NovEx Case ClickStream Clinical Decision Rationale Reflective Tool
Student Name:
Date:_October 23,2025
Patient Case: Mr.Borne_
Use this worksheet to help track your thinking process as you work through your case. Use shorthand, bullet
points, paraphrase. Use a different color for each of your 3 attempts.
You should be entering and exiting the patient’s room at minimum 3x. Follow the expectation guidelines.
This is to be submitted before your scheduled debriefing.
Click stream of interventions performed during care and rationale for evidence based clinical decision made.
Signs & symptoms identified from report: Significance or relevance of s/s identified:
Shortness of breath last 3 days even at rest This patient is suffering from severe shortness of breath
Dyspnea last 3 days due to COPD for the last three days. The body’s natural
Fever response is to go into distress due to the airway
Cough production of thick purulent sputum 2 days obstruction and oxygenation being impaired. The sputum
Tachycardia 126 that the body is producing is a sign of infection that is
Diminished breath sounds bilateral associated with COPD. Their increased HR is a natural
Struggle to speak response to attempt and compensate for the hypoxia. The
Respiratory distress patient is unable to fully let out all the necessary oxygen
Confusion and is the carbon dioxide is remain stuck inside. The
severity is show by the inability to speak and presenting in
hypoxia. Confusion might be a sign of the body not
allowing oxygen to reach the brain.
Chart Review, Hx, Diagnostic tests and/or lab Rationale of correlation and significance of these
results related to patient’s condition, Medications elements
First set of vitals BP:138/86 MAP:103 HR: 126 The history of CAD and MI adds extra complications to
T:98.6 O2: 82 RR:34 the heart when there is an inability to provide the body
After oxygen BP:138/86 MAP:103 HR: 126 with adequate oxygen. The stent is need to keep the
T:98.6 O2:84 RR:34 heart from straining because they are connected and
After BiPap BP:140/86 MAP:104 HR:98 T:98.6 right next to each other. The diaphragms inability to fully
O2:95 RR:18 expand adds complications on top that won’t allow the
HX: COPD and CAD with a stent placement in lungs to inflate as much as they need. When this
LAD 6 years post MI happens it causes the respiratory failure to increase and
DX: hyperinflation with flattening of diaphragm. causing his fatigue. The ABG indicated that the patient is
ABG: pH:7.21 (L) PaO2-52(L) PaCO2-84(H) acidotic because the CO2 high and O2 is low the pH
HCO3-29(H) low. This is caused mainly by the poor gas exchange
WBW-12,600 (H) and hypoxia. The elevated WBC indicate that there is a
MEDS infection and bacteria is present causing his COPD
- Spiriva, Symbicort, Atrovent exacerbation. The patients is reported to be taking
Hospital Spiriva at home for this reason. The inflammation is
- Atrovent being treated by his Symbicort and Atrovent is being
, - Methyl prednisone used to relieve any symptoms that come with this
- Antibiotics IV complication.
Highest priority / Urgent possible interventions Rationale: (ABCs, Maslow’s, logical prioritization, etc…)
identified:
1. Elevate HOB The body’s natural repose to respiratory distress is to
2. Administer oxygen attempt and compensate. When the HR is elevated, and
3. Administer BiPap they are struggling to breath our first reaction should be
4. Give Methyprednisone to elevate the bed and administer supplemental oxygen
5. Give IV antibiotics after assessing the patient and receiving vitals we are
able to see how the oxygen is still very low in the 84
range. From their our next resort is to administer a BiPap
machine and forcing the air to enter the body and
exhaling letting the body regulate. From there the
oxygen level reaches within proper range and we are
able to treat the side issues that are causing more
complications. We would administer the
methyprednisone to treat the inflammation that is
present. This steroid will act quickly and aggressively to
attempt and reduce the inflammation causing the
blockage as soon as possible. To treat the infection we
are able to see present with the WBC of 12,600 we
would give intravenous antibiotics.
safety, monitoring and complication prevention.
1. *Engagement of basic fundamental Rationale for clinical decision and action performed when it
nursing practices: was performed
Hand Hygiene Hand hygiene is always the patients number 1 prevention
PPE action taught because by doing this simple movement we
Patient identification are able to ensure to stop the spread of bacteria
Patient education everywhere and making the patients sicker. Always ensure
Med Admin rules to identify the patients because we wants to ensure we are
treating the right thing for the right person. Always wear
your proper PPE to ensure the spread doesn’t continue if
we can avoid it. Always do your 5 patient rights to ensure
that we are giving patients the proper medication, dose,
route, time and we document everything we do always.
Always provide education on what is going on and who is
doing what so the patient feels most as possible in control
of the situation. Always identify and use identifiers with
everything you hang or give.
