Nursing Case Study
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PRIORITY Patient Activity
Part I: Who does the nurse see first?
Herbie Saunders, 62 years old David Mueller, 71 years old Gladys Parker, 92 years old
CHF Exacerbation Below-the-Knee Amputation Weakness and Falls
NCLEX Client Need Categories Percentage of Items from Each
Category/Subcategory
Covered in
Case Study
Safe and Effective Care Environment
✓ Management of Care 17-23% ✓
✓ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12%
Physiological Integrity
✓ Basic Care and Comfort 6-12%
✓ Pharmacological and Parenteral Therapies 12-18%
✓ Reduction of Risk Potential 9-15% ✓
✓ Physiological Adaptation 11-17% ✓
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transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of KeithRN
Part I-Patient Care Scenarios
NOC Nurse Report
Patient #1: Herbie Saunders
What Do You Notice?
“Herbie Saunders is a 62-year-old male who came in last
night for a CHF exacerbation. His doctor is Dr. Davis
and he’s a full code. He’s alert and oriented and can
make his needs known. He’s on tele, normal sinus
rhythm with occasional PVCs. His pressures are fine,
heart rate is in the 70s. Lungs are clear in the uppers with
crackles in the bases.
He’s coughing up a small amount of white frothy
secretions. He’s been on room air since he arrived,
oxygen sats are in the low-mid 90s. He got 40 mg IV
Lasix last night in the ED; I think you might have
something scheduled during your shift but I haven’t
given anything overnight. He has a 20 gauge in his right
forearm. I’m not sure how he gets around since he’s been
in bed since he got here.”
Most Recent Vital Signs @ 0357 What Do You Notice? Clinical Significance:
T: 98.6 F (oral)
P: 76
R: 20
BP: 128/87 (MAP 101 mmHg)
O2 sat: 92% on room air
Pain: denies
Admission
196 lb (89.1 kg)
In one sentence, describe the ESSENCE of the patient scenario that will guide your plan of care?
What questions do you have for the nurse?
You are the RN on a busy medical-surgical/telemetry floor at Anytown General
Hospital. Each nurse on your unit typically cares for 3-5 patients.
You have just arrived for your day shift and are receiving nurse-to-nurse reports
from three different night shift nurses. After you receive reports, you will have
an opportunity to review the current orders for each of your patients.
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transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of KeithRN
Review Current Orders
Patient #1: Herbie Saunders
Q4H with telemetry and continuous pulse oximetry
Weight: Daily
I&O: Strict I&O Q8H
Supplemental oxygen to keeps sats >90%
Fingerstick blood glucose QID
Hypoglycemia protocol (includes PRN orders for glucose and dextrose)
Activity: ad lib
Diet: 2gm Na
Notify MD if temp >100.4, HR <40 or >120, RR <8 or >26, BP <90 or >180 or O2 <90%
sustained with supplemental oxygen
0800
0900
1200
1300
insulin aspart per sliding scale subq TID with meals
aspirin 81 mg PO daily
lisinopril 5 mg PO daily
metoprolol 25 mg PO BID
insulin glargine 20 units subq daily
furosemide 40 mg IV push BID
insulin aspart per sliding scale subq TID with meals
saline flush 10 ml IV TID
furosemide 40 mg IV push BID
Echocardiogram, on-call
BMP + Mg, drawn but not yet resulted
Complete Blood Count (CBC) – Yesterday @1730
WBC HGB Hct PLTs
7.9 13.4 45 186
Basic Metabolic Panel (BMP) + Mg – Yesterday @ 1730
Na K Cl CO2 BUN Creat. Gluc Mg
141 3.6 103 26 16 1.1 132 2.0
Basic Metabolic Panel (BMP) + Mg – Today @ 0530
Na K Cl CO2 BUN Creat. Gluc Mg
collected collected collected collected collected collected collected collected
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transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of KeithRN
NOC Nurse Report
Patient #2: David Mueller
Patient Report: What Do You Notice? Clinical Significance:
“David Mueller is 72 years old, here for a right
BKA. He is Dr. Snyder’s patient. Vitals are fine,
he’s not on telemetry. Lungs are clear, he’s on
room air. I think he still has an 18 gauge in his left
a/c but I didn’t get a chance to flush it because he
was sleeping most of the night.
