The FIve Rights of Clinical Reasoning

THINK Like a Nurse- Right Hip Fracture
The FIVE Rights of Clinical Reasoning

l. RIGHT Cues. Identify and recognize what clinical data is relevant or most important.
2. RIGHT Patient. Is your patient at high risk for a change in status due to age or being susceptible to
infection?
3. RIGHT Time. EARLY recognition of worst possible/most likely complication.
4. RIGHT Action. Once a problem is identified, what nursing interventions must be initiated?
5. RIGHT Reason. Rationale for implementing nursing interventions when a problem is recognized.
1. RIGHT CUES. What clinical data (VS, assessment, labs) did you collect that is relevant or most
important?
RELEVANT Data: Clinical Significance:
a) Vital Signs: Elevated  Tachycardia may indicate pain, stress, or early infection.
heart rate (HR 105
bpm), blood pressure
normal
b) Pain Assessment: 8/10  Severe pain affects mobility and recovery. It also signals the
pain in the right hip need for pain management.
c) Labs: Hemoglobin  Indicates mild anemia, possibly due to blood loss during surgery
(Hgb) 10.2 g/dL

d) Labs: WBC 15,000  Elevated WBC suggests inflammation or possible infection.
cells/μL
 Hypocalcaemia can impair bone healing and increase recovery
e) Labs: Calcium 7.8
time.
mg/dL
2. RIGHT PATIENT. Is your patient at high risk for a change in status because of age or being a
susceptible host?
Yes, this patient is high risk due to the following factors
 Older adults, especially those with osteoporosis, are more prone to complications.
 Post-surgical immobility increases the risk of complications such as DVT, pressure ulcers,
and pneumonia.
 Recent surgery increases susceptibility to infection, particularly at the incision site.
 Conditions such as diabetes or malnutrition can delay healing and increase risks.
What is the worst possible/most likely complication(s) to anticipate based on your patient's primary
problem?
 Infection at the surgical site or systemic can lead to sepsis if untreated.
 Deep Vein Thrombosis (DVT) due to immobility can lead to a pulmonary embolism.
 Delayed bone healing can occur due to low calcium levels or poor nutritional intake.
 Chronic pain or reduced mobility can result from improper healing or inadequate
rehabilitation.
3. RIGHT TIME. What nursing assessments will identify this complication EARLY if it develops?
 Monitor temperature and WBC count as early signs of infection include fever and elevated
WBC levels.
 Inspect the surgical site for redness, swelling, or drainage, indicating possible infection.
 Assess pain levels as increased or unrelieved pain can signal complications such as infection or
improper healing.
 Assess for DVT by monitoring for swelling, tenderness, or redness in the legs as potential signs
of blood clots.
 Track lab trends by monitoring calcium levels to ensure optimal bone healing
4. RIGHT ACTION. What nursing interventions will you initiate if this complication develops?
 Administering antibiotics promptly if infection is suspected.
 Using aseptic techniques for wound care to prevent or manage infection.
 Administering anticoagulants and encouraging physical movement to prevent DVT.
 Providing calcium and Vitamin D supplements to promote bone healing.
5. RIGHT REASON. What is the rationale for the interventions you identified? How will they make a
difference?
3. Assessments to Identify 4. Interventions to Rescue: 5. Rationale:
EARLY:
a) Monitor temperature, a) Administer antibiotics and a) Early infection treatment

use aseptic techniques for
WBC count, and surgical wound care. prevents systemic spread
site. and promotes healing.
b) Assess for swelling, b) Administer anticoagulants b) Decreases the chances of

tenderness, and redness and encourage mobility. deep vein thrombosis
in the legs. (DVT) and pulmonary
embolism due to extended
periods of immobility.
c) Promotes bone healing and
c) Monitor calcium levels c) Provide calcium and ensures faster recovery.

Vitamin D
and bone healing supplementation.
progress. d) Pain relief enhances patient
d) Evaluate pain levels and d) Administer pain mobility and improves

medication as
mobility. prescribed and rehabilitation compliance.
encourage physical
therapy.

The FIve Rights of Clinical Reasoning - patient 1

Uploaded by

Copyright:

Available Formats

The FIve Rights of Clinical Reasoning - patient 1

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

The FIve Rights of Clinical Reasoning - patient 1

Uploaded by

Copyright:

Available Formats

THINK Like a Nurse- Right Hip Fracture

3. RIGHT Time. EARLY recognition of worst possible/most likely complication.

RELEVANT Data: Clinical Significance:

heart rate (HR 105

bpm), blood pressure

pain in the right hip need for pain management.

(Hgb) 10.2 g/dL

Yes, this patient is high risk due to the following factors

 Recent surgery increases susceptibility to infection, particularly at the incision site.

 Infection at the surgical site or systemic can lead to sepsis if untreated.

 Administering antibiotics promptly if infection is suspected.

 Using aseptic techniques for wound care to prevent or manage infection.

 Administering anticoagulants and encouraging physical movement to prevent DVT.

 Providing calcium and Vitamin D supplements to promote bone healing.

3. Assessments to Identify 4. Interventions to Rescue: 5. Rationale:

a) Monitor temperature, a) Administer antibiotics and a) Early infection treatment

site. and promotes healing.

b) Assess for swelling, b) Administer anticoagulants b) Decreases the chances of

in the legs. (DVT) and pulmonary

embolism due to extended

c) Promotes bone healing and

c) Monitor calcium levels c) Provide calcium and ensures faster recovery.

progress. d) Pain relief enhances patient

d) Evaluate pain levels and d) Administer pain mobility and improves

You might also like