© National League for Nursing, 2018
NUR1115L Fundamentals of Nursing Clinical
Red Yoder Case Study – Student Version
This assignment will be discussed via Zoom Conferencing. See your instructor’s
email/announcement for when this written assignment is due.
Specific Directions for answering the following questions:
Read the case study and answer the following questions. Submit COMPLETE answers to your
instructor via email/assignment link. Be sure to list what academic/scholarly resources you used
to answer these questions. If using a textbook, be sure to put page numbers. Use examples from
the case study to support your answers. Be prepared to discuss your answers in detail, relating
them back to Mr. Yoder’s case study.
Case Study Learning Objectives
Students will be able to:
1. Assess the patient’s individual aging pattern and functional status using the following
standardized assessment tools: (See Attachment 1, titled – Standardized Assessment Tools):
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SPICES: An Overall Assessment Tool of Older Adults
Katz Index of Independence in Activities of Daily Living (ADL)
The Pittsburgh Sleep Quality Index (PSQI)
Elder Mistreatment Assessment
Alcohol Use Screening and Assessment
2. Use standardized communication tools to discuss the care of the client with other health care
providers.
3. Discuss pertinent assessment findings and what was found that was specific to the older adult
patient.
4. Implement appropriate interventions based on the assessment data collected. (wound care,
education related to management of diabetes).
5. Identify geriatric syndrome(s) evident in the scenario.
Part I Case Study Questions
1. Please read the following in order to answer the questions for Part I of this case study: (All
three areas are found below these questions)
a. The Overview
b. Red Yoder’s Introductory Monologue Script
c. The RN’s History and Subjective Assessment
Start collecting subjective and objective information and make a concept map to organize
and cluster the data.
2. See Attachment 1, titled: Standardized Assessment Tools and complete the following
assessments. Review the website found on this attachment document before completing
Mr. Yoder’s assessments.
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
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SPICES: An Overall Assessment Tool of Older Adults
Katz Index of Independence in Activities of Daily Living (ADL)
The Pittsburgh Sleep Quality Index (PSQI)
Elder Mistreatment Assessment
Alcohol Use Screening and Assessment
3. Using all assessment data, identify a priority nursing diagnose: Impaired Skin Integrity
related to pressure ulcer as evidence by disruption of epidermal and dermal tissues.
a. Identify a three-part priority nursing diagnose:
b. Identify the objective and subjective data to support this nursing diagnose:
Subjective: patient states that shoes were a little tight. Hurts when trying to put shoes on.
Objective data: bloody sock, sore on big toe, whole foot is red and big.
c. Identify one outcome: Patient describes measures to protect and heal the tissue,
including wound care. Pt’s wounds will be kept clean and free from any further infection.
d. Identify three interventions to help meet this outcome: Pt’s wounds will be changed daily.
Inspect patients skin every 8 hours, report changes. verbalize and demonstrate to the pt’s 3
ways on how to prevent pressure ulcers. verbalize and demonstrate to patient proper
wound care.
Attachment 1: Standardized Assessment Tools
Overview
Red Yoder is an 80-year-old farmer who lives alone in the farmhouse where he grew up. It is
located 20 miles outside of town. Red has been a widower for 10 years. His son, Jon, manages the
farm now, but Red is still involved in the decision making. Red's current medical problems include
insulin dependent diabetes complicated by an open foot wound that developed three weeks ago.
He also has some incontinence and difficulty sleeping.
Demographics:
Gender: Male
Race: Caucasian
Weight: 109 kg
Height: 183 cm
Religion: Protestant
Allergies: no known allergies
Immunizations: Influenza – November 2020, Tetanus 2017
Past Medical History: Diabetes Type 2 diagnosed September 2019
Primary Physician: Dr. Frank Baker
Previous surgeries: L4-5 laminectomy1986; Transurethral resection of the
Prostate, 2015
Red Yoder Introductory Monologue Script
I understand you want to hear my story; well, I’m not much for talking, but I can give you
the highlights. There’s a lot that’s happened over my 80 years.
