Case Study #1
Critical Thinking
1. You are a cardiac nurse with 12 years’ floor experience, caring for a patient who is 2
days postoperative extensive cardiac bypass. The previous shift’s nurse reports that the
patient was resting comfortably---an unremarkable shift. As you begin your first
assessment, “something” prompts you that this could be an eventful shift with this
patient. The patient is off the ventilator, conversing with you and his family. Everything
seems to be fine, but you just can’t get rid of the feeling that something may happen.
a. What data in this scenario are pertinent? The patient is on his second day after
a major cardiac bypass surgery and he is off the ventilator and making
conversation.
b. How would you explain the “something” that is giving you pause regarding the
patient’s condition? Contrast this experience with the other two approaches to
problem solving. This feeling that the nurse is getting could be derived from the
important creative thinking skill which involves imagination, intuition, and
spontaneity based on knowledge, skill and experience. (chp. 13 pg. 315) She is
getting this feeling based on her intuition. This differs from Trial and error
problem solving because this involves testing any number of solutions until one
is found that works for any particular problem which is dangerous to the patient.
(chp. 13 pg. 315) Creative Thinking also differs from scientific problem solving
because this form of problem solving is a systemic, seven step problem solving
process which is typically formed by facts and evidence. (chp. 13 pg. 315) Using
critical thinking which is a form of intuitive problem solving based on background
knowledge and skill naturally comes to you when you feel something is not
following the proper course or action or may eventually lead to a problem.
c. What steps could you take in response to your inkling? I would closely monitor
the patient and the patients’ vitals, most importantly their blood pressure, heart
rate, and cardiac output.
d. Where could you find help in your situation? The nurse could find help by
letting the patients’ care team as well as his primary cardiologist know about his
status and ensure that the other nurses that may come later in the evening know
about the concern as well. This will allow the other nurses to keep monitoring
him throughout the night.
Nursing Process - Assessment
2. You are a nurse admitting a patient to the hospital from the emergency department
(ED) with shortness of breath and recent weight loss. After receiving a report from the
ED nurse, you ready the patient’s room according to unit specifications and collect the
necessary equipment and forms. When the patient arrives, she is using oxygen via a
nasal cannula and seems to be comfortable. As you begin your admission activities and
paperwork, you note that her shortness of breath slightly increases as she answers your
questions.
a. What data in the scenario are pertinent? The data in the scenario that is
pertinent is the shortness of breath and recent weight loss, the oxygen via a
nasal cannula and that the patient's shortness of breath slightly increases when
speaking. This is important because the data can reflect how health function can
be compromised by illness and injury. (chp. 14 pg. 334)
b. What type of nursing assessment would you expect to complete and why? I
would expect to complete a focused assessment because the patient seems to
have trouble breathing. Focused assessments are often used to gather data
about a specific problem which has already been identified which is why this is
the type of assessment that should be used. (chp. 14 pg. 339)
c. Why would you need to establish assessment priorities? The ABCDE assessment
approach would be a good way to establish patient priorities because it can be
used for most emergency situations. In this situation, it would be important to
prioritize the Airway, Breathing, and Circulation and assess those areas
immediately to see if that is why the patient is experiencing shortness of breath.
It is important to establish assessment priorities so that a successful care plan
can be made. (Chp. 14 pg. 342)
d. What patient factors would assist in identifying and prioritizing data? Some
patient factors that would assist in identifying and prioritizing the data would be
to find out if the patient intentionally meant to lose weight and if they have a
preexisting lung condition due to the fact that the patient looked comfortable
and familiar with the nasal cannula.
e. What challenges might the nurse encounter during data collection? Some
challenges the nurse might encounter would be that it may be difficult for the
patient to be the primary source of data intake. (chp. 14 pg. 347) Due to the
patient's throat constricting when she speaks resulting in the shortness of breath
worsening, it may be better if she does not answer many questions.
Diagnosis
3. You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The
patient is a 71-year-old man who underwent a surgical repair of a fractured femur. As
you receive a report from the postanesthesia recovery unit, you learn that his medical
history includes hypertension, 40 pack-years of smoking, and COPD. His surgical repair
was successful but complicated by excessive bleeding, and he is receiving IV fluids to
compensate. He is widowed, and his three children are scattered throughout the United
States. He lives alone, receives Meals on Wheels, and pays a cleaning service to keep his
home clean.
a. What potential collaborative problem(s) could be applicable in this situation? A
collaborative problem is a certain physiologic complication that nurses monitor
to detect onset or changes in status. (chp. 15 pg. 364) A collaborative problem
that could be applicable in this situation would be that his medical history
includes hypertension and COPD which could result in a stroke or heart attack.
