One Case, Six Steps, Eight Minutes
A vertical time ribbon in the gutter divided into six unequal segments that darken downward, with a hatched extension at the foot labeled OVERRUN, and the six step icons at the head of each panel.
THE CASE. Clinical content owned by → BOOK 09 · P8 and → BOOK 03 · P6. Read each segment only when you reach it.
Segment one, 1400. A 68-year-old client is on a medical unit on the second day of treatment for a urinary tract infection. The assistive personnel reports that the client "seems off." The client is awake, answers questions but is slower than earlier, and asks the same question twice. Skin is warm. Temperature 100.8 F. Heart rate 104. Respirations 22. Blood pressure 104/58. Oxygen saturation 95 percent on room air.
Segment two, 1430. Heart rate 118. Respirations 26. Blood pressure 92/48. Skin remains warm and flushed. The client is now oriented to person and place only. Urine output over the last two hours totals less than the previous two-hour period by more than half.
Segment three, 1500. Blood pressure 84/44 after a fluid bolus has been started. Heart rate 124. The client is drowsy but rousable. Extremities remain warm.
| Step | Prompt | Allowance |
|---|---|---|
| Recognize Cues | List every finding from segment one that is a cue rather than background. | Short |
| Analyze Cues | Group the cues. What do the warm skin, the widening gap between heart rate and blood pressure, and the mental status change have in common? | Long |
| Prioritize Hypotheses | Rank the two most likely explanations and name the one cue that separates them. | Long |
| Generate Solutions | Name three actions that follow from your top hypothesis, and one that would not. | Medium |
| Take Actions | State what you do first, second, and third, and who you call. | Medium |
| Evaluate Outcomes | Name the three parameters that will tell you within thirty minutes whether the actions worked. | Short |
The allowances are unequal on purpose. Analysis and prioritization carry the weight.
OVERRUN LINE. The step that cost me the most time was ______________________. Carry this to page 15.
Margin noteslow at step two is fine, slow at step five is a leak.
Watch outAn overrun at Take Actions usually means Prioritize was skipped rather than done quickly. You cannot choose an action fast if you have not decided what you are treating.
TakeawayThe six steps are a pace, and knowing where you leak time is worth more today than knowing another disease. Step mechanics → BOOK 02 · P4 · Converter → BOOK 16 · P15