2. *Significant subjective/objective data Interpretation of data lab report
identified
Student Name:
Date:_October 23,2025
Patient Case: Mr.Borne_
Use this worksheet to help track your thinking process as you work through your case. Use shorthand, bullet
points, paraphrase. Use a different color for each of your 3 attempts.
You should be entering and exiting the patient’s room at minimum 3x. Follow the expectation guidelines.
This is to be submitted before your scheduled debriefing.
Click stream of interventions performed during care and rationale for evidence based clinical decision made.
Signs & symptoms identified from report: Significance or relevance of s/s identified:
Shortness of breath last 3 days even at rest This patient is suffering from severe shortness of breath
Dyspnea last 3 days due to COPD for the last three days. The body’s natural
Fever response is to go into distress due to the airway
Cough production of thick purulent sputum 2 days obstruction and oxygenation being impaired. The sputum
Tachycardia 126 that the body is producing is a sign of infection that is
Diminished breath sounds bilateral associated with COPD. Their increased HR is a natural
Struggle to speak response to attempt and compensate for the hypoxia. The
Respiratory distress patient is unable to fully let out all the necessary oxygen
Confusion and is the carbon dioxide is remain stuck inside. The
severity is show by the inability to speak and presenting in
hypoxia. Confusion might be a sign of the body not
allowing oxygen to reach the brain.
Chart Review, Hx, Diagnostic tests and/or lab Rationale of correlation and significance of these
results related to patient’s condition, Medications elements
First set of vitals BP:138/86 MAP:103 HR: 126 The history of CAD and MI adds extra complications to
T:98.6 O2: 82 RR:34 the heart when there is an inability to provide the body
After oxygen BP:138/86 MAP:103 HR: 126 with adequate oxygen. The stent is need to keep the
T:98.6 O2:84 RR:34 heart from straining because they are connected and
After BiPap BP:140/86 MAP:104 HR:98 T:98.6 right next to each other. The diaphragms inability to fully
O2:95 RR:18 expand adds complications on top that won’t allow the
HX: COPD and CAD with a stent placement in lungs to inflate as much as they need. When this
LAD 6 years post MI happens it causes the respiratory failure to increase and
DX: hyperinflation with flattening of diaphragm. causing his fatigue. The ABG indicated that the patient is
ABG: pH:7.21 (L) PaO2-52(L) PaCO2-84(H) acidotic because the CO2 high and O2 is low the pH
HCO3-29(H) low. This is caused mainly by the poor gas exchange
WBW-12,600 (H) and hypoxia. The elevated WBC indicate that there is a
MEDS infection and bacteria is present causing his COPD
- Spiriva, Symbicort, Atrovent exacerbation. The patients is reported to be taking
Hospital Spiriva at home for this reason. The inflammation is
- Atrovent being treated by his Symbicort and Atrovent is being
, - Methyl prednisone used to relieve any symptoms that come with this
- Antibiotics IV complication.
Highest priority / Urgent possible interventions Rationale: (ABCs, Maslow’s, logical prioritization, etc…)
identified:
1. Elevate HOB The body’s natural repose to respiratory distress is to
2. Administer oxygen attempt and compensate. When the HR is elevated, and
3. Administer BiPap they are struggling to breath our first reaction should be
4. Give Methyprednisone to elevate the bed and administer supplemental oxygen
5. Give IV antibiotics after assessing the patient and receiving vitals we are
able to see how the oxygen is still very low in the 84
range. From their our next resort is to administer a BiPap
machine and forcing the air to enter the body and
exhaling letting the body regulate. From there the
oxygen level reaches within proper range and we are
able to treat the side issues that are causing more
complications. We would administer the
methyprednisone to treat the inflammation that is
present. This steroid will act quickly and aggressively to
attempt and reduce the inflammation causing the
blockage as soon as possible. To treat the infection we
are able to see present with the WBC of 12,600 we
would give intravenous antibiotics.
safety, monitoring and complication prevention.
1. *Engagement of basic fundamental Rationale for clinical decision and action performed when it
nursing practices: was performed
Hand Hygiene Hand hygiene is always the patients number 1 prevention
PPE action taught because by doing this simple movement we
Patient identification are able to ensure to stop the spread of bacteria
Patient education everywhere and making the patients sicker. Always ensure
Med Admin rules to identify the patients because we wants to ensure we are
treating the right thing for the right person. Always wear
your proper PPE to ensure the spread doesn’t continue if
we can avoid it. Always do your 5 patient rights to ensure
that we are giving patients the proper medication, dose,
route, time and we document everything we do always.
Always provide education on what is going on and who is
doing what so the patient feels most as possible in control
of the situation. Always identify and use identifiers with
everything you hang or give.
2. *Significant subjective/objective data Interpretation of data lab report
identified
