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 #4, previously provided in Chapter 19 Oxygenation and Perfusion, Chapter 22 Activity, Chapter 24 Skin Integrity, Chapter 26 Urinary Elimination, and Chapter 30 Pain Assessment.
Unfolding Case Study
Unfolding Case Study #4
Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living (ADLs) due to weakness and increased dyspnea.
| Past Medical History | Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis Family history: No significant family history reported. Social history: Widowed ten years ago, currently living in an assisted care facility. No children. Current medications:
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| Nursing Notes | 0830: Assessment Neurological: Alert and oriented x4, follows commands appropriately Respiratory: Labored and shallow breathing pattern, bilateral crackles in bases Cardiovascular: Bilateral lower extremity edema, tachycardia Abdominal: Bowel sounds present in all four quadrants, no pain or tenderness noted Musculoskeletal: Limited range of motion in bilateral shoulder joints, patient reports pain in wrist joints related to osteoarthritis Integumentary: Generalized pallor |
| Flow Chart | 0845: Assessment Blood pressure: 158/89 mm Hg Heart rate: 111 beats/minute Respiratory rate: 27 breaths/minute Temperature: 98.9°F (37.2°C) Oxygen saturation: 88 percent on room air Pain: 6/10 (joint pain) |
| Provider’s Orders |
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| Nursing Notes | 1200: 12-lead ECG completed; results show sinus tachycardia. 2 L oxygen via nasal cannula applied, patient reports slight improvement in dyspnea. IV placed in right AC, 20 mg furosemide IV administered. Patient instructed to call before getting up to use bathroom. Patient has not voided since admission. Patient admitted to room on cardiac unit and handoff given to telemetry nurse. |
| Flow Chart | 1230: Assessment Blood pressure: 150/82 mm Hg Heart rate: 108 beats/minute Respiratory rate: 22 breaths/minute Temperature: 98.9°F (37.2°C) Oxygen saturation: 93 percent on 2 L nasal cannula Pain: 6/10 (joint pain) |
| Flow Chart | 1300: Assessment Blood pressure: 142/80 mm Hg Heart rate: 98 beats/minute Respiratory rate: 20 breaths/minute Temperature: 98.9°F (37.2°C) Oxygen saturation: 94 percent on 2 L nasal cannula Pain: 6/10 (joint pain) |
| Nursing Notes | 1315: Patient reports experiencing persistent joint pain, particularly in the shoulders and wrists, rated at 6/10 on the pain scale. Patient states that pain interferes with daily activities, such as getting dressed and cooking. Patient also reports stiffness in affected joints, especially in the morning or after prolonged periods of rest, which improves with movement throughout the day. |
| Provider’s Orders | 1400: New Orders
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| Nursing Notes | 1500: Occupational therapy referral sent per provider’s orders. Acetaminophen administered and patient reports improvement in pain level to a 2/10. 1530: During shift assessment, nonblanchable redness was noted on the patient’s sacrum. When asked about it, patient reports tenderness in the area that gets worse with prolonged sitting. Patient describes the sensation as a mild “stinging” feeling. 1600: Focused skin assessment performed. Open wound noted on bottom of left foot. Patient reports stepping on broken glass about a month ago but states, “I assumed my foot was fully healed because it doesn’t hurt at all.” Upon assessment, the wound is red with purulent drainage and surrounded by edematous tissue. Prophylactic dressing applied to sacral area. Wound consultation placed. |
| Provider’s Orders |
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| Flow Chart | 1730: Assessment Blood pressure: 132/80 mm Hg Heart rate: 94 beats/minute Respiratory rate: 18 breaths/minute Temperature: 98.9°F (37.2°C) Oxygen saturation: 94 percent on room air Pain: 7/10 (joint pain) |
| Nursing Notes | 1800: Patient pressed call light to request to use the bathroom. Ambulated with x1 assist from nurse due to unsteady gait. Patient was unable to void. Focused pain assessment performed. Patient reports 7/10 lower back pain that began last night. The patient states, “I think it’s coming from the hospital bed because I can’t get comfortable.” Patient says that pain is worse with immobility but improves slightly with ambulation. |
| Provider’s Orders | 1830: New Orders
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Clinical Decisions Based on Patient Needs
Referring to the scenario in Unfolding Case Study 4, 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 complaints about worsening shortness of breath, fatigue, and swelling in her lower extremities were important cues to notice because these symptoms were what led her to the hospital to seek 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 taking shallow breaths and heard bilateral crackles in the bases of the lungs, both of which are consistent with the patient’s chief complaint of shortness of breath. During the assessment, the nurse obtained more information including musculoskeletal, integumentary, and pain assessments to use as baseline comparisons later.