Another collaborative problem would be his excessive bleeding which could lead
to organ failure.
b. Which nursing diagnoses would you expect to be applicable regarding the
medical procedures in this situation? Nursing diagnoses focus on unhealthy
responses to health and illness. (chp. 15 pg. 364) A nursing diagnosis that would
be applicable regarding the medical procedure would be the risk of a
hemorrhage and risk of infection or post-surgical complications due to smoking.
Another nursing diagnosis could be risk of falling due to old age.
c. Which nursing diagnoses would you expect to be applicable regarding the
nursing/medical history in this situation? A nursing diagnosis that would be
applicable regarding the nursing/medical history would be the risk of anemia due
to the excessive blood loss. His history of hypertension and COPD as well as
stress due to surgery may lead to a heart attack, stroke, or flare ups of his
preexisting COPD.
d. Which nursing diagnoses would you expect to be applicable regarding the
discharge planning in this situation? A nursing diagnosis that would be
applicable regarding the discharge planning would be the risk of the bone not
healing correctly due to his age. Another nursing diagnosis would be risk of injury
due to him being on his own with no support.
Planning
4. You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The
patient is a 71-year-old man who underwent a surgical repair of a fractured femur. As
you receive a report from the postanesthesia recovery unit, you learn that his medical
history includes hypertension, 40 pack-years of smoking, and COPD. His surgical repair
was successful but complicated by excessive bleeding, and he is receiving IV fluids to
compensate. He is widowed, and his three children are scattered throughout the United
States. He lives alone, receives Meals on Wheels, and pays a cleaning service to keep his
home clean.
a. What general priorities would you expect to establish from this information?
This information would allow me to begin the “initial planning” stage of care
planning. (chp. 16 pg. 389) I would make mental and documented notes of
b.
c.
d.
e.
general priorities such as maintaining the surgical wound and dressing, being
mindful of his age due to the risk of falling, and make sure to monitor his vitals
due to his hypertension, COPD, and excessive bleeding.
What might you identify as expected patient outcomes in this case? I would
identify the expected patient outcome feeling optimistic for a full recovery with
little to no complications but will be prepared in case there are complications
related to both his past health history and/or current complications due to the
surgery.
What information would be included in evidence-based nursing interventions?
A nursing intervention is any treatment based upon clinical judgment and
knowledge that a nurse performs to enhance patient/client outcome. (chp. 16
pg. 394) I think it would be important to include his history of heavy smoking,
hypertension, COPD, excessive blood loss and his lonely status. These are
important variables that should be planned out to “promote higher-level
wellness” and ensure the patient is monitored relatively frequently. (chp. 16 pg.
394) All of these variables lead to many potential risks such as heart attack,
stroke, or anemia.
How would you evaluate the outcome of your interventions in this case? I
would evaluate the outcome of my interventions by taking blood and monitoring
the hemoglobin levels to regulate the risk of anemia due to the blood loss. I
would also make sure to strictly monitor the patient's vitals such as blood
pressure, heart rate, and cardiac output due to the hypertension. I would also
make sure to monitor the respiratory rate due to his COPD.
What are the challenges related to developing a formal care plan? Some
challenges related to developing a formal care plan include his age due to the
risk of bone healing incorrectly and his history of hypertension and COPD which
put him at a life threatening risk.
Implementation
5. You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The
patient is a 71-year-old man who underwent a surgical repair of a fractured femur. As
you receive a report from the postanesthesia recovery unit, you learn that his medical
history includes hypertension, 40 pack-years of smoking, and COPD. His surgical repair
was successful but complicated by excessive bleeding, and he is receiving IV fluids to
compensate. He is widowed, and his three children are scattered throughout the United
States. He lives alone, receives Meals on Wheels, and pays a cleaning service to keep his
home clean. (Learning Objectives 3, 4, and 8)
a. What general priorities would you expect to establish from this information?
