Case Instructions

 

Points are earned based on following rubric guidelines for accuracy, thoroughness and completeness of findings.  All areas/sections must be addressed to receive credit.

 

Instructions:  Complete all areas, text boxes will expand to accommodate all information entered. All areas need to be addressed to receive credit.  Omissions will result in failure of the assignment.  Create an APA Title page with your name, date, course info, etc.

 

1. Data Collection/Identifying Data (total 11 points):

Pt. gender & age:          Admit Date:                            Insurance type:

Admitting diagnosis (not chief complaint) with definition for each medical & surgical issue:

 

History of Present Problem (must include dates and/or timeline):

 

What data from the history is important & RELEVANT; therefore, it has clinical significance to the nurse?

RELEVANT Data from Present Problem:	Clinical Significance:
RELEVANT Data from Social History:	Clinical Significance:

2) What is the RELATIONSHIP of your patient’s past medical history, chronic conditions (PMH) and current meds?

(Draw a line from the condition in the left box to the necessary meds in the right box)

 

Past Medical & Surgical History, Chronic Conditions:	Home Meds: Name, dose, frequency
1)     2)     3)	1)     2)     3)

 

Lab/diagnostic Results:

Basic Metabolic Panel (BMP)	Current	High/Low/WNL?	Rational for results
Sodium (135-145 mEq/L)
Potassium (3.5-5.0 mEq/L)
Glucose (70-110 mg/dL)
BUN (10-12  mEq/dL)
Creatinine (0.6-1.2 mg/dL)
Other Misc. Chemistry

 

Complete Blood Count (CBC)	Current	High/Low/WNL?	Rational for Results
WBC (4.5-11.0 mm 3)
Hgb (F: 12-16 g/dL)(M: 13.5-17.5 g/dL)
Hct (F: 35-44%) (M:39-50%)
Platelets(150-450x 100/µl)
Neutrophil % (42-72)
Other:

 

 

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s):	Clinical Significance:	TREND: Improve/Worsening/Stable:

 

Diagnostic test, procedures & radiology reports:

3) What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Diagnostic Procedure & Results:	Clinical Significance:

 

 

1. Routine Patient Care, Vital Signs & Pain Assessment (total 7 points):

Current VS:	OLDCART Pain Scale (5th VS)
Time:	Time:
T:	Onset:
P:	Location:
R:	Duration:
BP:	Characteristics:
O2 sat:	Aggravating Factors
R/A or O2?	Relieving Factors
O2 source:	Treatment

 

1) What VS data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data:	Clinical Significance:

Current Physical Assessment: These are examples, write in your actual & complete assessment findings! Be sure to use appropriate terminology by using your Health Assessment textbook and other provided resources
GENERAL APPEARANCE:	A/A/O x4. Resting comfortably in bed, appears in no acute distress. VSS, Dressed appropriately for the situation and season (in hospital gown). Daughter present at bedside.
RESP:	Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort. RR 18/min, O2 sat at 98% w/ 2L O2 via NC, skin pink, warm and dry
CARDIAC:	Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks. B/P 144/82, HR 67 bpm
NEURO:	Alert & oriented to person, place, time, and situation (x4). Speech clear, smile symmetric
GI:	Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU:	Voiding without difficulty, urine clear/yellow
SKIN:	Skin integrity intact, no lesions, redness or bruising present.  22 gauge S/L in left AC.
PSYCH/SPIRITUAL	Calm & cooperative, resting quietly in bed, praying with rosary. Bible on nightstand table

 

 

2. What body system(s) will you most thoroughly assess based on the primary problem or nursing care priority?

 

 

 

What above assessment data is RELEVANT that must be recognized as clinically significant? Please elaborate here…

RELEVANT Assessment Data:	Clinical Significance:

 

 

If your patient is on Telemetry, include the rhythm strip here with correct interpretation:

HR:      PR interval:	1:1 ratio of P wave to QRS complex?         Regularity?          Interpretation:

 

III. Clinical Reasoning (total 22 points):

 

What is the primary problem/problems that your patient is presenting with?

 

 

 

2. What is the underlying cause/pathophysiology of this/these problems? (Note: Discussing patho usually requires 1&½- 2 pages double spaced per APA format and MUST be referenced!! This needs to be a very thorough discussion & include past medical history, current problem, labs, meds, diagnostic test and any treatments & procedure, linking them all together)

 

 

 

 

3-4. What nursing priorities captures the “essence” of your patient’s current status and will guide your plan of care?(List each in the form of a NANDA three-part nursing diagnosis, MUST have a minimum of three) Provide one long term and one short term goal for each diagnosis:

 

Nursing Diagnosis #1

Long term goal:

Short term goal:

 

Nursing Diagnosis #2

Long term goal:

Short term goal:

 

Nursing Diagnosis #3

Long term goal:

Short term goal:

 

 

5. What interventions will you initiate based on these priorities? List ALL here

Intervention  (to meet the Goal) Include are least 1 in each area:

A-Assess

A-Activity

M-Medication

T-Teaching

T-Treatment

Nursing Interventions:	Rationale:	Expected Outcome:
Assess A-
Activity A-
Medication A-
Teaching A-
Treatment A-

 

 

 

6. What is the worst possible/most likely complication to anticipate based on the primary problem?

 

 

7. What nursing assessments will identify this complication EARLY if it develops?

 

 

8. What nursing interventions will you initiate if this complication develops?

 

 

Medical Management: Rationale for Treatments, Procedures, Surgery & Expected Outcomes

Care Provider Orders:	Rationale:	Expected Outcome:

 

PRIORITY Setting: Which Orders Do You Implement First, Next and Why?