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. The nurse anticipated that the provider would order supplemental oxygen to improve the oxygen saturation level and maybe a diuretic medication to clear the excess fluid from the lungs. The patient also reported 6/10 joint pain, but this was not the priority concern at the time of ER admission. The nurse chose to address the patient’s pain later because it was not as important as stabilizing the patient’s respiratory status.
Develop and Refine Interventions
Based on the provider’s orders, the nurse performed a 12-lead ECG and saw that the patient was experiencing sinus tachycardia on the monitor. The nurse also applied supplemental oxygen via nasal cannula based on the provider’s order to keep the oxygen saturation greater than 92 percent. Other nursing interventions included admitting the patient to the telemetry unit, administering IV furosemide, monitoring electrolyte levels, and accurately recording intake and output. As you can see in the new vitals taken 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. After the patient’s respiratory status was more stable, the nurse began to gather more information about the patient’s joint pain. The nurse performed a functional assessment and determined that the patient was unable to perform ADLs effectively because of the pain. The nurse relayed these findings to the provider who then ordered acetaminophen and a referral to occupational therapy.
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 about the importance of maintaining skin integrity. While performing a skin assessment, the nurse noticed that the patient had an open wound on the bottom of her foot but the patient reported that it did not cause her any pain. The nurse recognized that the patient has a history of diabetes and peripheral neuropathy, which affects both the skin-healing process and the patient’s ability to feel pain on her lower extremities. The nurse counseled the patient about the importance of maintaining skin integrity, especially on the feet, and put in a referral to meet with a diabetes educator who could provide her with more resources.
Incorporate Factors Affecting Patient Care
Shortly after the nurse applied a dressing on the patient’s foot wound, the patient pressed the call light to ask for assistance to walk to the bathroom. The nurse assisted the patient to the bathroom, but the patient was unable to void. At this point, the nurse became concerned that the patient had not voided in more than six hours, especially since she had received an IV diuretic earlier. The nurse recognized that a contributing factor to being unable to void could be embarrassment. Urinary elimination is highly personal, and it can be difficult for patients to void when they feel as though healthcare staff is watching them. The nurse performed a bladder scan and determined that the patient had a significant amount of urine in her bladder. Because of this, the nurse anticipated that the provider would order straight catheterization. If the nurse were to perform this procedure, it would be important to make the patient as comfortable as possible and provide support as needed, as this procedure can be uncomfortable or embarrassing for some patients.
Revise Application of Care
Later in the shift, the patient reported new onset of 7/10 back pain, requiring a revision of the patient’s plan of care. The nurse performed a focused pain assessment and noted that the patient’s pain is worse with immobility and improves slightly with ambulation. The nurse reported these findings to the provider who ordered IV ketorolac (Toradol) and a referral to physical therapy.
Evaluate Outcomes
After performing interventions, the nurse evaluated outcomes by assessing the patient’s vital signs and their 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 93 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. After administering the ketorolac for the patient’s back pain, the nurse reassessed the patient’s pain level, looking for a decreased pain level.
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, educating the patient about deep breathing exercises to improve respiratory status, or requesting alternate analgesic medications. 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.