Nursing Case Study
1. Suzanne Jones, 76-year-old patient with COPD is admitted to the ICU. Mrs. Jones is placed on mechanical ventilation to assist with her breathing. After 2 days on the ventilator, Mrs. Jones is extubated and then transferred to a medical-surgical unit. The medication regimen is adjusted during the hospitalization. Mrs. Jones is discharged home after 6 days. She and her family are pleased with the care she receive in the hospital. (Learning Objectives 3 and 6)
a. Describe the quality performance tools that may be used to demonstrate that the care and treatment rendered are both cost-efficient and of high quality.
b. Describe the quality performance tools that may be used to demonstrate that the nursing care utilized is evidence-based care and high quality, resulting in patient satisfaction and good patient outcomes.
2. The registered nurse working in the cardiac care clinic is tasked with implementing quality improvement measures. To educate the clinic staff, the nurse plans an in-service program to introduce concepts of quality improvement and evidence-based practice. Additionally, the role of the case manager will be included in the presentation. The nurse plans on using care of the patient with Congestive Heart Failure as a template, and prepares sample clinical pathways, care maps, and multidisciplinary action plans. (Learning Objective 3)
a. Describe how clinical pathways are used to coordinate care of caseloads of patients.
b. What is the role of the case manager in evaluating a patient’s progress?
c. What are examples of evidence-based practice tools used for planning patient care?
3. Mr. Jones, who is 74 years of age, is being discharged home after having a right knee replacement. The discharge orders from the orthopedic surgeon include: continuous passive motion (CPM) at the current setting of 0-degrees extension worn when walking with crutches (nonweight-bearing postdischarge day 1, and may begin weight-bearing postdischarge day 2); and home nurse visits, as needed. Physical therapy should begin the day after discharge at an orthopedic center. The orders will be faxed to the center. The following medications with prescriptions attached include: Lovenox (enoxaparin) 70 mg subcutaneously once daily for 7 days, Vicodin (hydrocodone bitartrate) 10 mg every 4 hours PRN, and Colace (docusate sodium) 100 mg every day. The patient is to follow up with the orthopedic surgeon in 3 weeks. His daughter plans to stay with him for several weeks to assist him with meals and household chores, and take him to physical therapy and the orthopedic surgeon for follow-up. Mr. Jones has three other children who live in other states. He is a widower and attends a local church. (Learning Objective 4)
a. What preparations should the nurse make in advance before attaining necessary community resources and referrals before the patient is discharged?
1. What necessary community resources and referrals will the patient need?
4. Mrs. Johnson, a 67-year-old female patient, has recently been discharged from the hospital following an admission for COPD. She has a past medical history of a colon resection related to acute diverticulitis. She developed a surgical wound infection that requires daily wet to dry wound packing and IV Zosyn. Mrs. Johnson was discharged with home oxygen. To manage her care at home, home care visits were ordered. (Learning Objective 5)
a. What would be involved in setting up the first home care visit?
1. Describe the nursing assessments and management that would occur during the visit.
5. Mrs. Elle, 80 years of age, is a female patient who is diagnosed with end-stage cancer of the small intestine. She is currently receiving comfort measures only in hospice. She has gangrene of her right foot and has a history of diabetes controlled with oral agents. She is confused and the physician has determined that she is unable to make her own informed decisions. The hospice nurse, not realizing that the weekly order for CBC and renal profile had been discontinued, obtained the labs and sent them to the nearby laboratory for processing. The abnormal lab results obtained later that day revealed that the patient needed a blood transfusion. The hospice nurse updated the patient’s medical power of attorney who was distressed at the report. The patient’s wishes were to die peacefully and to not have to undergo an amputation of her right foot. But if the patient receives the blood transfusion, she may live long enough to need the amputation. The patient’s physician had previously informed the medical power of attorney that the patient would most likely not be able to survive the amputation. The patient’s medical power of attorney had made the request to cease all labs so that the patient would receive comfort measures until she died. The patient has no complaint of shortness of breath or discomfort. (Learning Objective 4)
a. What ethical dilemma exists?
1. Who are the stakeholders and what gains or losses do each have?
1. What strategies should the hospice nurse take to resolve the ethical dilemma?
6. The nurse receives a 12-year-old girl from the operating room after an emergent appendectomy due to ruptured appendix. Upon arrival to the postanesthesia care unit, the patient is drowsy, but arousable to voice; she was extubated in the operating room and is receiving oxygen by facemask at 40%. She has two peripheral IVs in her left arm that are infusing Lactated Ringers solution at 100 mL/hr. A nasogastric tube is attached to low constant suction, and a small amount of aspirate is noted. She has a urinary catheter that is draining clear, yellow urine. Her abdominal dressing is dry and intact. Upon arousal, she complains of abdominal pain. (Learning Objective 5)
a. What NANDA-approved nursing diagnoses may be relevant to this patient?
1. Once the nursing diagnoses are determined, what steps does the nurse take to complete the Planning Phase of the Nursing Process?
1. What is the difference between nursing diagnoses and collaborative problems?
Case Study, Chapter 4, Health Education and Health Promotion
7. Mr. Smith, a 57-year-old patient, presents at a health fair asking questions about the age-appropriate health maintenance and promotion considerations he should be concerned about. He stated that he only goes to his physician when he is sick and the last time he saw his physician was 2 years ago when he had a sinus infection. (Learning Objectives 7 to 9)
a. What further assessment does the nurse need to make before designing a teaching plan?
1. What topics does the nurse need to include for Mr. Smith based on current medical recommendations?
1. Design a teaching plan that covers the topics.
8. The community health nurse is planning a health promotion workshop for a high school PTSO (Parent-Teacher-Student Organization). The choice of topics was suggested by the high school’s registered nurse who has observed a gradual increase in student obesity. The two nurses have collaborated to develop this workshop to provide parents, students, and teachers with information about the importance of health promotion. (Learning Objectives 6, 8, and 9)
a. Describe the importance of a focus on health promotion.
1. According to the health promotion model developed by Becker (1993), what four variables influence the selection and use of health promotion behaviors?
1. Describe four components of health promotion.
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