From the top. My name is Sherman Yoder, but I answer to “Red.” No one around here even
remembers my real name. I was born in this house in the downstairs bedroom. Mom had
already delivered six kids and there was no way I was waiting for Dad to finish feeding the
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hogs and get Mom to town before I come out. Mom used to love to tell that story.
Dad bought this farmhouse and the first hundred acres right before he went off to WWI. The
folks saw good times and bad in this ol’ place and so have I. All my brothers and sisters left the
land as soon as they could. I was the only one of the lot to care about this place and want to
carry on what Dad started. I really haven’t gone far from this spot in my entire life. The one time I
got it in my head to try something different; I wound up in Korea with an Army uniform on. I was
glad to get back to this place after that stint and here I’ve been ever since.
Married the neighbor girl Bessie when I got back. Her dad wasn’t so sure that it would work out
since she was 8 years younger than me and she intended to go off to the state college. We sure
did prove him wrong; we celebrated our 50th anniversary the week before Bessie died. The
ladies at the church had the hall all decorated up and we brought Bessie home from the hospital
for the afternoon. She was bound and determined to live for that day; no way did she want her
friends to go to that much work for her to not show up. I couldn’t believe it when the ladies had to
prepare for the reception after we buried Bessie in that same hall one week later. We had such a
good life together. That was 10 years ago.
I don’t do much of the farm work anymore. Our son Jon takes care of the crops and the few
animals we have. I still go out to the hen house every morning to collect the eggs. I’m a little stiff
in the morning, but I get loosened up enough to walk out to gather some fresh eggs to go with
my bacon for breakfast. I get in to town at least once a week; on Monday morning me and my
buddies meet at the VFW for our coffee and donut break. I get caught up on all the town gossip
and we laugh and bellyache about what’s going on in the world.
Three weeks ago, I celebrated my 80th birthday. My daughter in law, Judy, organized a big “to
do” at the church after the Sunday service with cake and ice cream and all the fixins’ for my
party. I had a big piece of cake but skipped the ice cream. Doc Baker was there and I knew he
would scold me about too much sugar. Six months ago he told me I had diabetes and I started
taking a pill for it, but a few weeks ago he put me on insulin. I figure I should be able to eat what
I want; come on, I’m not going to live forever, and it was my favorite cake, German chocolate. I
ate it in the kitchen so the Doc wouldn’t see me; wouldn’t you know, his office nurse Helen came
in the kitchen with a load of dishes just as I was putting the last bite in my mouth. She just
winked at me and smiled.
After the party I went out to the mall with Jon and the grandkids. I’m not one for shopping much,
but I needed a new ink cartridge for my printer and the computer store is the one place I like to
look around in. Too bad we parked clear on the other end of the mall so the kids could go by their
favorite stores for Grandpa to buy them a little something. Jon got real mad at me when I asked if
I could sit and rest for a while, so I just kept walking. I guess my new shoes were a little tight; I
didn’t feel anything but when I got home there was some blood on my sock, and then I saw a
sore on my big toe. It must not be too bad since it’s not hurting except when I try to put my shoes
on.
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Image #1
I showed the sore to Jon and Judy the other day and Judy said she would call the doctor to see
what she should put on it. Jon gets so irritated when I need extra help; I hope I can just continue
to soak my foot in hot water to clean it out. Judy was a nursing assistant out at the old folk’s home
for many years; I’m hoping she will be able to help me with this. I like the idea of the home nurses
coming out here as long as my VA benefits pay for it. That way they can see that I’m doing just
fine living here on my own.
I was searching on the Internet for the best way to treat this sore; there are so many sites that
talk about foot sores if you’re a diabetic. Some of those pictures are pretty scary; I can’t sleep
at night thinking about what could happen if this doesn’t heal. Of course I haven’t slept
through the night for years. Even the couple of beers I have at night when I’m on the computer
don’t seem to be helping anymore. Judy sometimes gives the kids Benadryl to help them
sleep so I’ve been taking a couple when I go to bed; they seem to help me sleep a little better.