One of my priorities would be to eliminate the risk of infection by checking on
the surgical wound and dressing to ensure it is protected and not releasing
colored discharge. I would also make sure to keep the bars on the bed up and
b.
c.
d.
e.
the bed at a low level due to his age and the risk of falling. I would also make
sure that the patient is comfortable so he can better adjust to his altered
functioning. I would also strictly check his vitals every 20 minutes for the first few
hours he is there due to his past medical history of COPD and hypertension. I
would make these my priorities to “promote health, prevent disease and illness,
restore health and facilitate coping with altered functioning.” (chp. 17 pg. 413)
What might you identify as expected patient outcomes in this case? I would use
my specialized abilities to determine the patient's new or continuing need for
nursing assistance and assist the patient to achieve a valued health outcome.
(chp. 17 pg. 419) In this case with the interventions, I would expect the patient
to maintain healthy vitals, have little to no risk of infection and have a smooth
recovery process.
What information would be included in evidence-based nursing interventions?
I would include his history of heavy smoking, hypertension, COPD, excessive
blood loss and his lonely status.
How would you evaluate the outcome of your interventions in this case? I
would reassess the patient and review my plan on care to ensure a positive
outcome. (chp. 17 pg. 419
What are the challenges related to developing a formal care plan? Some
challenges related to developing a formal care plan for the patient include his
age due to the risk of bone healing incorrectly and being at higher risk of falling.
Also, his history of hypertension and COPD which put him at a life threatening
risk.
Evaluation
6. You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The
patient is a 71-year-old man who underwent a surgical repair of a fractured femur. As
you receive a report from the postanesthesia recovery unit, you learn that his medical
history includes hypertension, 40 pack-years of smoking, and COPD. His surgical repair
was successful but complicated by excessive bleeding, and he is receiving IV fluids to
compensate. He is widowed, and his three children are scattered throughout the United
States. He lives alone, receives Meals on Wheels, and pays a cleaning service to keep his
home clean. (Learning Objectives 3, 4, and 8)
a. What general outcomes would you expect to establish from this information?
After following and implementing the care plan, I would expect a smooth
recovery with little to no complications.
b. List potential care plan revisions available to nurses. Some potential care plan
revisions available to nurses include modifying the nursing diagnosis, making the
outcome more realistic, and changing nursing interventions. (chp. 18 pg. 435)
c. To effect performance improvement in nursing, what steps are necessary in the
process? To improve performance it is necessary to “discover a problem, plan a
strategy using indicators, implement a change, and assess the change and if the
outcome is not met, plan a new strategy.” (chp 18. pg. 442)
d. Health care facilities and organizations implement programs to promote
excellence in nursing that are called quality-assurance programs. How do these
programs work? “These programs allow nurses to be accountable to society for
the quality of nursing care. They ensure survival of the profession, encourage
nursing;s fidelity to its moral and ethical responsibilities, and assist nursing to
comply with other external pressures.” (chp. 18 pg. 445)
Documentation
1. You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The
patient is a 12-year-old boy who underwent an emergency appendectomy. According to the
report, his appendix ruptured and significant actions were performed to decrease the
chances of his developing peritonitis. Upon arrival to your unit, you perform your initial
assessment, including the wound site. After completing your assessment and performing
the immediate postoperative orders the health care provider wrote, you return to offering
nursing care to the rest of the patients on your team.
a. Which topics would you expect to include in your documentation from this case? I
would include the patient record which is a compilation of a patient's health
information, the information and data I gathered from assessing the patient and my
nursing patient care plan. (chp. 19 pg. 453)
b. When would you expect to record your documentation? Due to often meaningless
or inaccurate entries being common, I would record my documentation immediately
after assessing and checking on the patient to ensure I do not forget any
information. (chp. 19 pg. 453)
c. How often would you collect data (perform assessments) from the patient? When
the patient first arrives in the unit you should perform more routine assessments
but when they are there over a specific amount of time you can check on them
every so often as long as you make sure to keep track of their vital signs.
d. Where would you expect to find pertinent information regarding the patient’s
surgery and interventions performed during surgery? Due to the importance of
documenting everything that happens in the medical field, I would expect to find
pertinent information in the surgical notes regarding information about the surgery
and interventions performed during the surgery.
e. Regarding confidentiality, what information can be shared with classmates?
Describe the criteria and purpose for sharing patient information with others.
Most facilities grant student access to patient records for educational purposes but
those students must keep the patient information confidential. (chp. 19 pg. 453) You
should not share patient information with classmates unless they have access to the
patients files as well. If you are collaborating with a student to come up with a
course of action for a specific patient you both are assigned to then you can speak
about the patient’s file.