His finger sticks have been in the high 200s and he
gets a sliding scale. That’s really all I have for him.
I was so busy last night with a new admission and
another patient who was on the call light all night
long.”
Most Recent Vital Signs @ 0412 What Do You Notice? Clinical Significance:
T: 98.9 F (oral)
P: 96
R: 16
BP: 110/82 (MAP 91 mmHg)
O2 sat: 95% on room air
Pain: 2/10
Admission Weight: 202 lbs (91.8 kg)
In one sentence, describe the ESSENCE of the patient scenario that will guide your plan of care?
What questions do you have for the nurse?
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transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of KeithRN
Review Current Orders
Patient #2: David Mueller
Vital Signs: Q8H, does not require telemetry or continuous oximetry
Weight: n/a
I&O: n/a
General Orders: Fingerstick blood glucose QID
Hypoglycemia protocol (includes PRN orders for glucose and dextrose)
Dressing change to be completed by orthopedic surgery team. If dressing is saturated, reinforce
and notify attending or on-call surgeon after hours.
Elevate right leg
Activity: with assistance, out of bed for meals
Diet: Diabetic 2 gm na
Notify MD if temp >100.4, HR <40 or >120, RR <8 or >26, BP <90 or >180 or O2 <90% sustained with supplemental oxygen
Medications: 0800
0900
1200
1300
PRN
insulin aspart per sliding scale, subq TID with meals
acetaminophen 650 mg PO QID
amlodipine 10 mg PO daily
fluoxetine 20 mg PO daily
gabapentin 300 mg PO TID
insulin aspart per sliding scale, subq TID with meals
acetaminophen 650 mg PO QID
gabapentin 300 mg PO TID
saline flush 10 ml IV TID
oxycodone 5 mg Q6H PRN for pain,
Diagnostics: No new labs ordered today
Physical Therapy at 0930
Occupational Therapy at 1400
Complete Blood Count (CBC) – Yesterday @0530
WBC HGB Hct PLTs
9.8 13.2 47 165
Basic Metabolic Panel (BMP) + Mg – Yesterday @ 0530
Na K Cl CO2 BUN Creat. Gluc Mg
140 4.1 104 28 10 0.9 224 2.1
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transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of KeithRN
NOC Nurse Report
Patient #3: Gladys Parker
Patient Report: What Do You Notice? Clinical Significance:
“Gladys Parker is a sweet little 92-year-old lady. She’s
here because she had a fall at her nursing home that
they think was due to dehydration and weakness. She
was admitted by the night float but Dr. Howard will
probably be her attending. She’s DNR/DNI. Alert to
self and place, but definitely disoriented to time and
situation. She’s really forgetful and doesn’t seem to
want to bother anyone so she hasn’t used her call light
all night. I’d guess she’s at least an assist of one for
transfers.
She’s on telemetry because her electrolytes were off
when she arrived. EKG showed Afib with a heart rate
in the 90s. Blood pressures are pretty soft, her systolic
blood pressures were in the low 90s for me. Lungs are
clear, she’s on room air. They put her on a mechanical
soft diet. She takes her pills whole in pudding or
applesauce. The nursing home said her last bowel
movement was 3 days ago and that she’s incontinent of
both bowel and bladder.
Her urine seems really concentrated and has a strong
odor. I noticed that there is still an outstanding order to
collect a UA but I couldn’t get one since she was
incontinent all night. Maybe you can address that with
the doctor today if they still want it. She’s got a 22
gauge in her left wrist with LR running at 100 mls/hr
for a total of one liter. I started that at 0200.”
Most Recent Vital Signs @0425 What Do You Notice? Clinical Significance:
T: 97.2 F (oral)
P: 92
R: 18
BP: 94/63 (MAP 73 mmHg)
O2 sat: 95% on room air
Pain: denies
Admission Weight: 117 lbs (53.2 kg)
In one sentence, describe the ESSENCE of the patient scenario that will guide your plan of care?
What questions do you have for the nurse?
