SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Minnie Taylor is a 62-year-old African-American female with a history of diabetes mellitus type II, hypertension, and
peripheral
...
SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Minnie Taylor is a 62-year-old African-American female with a history of diabetes mellitus type II, hypertension, and
peripheral arterial disease who had a left below the knee amputation (LBKA) three days ago. She had two small loose,
watery stools last night and a third large watery brown stool this afternoon that had a distinct foul odor. Minnie is now
complaining of generalized lower abdominal cramping that she rates 3/10. She does not have an appetite and does not feel
like drinking fluids. Minnie was awake and alert after lunch, but later that afternoon just before supper you note that
Minnie is sleepy and once aroused, falls right back to sleep.
Personal/Social History:
Minnie is a retired teacher who never married and has no close friends. She lives alone in her own apartment.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
.
Which medication(s) are clinically significant and have a relationship to the current problem?
RELEVANT Medication(s): Clinical Significance:
Patient Care Begins:
Current VS: 4 Hours Ago: Current PQRST:
T: 100.8 F/38.2 C T: 98.7 F/37.1 C Provoking/Palliative: Movement provokes pain
P: 98 (reg) P: 84 (reg) Quality: Cramping
R: 20 (reg) R: 18 (reg) Region/Radiation: Generalized lower abdomen
BP: 92/64 MAP: 73 BP: 118/74 MAP: 89 Severity: 3/10
O2 sat: 94% RA O2 sat: 95% RA Timing: Ongoing since onset two hours ago
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