As a matter of fact, I need to wrap this up now. I promised Jack, my grandson in college, that
I’d Skype him in a few minutes. He just started the agronomy program at the university. I love
to hear about what he’s learning and give him encouragement to come back to the farm.
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Registered Nurse’s History and Subjective Assessment of Red Yoder
RN’s assessment notes:
Mr. Yoder has a steady gait but admits he has fallen several times in the last couple of months
when he gets up too fast. “I just can’t remember to rise slowing. By the time I feel woozy, it is too
late, and I can’t stop myself from falling. I don’t let me son know this though, he gets upset when I
can’t do things by myself, like stand up!”
Mr. Yoder also admits he must use a shower chair off and on when he is “feeling tire at the end of
the day”. He confides that he does not let anyone know this either, since he knows it would upset
his son. He states he has started putting on clothes that are “easy to pull on or off”. He is
concerned about being incontinent of urine and “just not being able to make it to the bathroom in
time since they did that surgery on my prostate”. He states, it is embarrassing when I can’t make it
to the bathroom in time, because Judy, my daughter-in-law, washes my clothes and she knows I
am having problems “holding my water”.
Mr. Yoder states, he does a lot of microwave cooking, simple things that he can fix quickly or just
open the can and heat up. He states, Judy brings over casseroles so I can just heat them up too,
that way I am not tired out from standing at the stove. When asked what his normal meals consist
of, he states the following:
Breakfast every morning – bacon and eggs, 2 pieces of wheat toast with sugar free jelly.
Lunch – bologna sandwich, glass of milk and bag of baked potato chips
Supper – casseroles that Judy brings over or a can of soup.
He also adds, “I prick my finger about once a week, or if I’m not feeling good. It is usually around
120-130.”
When assessing Mr. Yoder’s sleep pattern, he gave the following information: he goes to bed at
9:00 each night, takes about an hour to fall asleep, gets up at 5:00 in the morning. He states, he
normally gets between five (5) or six (6) hours of sleep per night. He normally cannot get to sleep
for what seems like “hours, a couple of times a week.” He wakes up in the middle of the night to
use the bathroom. He rates is sleep as “fairly bad”. When asked if he does anything to help him fall
asleep, he states, “Judy gives Benadryl to her kids sometimes to help them sleep, so I decided to
try it too. I figure it can’t hurt, right?” He says, “for the last three weeks, I have been taking two
Benadryl before going to bed at night”. He also states he drinks a couple of beers before going to
bed to help him relax and get to sleep.
Current Medications:
“Tylenol for knee or back pain”
“One baby aspirin every day”
“Multivitamin every day”
Lantus 20 units subQ every morning
Vital Signs
Temperature 98.4 F oral
Pulse 77 and regular
Respirations 14 and regular
BP 133/77
Glucose – 190 mg/dL
Neuro Status - Able to answer all assessment questions appropriately
Skin Assessment - see above (Picture, monologue script and RN’s assessment data.)
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PART 2
Red Yoder Second Monologue Script
Occurs two weeks later
“As much as I hate to miss it, I don’t think I’ll go into town today. I never miss Monday morning
coffee at the VFW with my buddies. Sometimes my friends worry about me; they will probably
wonder where I am. I know it’s only 20 miles, but I just haven’t felt like eating the last couple of
days; maybe I’ve got the flu that’s going around. I’m not sure if I should take my insulin because
I’m not eating, but my blood sugar was 203 when I poked my finger this morning. How can that
be when I’m not eating?
Wow! I just took of my sock to check on my sore and my whole foot is red and big. I haven’t
looked at it for a few days; it was just a little pink the last time I checked it. I should have paid
closer attention to those pills I was supposed to take, that antibiotic. The nurse wanted to make
sure I didn’t get an infection in that toe. She comes tomorrow to change the bandage; I’d better
make sure to take the antibiotic today.”