Care Provider Orders:	Order of Priority:	Rationale:

 

Medication Dosage, Calculation & Purpose: List ALL current routine & PRN meds here

Medication Name & Dose:	Classification & Mechanism of Action:	Purpose why THIS pt. needs THIS medication	Nursing Assessment/Considerations & Follow -up:
Normal Range: (high/low/avg?)
Normal Range: (high/low/avg?)
Normal Range: (high/low/avg?)
Normal Range: (high/low/avg?)
Normal Range: (high/low/avg?)
Normal Range: (high/low/avg?)

 

 

9. What educational/discharge priorities will you identify regarding medications or treatments?

 

1. Education Priorities/Discharge Planning (total 10 points):
2. What will be the most important discharge/education priorities you will reinforce regarding their medical condition to prevent future readmission with the same problem?

 

 

What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

 

 

Spiritual & Emotional Caring; the “Art” of Nursing

What is the patient likely experiencing/feeling right now in this situation? How do you know?

 

 

What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person?

(Note: This is your opportunity to address spiritual care, therapeutic interventions & communication strategies)

 

It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job for this patient, now finish strong and provide an SBAR report to the nurse who will be caring for this patient after you J

Situation:

Background:

Assessment:

Recommendation:

 

 

 

Choose three QSEN Questions to Incorporate into Case Study

Choose any three questions, from the list below, to address in this case study

Patient-Centered Care:

What can you/did you do to demonstrate intentional caring and promote patient-centered care with sensitivity and respect for your patient in the context of this clinical presentation? (QSEN-Patient-Centered care)

How can you ensure and assess the effectiveness of communication with the patient and family? (QSEN-Patient-Centered care)

How can you integrate your patient’s preferences/values as you coordinate your plan of care or provide any needed education? (QSEN-Patient-Centered care)

How can you ensure that your patient is an active partner while under your care and promote self-care once they are discharged?  (QSEN-Patient-Centered care)

Teamwork and Collaboration:

What can you do to facilitate a safe and effective update/report to the physician or oncoming nurse? (QSEN-Teamwork and Collaboration)

What would you do if you were not comfortable performing any new skill that was required to take care of this patient? (QSEN-Teamwork and Collaboration)

Evidence-Based Practice:

As a new nurse, what resources could you utilize to provide current, evidence-based, and individualized care planning based on the needs of this patient? (QSEN-Evidence-Based Practice)

Safety/Quality Improvement:

What would you as the nurse do if you almost gave the wrong dose of one of the ordered medications because of a similarity in the label provided by pharmacy to another drug? (QSEN-Safety/Quality Improvement)

Informatics:

What medical electronic data bases are available in your clinical setting that would be a resource if needed to obtain needed information on a medication you have not given before or an illness/surgery you have never seen before? (QSEN-Informatics)

 

 

2019 National Patient Safety Goals Questions to Incorporate into Case Study

Choose any three questions, from the list below, to address in this case study

Identify Patients Correctly:

What are the two patient identifiers that I must use at my clinical site each time I administer medications? (2019 National Patient Safety Goals—Identify patients correctly)

When should lab specimens that are collected by the nurse be labeled? (2019 National Patient Safety Goals—Identify patients correctly)

What process is used to ensure that the patient is receiving the correct blood products? ((2019 National Patient Safety Goals—Eliminate transfusion errors related to patient misidentification)

 

Improve Staff / Caregiver Communication:

If any of my patient’s lab results were “critical” or “panic values” what is the policy at my clinical site that guides me as to how quickly the physician must be notified? (2019 National Patient Safety Goals—Improve staff communication)

Use Medicines Safely:

What can I do with my patient to promote and ensure that patients take their anti-coagulants such as Warfarin safely and with no harmful consequences?  (2019 National Patient Safety Goals—Reduce the likelihood of patient harm associated with the use of anticoagulant therapy)

 

What are my responsibilities as a primary nurse when my patient is admitted to ensure that all of their home medications, dosages, and when last taken are accurate for the physician? (2019 National Patient Safety Goals—Use medicines safely)

What are my responsibilities as a primary nurse when my patient is discharged to ensure that they are knowledgeable and compliant with their ordered home medications? (2019 National Patient Safety Goals—Use medicines safely)

Use Alarms Safely

Make improvements to ensure that alarms on medical equipment are heard and responded to on time. (2019 National Patient Safety Goals—Improve the safety of clinical alarm systems)

Prevent Infection:

What can I do before I go into my patient’s room and before I leave that will dramatically decrease the risk/rate of infection? (2019 National Patient Safety Goals—Prevent infections)

