove hard stool from her colon. Fifteen seconds into the digital disimpaction she calls out, “I feel dizzy!”
and becomes limp. The nurse sets her down on the toilet so she does not fall. She is pale and does not respond to verbal
commands. Within 30 seconds she is responsive, alert and insists on going back to bed. The nurse calls for help and she is
safely positioned back in bed.
1. What clinical data do you NOTICE that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data: Clinical Significance:
• 82 yr old Caucasian female • Age and ethnicity play a role in the disease processes and treatment
• Hx: HTN, DM II, HF w/ hx solution for her.
exacerbation of HF. • Hx of disease processes could warrant evaluation of current medications
• OT/PT services required for and patient understanding of diet/meds/fluid intake/physical activity.
strengthening to regain her •
independence
• No BM x 3 days while taking
daily BM meds: Metamucil,
docusate and bisacodyl.
• Recently D/C from cardiac
telemetry unit to transitional
care
• Unresponsive episode for 30
seconds post digital
disimpaction attempt her of
bowels in the colon.
2. What additional clinical data (if applicable) do you need to collect to ensure that you make a correct
clinical judgment? (Management of Care)
3. Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess
most thoroughly based on the current problem? (Management of Care/Physiologic Adaptation)
Problem: Pathophysiology of Problem in OWN Words: PRIORITY Body
System:
4. What are the specific nursing assessments the nurse will initiate to thoroughly assess this priority body system?
(Reduction of Risk Potential/Physiologic Adaptation)
PRIORITY Nursing Assessments: Rationale:
5. What nursing priority (ies) will guide your plan of care that determines how you will RESPOND? (Mgmt. of Care)
Nursing PRIORITY:
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
Part II: How Will You Respond Now? Reflect and Evaluate
Two minutes later…
After getting Marge back to bed you collect the following assessment data: T: 98.8 (o) P: 88 (reg) R: 18 BP: 168/78 O2
sat: 97% room air. Her head to toe assessment is within normal limits. She is alert and oriented times four, and no
neurologic deficits are present. Her blood glucose is 118. She is resting comfortably in a semi Fowlers position with no
complaints of dizziness or lightheadedness.
1. What clinical data do you NOTICE that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data: Clinical Significance:
2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to
be modified after this evaluation assessment? (Management of Care, Physiological Adaptation)
Evaluation of Current Status: Modifications to Current Plan of Care:
3. What did you learn that you can apply to future patients you care for? Reflect on your current strengths
and weaknesses this case study identified. What is your plan to make any weakness a future strength?
What Did You Learn? What did you do well in this case study?
What could have been done better? What is your plan to make any weakness a future strength?

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Altered Mental Status: Clinical Reasoning Activity

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Altered Mental Status

Clinical Reasoning Activity

Marge Goetz, 82 years old

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com All Rights reserved.

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