Acute Delirium SKINNY Reasoning

John Kelly, 77 years old

Primary Concept

Cognition

Interrelated Concepts (In order of emphasis)

 Stress

 Coping

 Clinical Judgment

 Patient Education

NCLEX Client Need Categories Percentage of Items from Each

Category/Subcategory

Covered in

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% 

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SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data

History of Present Problem:

John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure

who had a right total hip arthroplasty and is post-operative day one. Since surgery he has been on path, resting

comfortably and his pain has been controlled with oxycodone 5 mg PO. When the nurse enters the room to do his morning

assessment, John is agitated, combative and resistive to staff. He pulled out his Foley urinary catheter, his IV catheter and

removed his surgical dressing. His legs are swung over the side rails and is trying to get out of bed. John does not know

where he is and oriented to self only. He insists that he is at home and yells out, “You get the hell out of my home or I am

going to call the police!” His wife is visibly upset and states that she has never seen him behave like this before. With

tears in her eyes she asks you, “What is happening to my husband! Please do something to help him!”

Personal/Social History:

John is a retired high school math teacher who lives at home with his wife and lives independently. He is active at the

senior center where he attends social activities 3-4 times a week. He attends Catholic Mass every Sunday with his wife.

He is a nonsmoker and has a glass of wine 2-3 times a week with dinner.

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:

-77 y/o male

-Right total hip arthroplasty post op day one

-John is agitated, combative and resistive to

staff

-Pulled out foley, iv and removed his surgical

bandage

-Pt is oriented to self only

-Pt insists he is in his home and yells “ You get

the hell out of my home or I am going to call

the police”

The patient is an elderly gentleman who is post op day one from an

arthroplasty which will put the patient at risk for falls and infection. The

patients age puts him at a higher risk for delirium. The patient is

aggravated, combative and resistive to staff which leads me to believe this

is being caused by either medication he is taking maybe causing delirium.

The patient has pulled out his foley cath and IV so that will need to be

monitored for infection. The patient is oriented to self only which is

significant to changes in his LOC due to possible UTI from infection or

delirium from medication.

RELEVANT Data from Social History: Clinical Significance:

Pt lives at home independently with wife.

Pt is a nonsmoker and has a glass of wine 2-3

times a week with dinner

Pt is self-sufficient and not dependent on anyone

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment:

T: 99.1 F/37.3 C (oral) Provoking/Palliative: Pain in his right hip but unable to give details

P: 102 (regular) Quality: Tenderness to palpation over incision site

R: 18 (regular) Region/Radiation: Right hip

BP: 155/65 Severity: Unable to verbalize due to confusion, tenderness to palpation but

does not appear to be in acute discomfort based on assessment

O2 sat: 95% room air Timing: Unable to verbalize

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?

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