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Clinical Nursing Skills

28.3 Unfolding Case Study Dissection

Clinical Nursing Skills28.3 Unfolding Case Study Dissection

Learning Objectives

By the end of this section, you will be able to:

  • Examine the clinical decisions based on patient needs in the case study
  • Recognize steps in application of patient care in the case study
  • Identify patient care outcomes in the case study

In this section, we will examine the critical thinking and clinical decision-making used in Unfolding Case Study #3, previously provided in Chapter 15 General Survey, Anthropometric Measurement, and Vital Signs, Chapter 17 Nutrition Assessment, Chapter 18 Oxygenation and Perfusion, Chapter 19 Fluids, Electrolytes, and Elimination, and Chapter 24 Assessment of the Cardiovascular and Peripheral Vascular System.

Unfolding Case Study

Unfolding Case Study #3

Mrs. Ramirez, a 68-year-old female, is brought to the emergency room by her husband. The patient reports shortness of breath with exertion and feeling “off” for the past 3 days.

Past Medical History Patient reports shortness of breath “gets worse with walking and only gets better after sitting down for at least 15 minutes.”
Medical history: Myocardial infarction with stents 10 years ago, heart failure, COPD [chronic obstructive pulmonary disease], GERD [gastroesophageal reflux disease], and hypertension
Family history: Married for 50 years, three grown children. Mother deceased from Alzheimer disease. Father alive, with hypertension and prostate cancer, currently undergoing treatment.
Social history: Former 1 pack/day smoker, quit 20 years ago. Social drinker, 1 drink/week
Allergies: None
Current medications:
  • aspirin 81 mg PO [by mouth] daily
  • carvedilol 6.25 mg PO twice daily
  • furosemide 40 mg PO daily
  • lisinopril 10 mg PO daily
Assessment 1130:
General survey: Alert and oriented ×4. Patient appears short of breath and anxious, leaning forward to assist with breathing. Skin is pale.
Assessment 1200:
Neurological: Alert and oriented ×4, Glascow Coma Scale score 15
HEENT [head, eyes, ears, nose, and throat]: Within normal limits
Respiratory: Accessory muscle use, tripod positioning, crackles in lung bases, fingernail clubbing noted
Cardiovascular: Weak, thready pulse. 1+ pitting edema of bilateral lower extremities
Abdominal: Within normal limits
Musculoskeletal: 4/5 muscle strength of right arm, all other extremities 5/5
Integumentary: Skin pale but dry and intact
Provider’s Orders 1215:
Admit to medical-surgical unit for observation
Continuous ECG [electrocardiographic] monitoring
Start home medications
Supplemental oxygen to maintain saturation >90 percent
Vital signs every 4 hours
Flow Chart 1230:
Blood pressure: 142/78 mm Hg
Heart rate: 112 beats/minute
Respiratory rate: 29 breaths/minute
Temperature: 99.6°F (37.5°C)
Oxygen saturation: 82 percent on room air
Pain: 3/10 with breathing
Weight: 221 lb. (102.2 kg)
Height: 5 ft. 5 in. (1.6 m)
Nursing Notes 1300:
While collecting the patient’s weight, she expresses concern about her weight. She states, “I know I’m not at a healthy weight, but it’s just so hard to eat healthy. Healthy food is so expensive.”
Flow Chart 1400:
Blood pressure: 137/76 mm Hg
Heart rate: 105 beats/minute
Respiratory rate: 25 breaths/minute
Temperature: 99.6°F (37.5°C)
Oxygen saturation: 92 percent on 2 L nasal cannula
Pain: 3/10 with breathing
Nursing Notes 1600:
When asked about diet, patient reports eating out for most meals. She states, “I just don’t have time to cook. It’s much easier to grab a burger on the way home. I work crazy hours, so by the time I get home, all I want to do is eat my burger and go to bed. No way I could cook after a work shift.”

Clinical Decisions Based on Patient Needs

Referring to the scenario in Unfolding Case Study 3, as soon as the patient arrived at the emergency room, the nurse began the process of critically thinking about what needed to be done. The nurse assessed the patient’s situation and then recognized, analyzed, and prioritized the patient’s needs. Once the needs were prioritized, the nurse made clinical decisions about care to be provided and developed and refined planned nursing interventions. Each of these actions by the nurse is discussed in more detail in the following sections.

Assessment of Patient Situation

The nurse began to assess the patient as soon as they arrived at the hospital. The patient’s chief complaint about shortness of breath and feeling “off” were important cues to notice because this was what brought them to the hospital for care. Additionally, another important cue that was recognized by the nurse was the patient’s past medical history, which the nurse hypothesized might have been relevant to their symptoms. Specifically, the nurse took note of all medications the patient was currently taking, because that often provides even more information about a patient’s situation. The nurse noticed that the patient was anxious and leaning forward, which is another important cue to recognize, because it was consistent with the patient’s chief complaint of shortness of breath. During the assessment, the nurse obtained more information including a Glasgow Coma Scale assessment to use as a baseline comparison later and an assessment of the patient’s mobility and functional status.