Image #2
Mr. Yoder’s son Jon stopped by to check on Red after one of his friends from the VFW called to
say that Red didn’t make it for coffee. Red looks flushed and is confused. Jon calls Red’s doctor.
The nearest VA hospital is over 100 miles away and the doctor told him that Red needed to be
seen immediately. Jon takes his father to the Emergency Department (ED).
You are Mr. Yoder’s nurse in the ED. Please use the above image for your wound assessment.
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Below is his assessment.
ED Vital Signs on March 29, 2021 at 1330
TEMP 101.1 F oral
HR 110 bpm
RR 22 bpm
BP 109/55
Last home Glucose check on March 29, 2021 at 1130.
230 mg/dL
New Lab Diagnostics
Diagnostic Date and Time 3/29/2021 at 1345
Patient Name
Yoder, Sherman
Type
Result Name
Result
Complete Blood
WBC (10 x 3/uL)
12,000 mm3
Count w/o
Differential
RBC (mill/cumm)
Hemoglobin (gm/dL)
14.4gm/dL
Hematocrit (%)
43.1 gm/dL
MCL (fL)
MCH (pg)
MCHC (gm/dL)
RDW (%)
Basic Metabolic
Panel
Platelet Count
(1000/mm3)
Mean Platelet
Volume (MPV) (fL)
Sodium (mEq/L)
290mm3
Potassium (mEq/L)
4.0mEq/L
Chloride (mEq/L)
101mEq/L
CO2 (mEq/L)
CO2 26
Glucose (mg/dL)
260mg/dL
Blood Urea Nitrogen
(mg/dL)
Creatinine (mg/dL)
10mg/dL
Calcium (mg/dL)
9.0mg/dL
149mEq/L
0.7mg/dL
Flag
Normal/High/Lo
w
Reference Ranges
4.0-9.0
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
w
Normal/High/Lo
3.90-4.98
12.0-15.5
35-45
81-93
28-35
33-37
11.4-15.2
140-400
6.0-11.1
135-145
3.5-5.1
98-107
22-29
70-99
6-20
0.50-1.00
8.4-10.5
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HbA1c
Glycohemoglobin (%)
9.7
w
Normal/High/Lo
w
0.0-6.4
Mentation
Patient is oriented to self and needs frequent reorientation for place, time, and situation.
Right Lower Extremity
Right foot is warm to touch
Please provide remaining assessment data from image #2. Compare this image to image #1.
Part II: Critical Thinking Questions
Please type your answers on this document and return this document to your instructor as an
attachment. Support your answers with information from this case study and your course
resources.
1. What factors contributed toward a change in Mr. Yoder’s physical condition?
o Tight fitting shoes. People with diabetes have an increased risk of developing major
foot problems thus properly fitting shoes are very important. In this case, the patient
wore shoes that were too tight for him which caused rubbing.
o Mr. Yoder does not check his blood sugar as often as he should. He states that he
only checks it about once a week of if he is not feeling well but, he should be
checking it daily. This way he knows whether blood sugar is too high or too low and
take the proper steps when managing these levels.
o His diet is poor. He often eats microwave meals which are usually high in sodium
(salt). Later, he discussed that he loss his appetite and stopped eating. Skipping
meals can have dangerous effects on blood sugar levels hence why his jumped up.
o He drinks alcohol (several drinks) every night. Alcohol impacts the functioning of the
liver and the liver helps with regulating blood sugar. Alcohol can interact with meds
causing you blood sugar to increase or decrease.
o Having not been taking antibiotic to prevent infection. He developed an infection
because he did not bother to take antibiotics. He also was not checking and taking
care of his feet like he should.
2. What factors contributed toward a change in Mr. Yoder’s mentation?
o Elevated high blood sugar levels can cause confusion. High blood sugar can lead to
confusion because it damages blood vessels, which will result in poor circulation.
Low blood levels can also cause confusion. This will mean there is insufficient blood
circulation in the brain.
o Infection can cause blood sugar to rise as well. Confusion and decreased alertness
are symptoms of infections.
