Part I: Emergency Department (ED)
Unfolding Reasoning
John Taylor, 68 years old
Primary Concept
Infection/Immunity
Interrelated Concepts (In order of emphasis)
Clinical judgment and Communication
NCLEX Client Need Categories Covered in Case Study NCSBN Clinical Judgment Model Covered in Case Study
Safe and Effective Care Environment Step 1: Recognize Cues
Management of Care Step 2: Analyze Cues
Safety and Infection Control Step 3: Prioritize Hypotheses
Health Promotion and Maintenance Step 4: Generate Solutions
Psychosocial Integrity Step 5: Take Action
Physiological Integrity Step 6: Evaluate Outcomes
Basic Care and Comfort
Pharmacological and
Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
Initial Triage Assessment in ED
Present Problem:
John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension who came to the
emergency department (ED) triage window because he felt crummy; complaining of a headache, runny nose, feeling weake
“achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but
began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his
breath” when he gets up to go the bathroom. John is visibly anxious and asks, “Do I have that killer virus that I hear about o
the news?”
Personal/Social History:
John lives in a large metropolitan area that has had over three thousand confirmed cases of COVID-19. He has been marri
to Maxine, his wife of 45 years and is retired police officer and active in his local church.
1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
, 68 year old 65 and older are more susceptible to COVID19
Type 2 diabetes and HTN Comorbidities increase his risk
Headache, runny nose, weak, achy all over Symptoms of COVID
hot to touch, sweaty, nagging cough Increased SOB with symptoms and many cases in area he lives
worsening. increases risk for getting COVID.
Cannot catch breath. Active at church may have gone and not worn mask
RELEVANT Data from Social History: Clinical Significance:
Live in highly populated area with high cases
More cases of COVID in condensed area that he lives increases his risk
of COVID for getting COVID
Married 45 years May be active at church increasing risk
Active in church
2. What additional clarifying questions does the triage nurse need to ask John to determine if his cluster of physical
symptoms are consistent with COVID-19?
o Take vital signs, temperature. Chest x-ray.
o Have you traveled in the last 14 days?
o Have you tested positive for COVID or been around anyone positive or suspected of COVID?
o Have you lost your sense of taste or smell?
o Have you been social distancing and wearing masks?
o Have you had fever or chills?
3. Based on the clinical data collected, identify what measures need to be immediately implemented using the following
clinical pathway.
o Mask
o Possible COVID precautions
o Negative pressure room
o Isolation precautions and signs placed
o Doctor order COVID swab
4. What type of isolation precautions does the nurse need to implement if COVID-19 is suspected? What specific
measures must be implemented to prevent transmission?
Type of Isolation: Implementation Components:
Droplet/Aerosol/Standard Protects against aerosol treatments (intubation, breathing nebulizer treatments)
Precautions Reverse air flow to outside, not allowing pt. room air to recirculate.
Respirator Droplet precaution
Negative pressure room Hand Hygiene
N95 Barrier for droplets
Safety goggle or shield Protect uniform from getting and spreading possible
Iso gown Barrier
Gloves Barrier
Hair Net
5. What are the six steps in the chain of infection? Apply what is known about COVID-19 to each step.
Six Steps: Coronavirus COVID-19:
1. Infection agent Covid-19
2. Reservoir Frequently touched surfaces
Unfolding Reasoning
John Taylor, 68 years old
Primary Concept
Infection/Immunity
Interrelated Concepts (In order of emphasis)
Clinical judgment and Communication
NCLEX Client Need Categories Covered in Case Study NCSBN Clinical Judgment Model Covered in Case Study
Safe and Effective Care Environment Step 1: Recognize Cues
Management of Care Step 2: Analyze Cues
Safety and Infection Control Step 3: Prioritize Hypotheses
Health Promotion and Maintenance Step 4: Generate Solutions
Psychosocial Integrity Step 5: Take Action
Physiological Integrity Step 6: Evaluate Outcomes
Basic Care and Comfort
Pharmacological and
Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
Initial Triage Assessment in ED
Present Problem:
John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension who came to the
emergency department (ED) triage window because he felt crummy; complaining of a headache, runny nose, feeling weake
“achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but
began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his
breath” when he gets up to go the bathroom. John is visibly anxious and asks, “Do I have that killer virus that I hear about o
the news?”
Personal/Social History:
John lives in a large metropolitan area that has had over three thousand confirmed cases of COVID-19. He has been marri
to Maxine, his wife of 45 years and is retired police officer and active in his local church.
1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
, 68 year old 65 and older are more susceptible to COVID19
Type 2 diabetes and HTN Comorbidities increase his risk
Headache, runny nose, weak, achy all over Symptoms of COVID
hot to touch, sweaty, nagging cough Increased SOB with symptoms and many cases in area he lives
worsening. increases risk for getting COVID.
Cannot catch breath. Active at church may have gone and not worn mask
RELEVANT Data from Social History: Clinical Significance:
Live in highly populated area with high cases
More cases of COVID in condensed area that he lives increases his risk
of COVID for getting COVID
Married 45 years May be active at church increasing risk
Active in church
2. What additional clarifying questions does the triage nurse need to ask John to determine if his cluster of physical
symptoms are consistent with COVID-19?
o Take vital signs, temperature. Chest x-ray.
o Have you traveled in the last 14 days?
o Have you tested positive for COVID or been around anyone positive or suspected of COVID?
o Have you lost your sense of taste or smell?
o Have you been social distancing and wearing masks?
o Have you had fever or chills?
3. Based on the clinical data collected, identify what measures need to be immediately implemented using the following
clinical pathway.
o Mask
o Possible COVID precautions
o Negative pressure room
o Isolation precautions and signs placed
o Doctor order COVID swab
4. What type of isolation precautions does the nurse need to implement if COVID-19 is suspected? What specific
measures must be implemented to prevent transmission?
Type of Isolation: Implementation Components:
Droplet/Aerosol/Standard Protects against aerosol treatments (intubation, breathing nebulizer treatments)
Precautions Reverse air flow to outside, not allowing pt. room air to recirculate.
Respirator Droplet precaution
Negative pressure room Hand Hygiene
N95 Barrier for droplets
Safety goggle or shield Protect uniform from getting and spreading possible
Iso gown Barrier
Gloves Barrier
Hair Net
5. What are the six steps in the chain of infection? Apply what is known about COVID-19 to each step.
Six Steps: Coronavirus COVID-19:
1. Infection agent Covid-19
2. Reservoir Frequently touched surfaces