Recognize, Analyze, and Prioritize Patient Needs

The nurse recognized that the most concerning vital signs were the low oxygen saturation and elevated respiratory rate. Because airway and breathing are always the top priority, the nurse implemented interventions to address those issues first. To start, the nurse re-measured the vitals signs, double checked that the pulse oximeter was working correctly, and made sure the patient was not wearing fingernail polish, which can skew the readings. After rechecking the vitals signs, the nurse contacted the treating provider to report the findings. The nurse anticipated that the provider would order supplemental oxygen to improve the oxygen saturation level and maybe antianxiety medication to slow the patient’s breathing rate. The patient also expressed concern about her weight gain and reported unhealthy eating habits; however, these were not the priority concerns at the time. The nurse chose to address those issues later because they were not as important as stabilizing the patient’s respiratory status.

Develop and Refine Interventions

On the basis of the provider’s orders, the nurse initiated continuous ECG monitoring and saw on the monitor that the patient was experiencing sinus tachycardia. The nurse also applied supplemental oxygen via nasal cannula, based on the provider’s order to keep the oxygen saturation greater than 90 percent. Other nursing interventions included admitting the patient to the medical-surgical unit, restarting home medications, and taking vital signs every 4 hours. As you can see from the new vitals signs data, after applying oxygen, nearly all parameters were improved. If they did not show improvement, the nurse would have revised the plan of care and refined interventions to treat the patient’s condition more effectively.

Application of Nursing Care

Application of nursing care in the case study included the interventions mentioned in the previous section as well as counseling the patient on dietary habits. Once the patient’s physical condition was stabilized, the nurse addressed the patient’s concerns about her weight gain. The nurse used an online calculator to determine the patient’s body mass index, which was found to be 36.8. This indicated obesity, which the nurse recognized as being clinically significant and contributing to cardiac issues.

Incorporate Factors Affecting Patient Care

The nurse recognized that finances may have been a contributing factor to the patient’s weight gain. The patient reported that it is hard for her to eat healthy food because it is expensive, indicating that her economic status affects her weight. Other contributing factors the nurse hypothesized may be involved included sociocultural or lifestyle behaviors that may result in overeating or unhealthy eating habits. Additionally, the nurse hypothesized that the patient may not have easy access to healthy foods, making it even more difficult to eat foods that promote a healthy body weight.

Revise Application of Care

The nurse planned to gather more information about these factors that may be contributing to the patient’s obesity and to gauge the her willingness to make dietary and lifestyle changes that would support a healthier body weight. The nurse also planned to counsel the patient about eating habits and limiting eating out when possible as a way to control sodium intake, because of the patient’s hypertension. The patient was provided information about healthy eating, including eating a large variety of foods, choosing healthy proteins, drinking lots of water, limiting salt and alcohol intake, and avoiding processed foods. The patient in the case study expressed a willingness to make healthy lifestyle changes, but if she had not, the nurse could revise the plan of care to focus patient education on other topics that were more amenable to the patient’s self-reported health and dietary needs.

Evaluate Outcomes

After performing interventions, the nurse evaluated outcomes by assessing the patient’s vital signs and her understanding of provided education. By assessing these parameters, the nurse was evaluating previous nursing actions that had been taken.

Evaluate Nursing Actions

Specifically, the nurse evaluated the action of applying supplemental oxygen by assessing the patient’s vital signs. The nurse noticed that the patient’s oxygen saturation went up to 92 percent after applying 2 L of oxygen via nasal cannula. This finding indicated that this intervention and nursing action were effective. Additionally, the nurse noticed that the patient’s heart rate, blood pressure, and respiratory rate all improved slightly, further confirming that supplemental oxygen was an effective nursing action. To assess the patient’s understanding of the provided education, the nurse had the patient “teach back” the information, asking them to also list out healthy alternatives to eating out that the patient was willing to try.

Revise Plan of Care

The nursing interventions were successful, as indicated by the improvement in vital signs. If they had not improved, the nurse would have revised the plan of care to treat the patient’s condition more effectively. This may have included alerting the provider about the lack of improvement in the patient’s condition, increasing the flow of supplemental oxygen, or educating the patient about deep breathing exercises to improve respiratory status. The nurse was continually assessing the patient’s condition, monitoring for signs of worsening or improvement to use as a guide for revising the plan of care as necessary.


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