3. Is your nursing diagnosis for Part I of this case study, still relevant? Why or why not?
Yes, the diagnosis is still relevant because his condition has worsened it has not been
resolved.
o Ineffective Health Maintenance related to Lack of knowledge about the disease
process as evidence by deteriorating health status.
o Hyperthermia related to infection as evidence by temperature 101.1 orally, Heart
rate of 110, and respiratory rate of 22.
Subjective date: patient states He just have not felt like eating the last couple of days;
maybe I have got the flu that is going around.
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Objective date: Right foot warm to touch. Looks flushed and is confused.
Patient is oriented to self and needs frequent reorientation for place, time, and situation.
Lab results indicates elevated WBC count.
Outcome: Pt’s temperature will between 97.8-98.6 within 24 hours of hospitalization.
Interventions: Take temperature every 1 to 4 hours. The nurse will encourage and offer oral
fluid intake every two hours to the patient. Monitor heart rate and rhythm, blood pressure
and respiratory rate every 1 to 4 hours.
4. What is the significance of the change in vital signs? Explain your answer.
Showed that his blood glucose levels increased significantly.
His temperature has become elevated which is a sign of infection.
Heart rate is high which could indicate sepsis. Blood flow decreases to organs which cause
the heart to try to compensate by working harder.
His blood pressure dropped which could indicate sepsis as well. Cytokines are released to
help the body fight infection but can cause blood vessels to dilate decreasing blood
pressure.
5. What orders do you anticipate from the ED physician? Why?
Antibiotic therapy to treat infection that developed.
Intravenous fluids can be given.
Vasopressors- This drug constricts blood vessels and helps increase blood pressure.
6. Are there any significant lab results? Please identify any abnormal labs and what they
indicate.
Sodium level slightly elevated at 149: Indicate that he could not be getting enough fluids
and eating too much salt.
Glycohemoglobin levels are elevated: Indicates that there has been too much sugar in
blood for an extended period. The higher the levels the poorer your blood sugar control and
you are at higher risk of diabetes complications.
Elevated white blood cell could indicate that his body is fighting off an infection.
7. Are there any missing diagnostics that you would like to see? Why?
I would like to see previous lab values specially with his glycohemoglobin levels to compare
results. This could be his normal levels.
8. Collaboration is an essential component of positive patient outcomes. What
interprofessional team members should be involved in Mr. Yoder’s care, and why?
primary care physician, a specialist in emergency medicine, nurse, pharmacist, respiratory
therapists, dieticians, Occupational therapists. They all can work together to treat and
manage is diagnosis. Nurse can continuously monitor, physician can provide orders,
Pharmacist can validate medications, dietician can monitor and create an appropriate diet
for the patient.
9. Go back to Part 1. Evaluate the priority nursing diagnose you identified in question 3. Has
the outcome been met? If not, what revisions are needed to help meet this outcome?
My first diagnosis impaired skin integrity outcome has not been met. Mr. Yoder would need to be
educated on proper wound care.
Communication
Mr. Yoder is admitted to the medical unit and you need to give report to the receiving RN. Please
write and SBAR report for the transfer from the ED to the medical floor. Add your SBAR report
below.
S: Yoder is an 80 yr. old male that was admitted for an infected diabetic ulcer on his right foot and
uncontrolled Type 2 diabetes.
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B: Patient son states that Mr. Yoder looked flushed and is confused when visiting
him earlier. Ulcer developed 3 weeks ago due to ill fitting shoes. Yoder has been treating himself
and not taking his prescribed antibiotics. He was diagnosed with type 2 diabetes in 2019.
A: Current vitals are:
TEMP 101.1 F oral
HR 110 bpm
RR 22 bpm
BP 109/55
Previous vitals are:
Temperature 98.4 F oral
Pulse 77 and regular
Respirations 14 and regular
BP 133/77
Patients right foot is warm to touch, and foot is red and swollen.
Lab results show that is WBC Count is 12,000, glucose levels are 260, and Glycohemoglobin
levels are 9.7.
R: I recommend that you come see the patient.
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