Scenario:
You recently finished new graduate orientation in the emergency room (ER) of a rural, 60-bed hospital, and tonight is the first shift you have worked independently. The Intensive Care Unit of the hospital has only four beds and usually sends the sickest clients in need of complex care to a regional medical facility located 50 miles from your location. During orientation, you were told the purpose of treatment in this ER is triage, stabilize, and send home or send to a larger network facility.
Tonight, your first client is an 82-year-old female named Ruth. Ruth was dropped off at the ER by a neighbor who said that she had nausea and vomiting for a week. Her husband was recently admitted to an Alzheimer’s Unit at a local Long-Term Care facility, and the neighbor thought stress was making it hard for Ruth to eat, but tonight she vomited up fresh blood and appeared dizzy. The neighbor also brought in a bag of medication she found in the home but was unsure which medication belonged to Ruth or her husband.

When you enter the room to begin the assessment, you find a frail woman sitting in a wheelchair with apparent labored breathing. She appears dirty with matted hair clothed in a bathrobe with numerous food stains and has a heavy smell of cigarette smoke. You notice the chart has a highlighted area noting the client has only Medicaid for insurance. You ask her if she understands why she is in the ER, and she asks, “Where is my husband? He is usually home by now.”

Past medical history:
• Two pack per day smoker for 58 years
• Type I Diabetic

Assessment data:
• Blood pressure: 178/98
• Heart rate: 84 beats per minute
• Oxygen saturation: 84
• Temperature: 101.8 degrees Fahrenheit
• Hyperactive bowel sounds in all 4 quadrants
• An open wound on the bottom of right foot

Content

You are feeling overwhelmed with your first client but remember first you need to evaluate internal and external cues to develop a priority hypothesis to guide clinical reasoning. Create notes for this client’s plan of care including:
• Design a hypothesis for each of the four modes of inquiry: empirical, ethical, aesthetic and sociopolitical.
• Prioritize the most relevant hypothesis aligned with data in the scenario and demonstrate appropriate clinical reasoning.
• Design an evaluation plan for the priority hypothesis.