What are some practical, evidence-based practices I can implement to prevent infection due to multidrug-resistant organisms such as MRSA or VRE? (2019 National Patient Safety Goals— Reduce the risk of healthcare associated infections)

What are some practical, evidence-based practices I can implement to prevent bloodstream infection due to central lines, including PICC? (2019 National Patient Safety Goals— Reduce the risk of healthcare associated infections)

What are some practical, evidence-based practices I can implement to prevent surgical site infections? (2019 National Patient Safety Goals— Reduce the risk of healthcare associated infections)

What are some practical, evidence-based practices I can implement to prevent indwelling urinary catheter infections?  (2019 National Patient Safety Goals— Reduce the risk of healthcare associated infections)

 

 

Universal Protocol for Any Invasive Procedure:

What is a “timeout” and what does it consist of that must be done before starting any invasive procedure? (2019 National Patient Safety Goals— Universal protocol)

 

Prevent Mistakes in Surgery

Discuss the pre-procedure verification process to prevent wrong site, wrong procedure, wrong person surgery. (2019 National Patient Safety Goals— Universal protocol)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spiritual Assessment
Spiritual Integrity			1)         Look: (Signs of Meaning, Relationships, Hope and Joy)					Spiritual Distress
Presence of…..			Provide checkmark in either box for each criteria					Absence of….
		Family, friends, visitors, wedding ring, photographs
		Cards, letters, phone calls, flowers, pets
		Attention to personal care and appearance
		Work, projects, hobbies, music, books, tapes
		Newspapers, magazines, television, radio
		Special dress, prayer cap, head scarf, cross
		Articles of faith, pictures, statues, rosary, star
		Books of faith, Bible, Koran, Torah prayers
		Smiles, motivation, coping skills, healthy lifestyle
Uses the observations listed above to begin your Spiritual Assessment
Acknowledge and inquire about photographs, cards, flowers, visitors
Acknowledge and inquire about hobbies, books, television/newspaper content
Acknowledge strength and inquire about profession
Acknowledge and inquire about articles of faith & religious preference
Acknowledge and inquire about mood (physical and psychological)
With your client as your guide, and after a sense of trust and connectedness have been established, continue with the assessment. Phrase your questions and indirect statement in ways that convey your genuineness, style, and comfort.
I would like to hear more about your life and/or your family.
When you return home, will there be someone available to help you?
What brings you joy, makes you happy, or makes you laugh?
What has brought you the greatest sense of pride and accomplishment to date?
What is your next goal?
What give you such strength?
Who do you turn to in tough times?
Would you like me to pray for you or with you?
Spiritual Integrity				Listen: (Actively listen for signs of meaning, relationships, hope, and joy)			Spiritual Distress
Pt verbalizes…				**Provide checkmark in each box that is applicable			Pt verbalizes…
		Sense of purpose and meaning				My life has no meaning
		Source of pride & accomplishment				Guilt, if only….I should have
		Source of joy & happiness				Sense of sadness and despair
		Future Goals and desires				Lack of motivation
		Hope and Courage				Hopelessness “What is the use?”
		Interest in world & concern for others				Lack of concern for others
		Personal Strengths				Powerlessness I am useless.
		Connection to others				Loneliness and isolation
		Connection to a higher source				Helplessness, anxiety, fear
		Religious affiliation				“This is not fair. Why me?”
		Request for special diets, clergy				“Why am I being punished?”
		Appreciation for nature				Apathy
		Ability to adapt to changes				Inflexibility

 

 

GNRS 556 Clinical Reasoning Case Study Data Form Criteria & Point Schedule:	Points possible	Points received Comments:
I. Data Collection Identifying Data                                          (total 11 points)
Admitting Diagnosis	1
History of present problem	1
Integration of relevant data from present problem & social history	1
Past Medical & Surgical Hx/ Chronic Conditions	2
Home Medications	1
Laboratory Tests	2
Relevant lab results & Clinical Significance	1
Diagnostic Tests and Diagnostic Procedures	2
II. Routine Patient Care, VS & Pain Assessment                      (total 7 points)
Relevance of VS & pain assessment	1
Physical Assessment Findings	4
Relevant assessment findings & clinical significance	2
III. Clinical reasoning                                                                (total 22 points)
Primary problem(s) the pt. is presenting with	1
Underlying cause/Pathophysiology	3
Nursing Diagnosis/Collaborative Problem	2
Long & short-term goals	2
Interventions, Rational, Expected outcomes	2
Potential Complications	2
Assessment to identify complication EARLY	1
Interventions to prevent complication	1
Medical Management: Rational for Treatments / Procedures / Surgery	2
Priority of treatment	1
Medication dosage, calculation and purpose	3
Education/ DC priorities for meds or treatments	2
VI. Education Priorities/DC Planning                                       (total 8 points)
Reinforcing	1
Assess effectiveness	1
S&E Caring; the ART of Nursing: What the pt is experiencing/feeling right now	1
Engaging with the pt.	1
SBAR	1
QSEN Questions	2
NPSG	1
VII. Formatting                                                                            (total 2 points)
References	1
APA/Format/Appearance	1
Instructor Comments:    Total:       DATE:	{50}

 

 

APA

 

 

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