NovEx Case ClickStream Clinical Decision Rationale Reflective Tool
Student Name:
Date: September 19
Patient Case: Ms. Gillian
Use this worksheet to help track your thinking process as you work through your case. Use shorthand, bullet
points, and 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:
Confusion and weakness. Dizziness, diarrhea, Hypoglycemia has many of the signs and symptoms that
diaphoretic unable to comprehend. appeared being reported. Due to her condition, we were
“I am just so weak” able to rule out important factors treat according to the
Vitals symptoms being presented. When the blood sugar is low
MAP the brain will be lacking the needed amount of glucose
causing the alternations in mental status. Glucose is the
main source of energy causing weakness and fatigue.
Chart Review, Hx, Diagnostic tests and/or lab Rationale of correlation and significance of these
results related to patient’s condition, Medications elements
Diabetes 2, hypertension, steatohepatitis, breast The first priority begins checking the patients glucose.
cancer, status post left mastectomy 11 years ago Upon obtaining a patients glucose being 40 mg we
with recurrence of breast cancer 8 years followed would instantly administer dextrose or IV glucose. We
by private physician, tonsillectomy, partial then would check again the glucose to see the level rise.
thyroidectomy, hysterectomy. Provide food and juice to maintain a proper blood sugar
ALLERGIES: Penicillin levels. We then would continue to monitor for the next
Get a POC blood glucose remaining 1-2 hours until wanted glucose is attained.
Stabilize with food and glucose IV
Monitor for further changes
Highest priority / Urgent possible interventions Rationale: (ABCs, Maslow’s, logical prioritization, etc…)
identified:
First glucose was 40 mg/dL The first glucose was 40 mg/dL, which is indicated as a
Then reassess was 119 mg/dL hypoglycemia. Because of the number we must require
a prompt action of aiming to raise the glucose. That is
why we would give a quick source of glucose.
After we administer the quick glucose we then stabilize
with food. Upon checking the levels it raised back up to
199 mg/dL and a reasonable range.
Student Name:
Date: September 19
Patient Case: Ms. Gillian
Use this worksheet to help track your thinking process as you work through your case. Use shorthand, bullet
points, and 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:
Confusion and weakness. Dizziness, diarrhea, Hypoglycemia has many of the signs and symptoms that
diaphoretic unable to comprehend. appeared being reported. Due to her condition, we were
“I am just so weak” able to rule out important factors treat according to the
Vitals symptoms being presented. When the blood sugar is low
MAP the brain will be lacking the needed amount of glucose
causing the alternations in mental status. Glucose is the
main source of energy causing weakness and fatigue.
Chart Review, Hx, Diagnostic tests and/or lab Rationale of correlation and significance of these
results related to patient’s condition, Medications elements
Diabetes 2, hypertension, steatohepatitis, breast The first priority begins checking the patients glucose.
cancer, status post left mastectomy 11 years ago Upon obtaining a patients glucose being 40 mg we
with recurrence of breast cancer 8 years followed would instantly administer dextrose or IV glucose. We
by private physician, tonsillectomy, partial then would check again the glucose to see the level rise.
thyroidectomy, hysterectomy. Provide food and juice to maintain a proper blood sugar
ALLERGIES: Penicillin levels. We then would continue to monitor for the next
Get a POC blood glucose remaining 1-2 hours until wanted glucose is attained.
Stabilize with food and glucose IV
Monitor for further changes
Highest priority / Urgent possible interventions Rationale: (ABCs, Maslow’s, logical prioritization, etc…)
identified:
First glucose was 40 mg/dL The first glucose was 40 mg/dL, which is indicated as a
Then reassess was 119 mg/dL hypoglycemia. Because of the number we must require
a prompt action of aiming to raise the glucose. That is
why we would give a quick source of glucose.
After we administer the quick glucose we then stabilize
with food. Upon checking the levels it raised back up to
199 mg/dL and a reasonable range.