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transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of KeithRN
Review Current Orders
Patient #3: Gladys Parker
Vital Signs: Q4H with telemetry, does not require continuous oximetry
Weight: upon admission
I&O: n/a
General Orders: Activity: with assistance, out of bed for meals
Notify MD if temp >100.4, HR <40 or >120, RR <8 or >26, BP <90 or >180 or O2 <90% sustained with supplemental oxygen
Medications: 0900
1300
Infusion
cholecalciferol 2000 units PO daily
docusate/senna 50/8.8 mg PO BID
donepezil 5 mg PO daily
metoprolol 12.5 mg PO BID
saline flush 10 ml IV TID
Lactated Ringer’s IV at 100 ml/hr for a total of one liter
Diagnostics: No new labs ordered today
Urinalysis/Urine Culture was ordered in ED but has not been collected
Physical Therapy consult pending
Occupational Therapy consult pending
Speech Therapy consult pending due to difficulty swallowing
Nutrition consult pending
Complete Blood Count (CBC) – Yesterday @2125
WBC HGB Hct PLTs
10.1 12.9 37 225
Basic Metabolic Panel (BMP) + Mg – Yesterday @ 2125
Na K Cl CO2 BUN Creat. Gluc Mg
144 3.3 103 23 19 1.4 93 1.5
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transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of KeithRN
Priority Setting: Who Do You See First?
What order are you going to see/assess your patients? Why?
Order of Priority: Rationale:
What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify top
three priority/focused assessments.
Patient #1:
PRIORITY Body System(s): PRIORITY Nursing Assessments:
Patient #2:
PRIORITY Body System(s): PRIORITY Nursing Assessments:
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transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
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Patient #3:
PRIORITY Body System(s): PRIORITY Nursing Assessments:
What order are you going to administer medications? Why?
Order of Priority: Rationale:
Your facility’s window for medication passes is within one hour of the scheduled time. Can you combine any
medication administrations to reduce the number of separate medication passes?
- Herbie Saunders 62 years old:
- NCLEX Client Need Categories:
- Safe and Effective Care Environment:
- Management of Care:
- Safety and Infection Control:
- 915:
- Health Promotion and Maintenance:
- Psychosocial Integrity:
- 612:
- Physiological Integrity:
- Basic Care and Comfort:
- 612_2:
- 1218:
- Reduction of Risk Potential:
- Physiological Adaptation:
- What Do You Notice:
- Most Recent Vital Signs 0357:
- What Do You Notice_2:
- Q4H with telemetry and continuous pulse oximetry:
- Daily:
- IO:
- Strict IO Q8H:
- insulin aspart per sliding scale subq TID with meals aspirin 81 mg PO daily lisinopril 5 mg PO daily metoprolol 25 mg PO BID insulin glargine 20 units subq daily furosemide 40 mg IV push BID insulin aspart per sliding scale subq TID with meals saline flush 10 ml IV TID furosemide 40 mg IV push BID:
- Echocardiogram oncall BMP Mg drawn but not yet resulted:
- Patient Report_2:
- What Do You Notice_3:
- Most Recent Vital Signs 0412:
- What Do You Notice_4:
- Vital Signs_2:
- Q8H does not require telemetry or continuous oximetry:
- Weight_2:
- na:
- IO_2:
- na_2:
- General Orders_2:
- Medications_2:
- insulin aspart per sliding scale subq TID with meals acetaminophen 650 mg PO QID amlodipine 10 mg PO daily fluoxetine 20 mg PO daily gabapentin 300 mg PO TID insulin aspart per sliding scale subq TID with meals acetaminophen 650 mg PO QID gabapentin 300 mg PO TID saline flush 10 ml IV TID oxycodone 5 mg Q6H PRN for pain:
- No new labs ordered today:
- Physical Therapy at 0930 Occupational Therapy at 1400:
- Patient Report_3:
- What Do You NoticeGladys Parker is a sweet little 92yearold lady Shes here because she had a fall at her nursing home that they think was due to dehydration and weakness She was admitted by the night float but Dr Howard will probably be her attending Shes DNRDNI Alert to self and place but definitely disoriented to time and situation Shes really forgetful and doesnt seem to want to bother anyone so she hasnt used her call light all night Id guess shes at least an assist of one for transfers Shes on telemetry because her electrolytes were off when she arrived EKG showed Afib with a heart rate in the 90s Blood pressures are pretty soft her systolic blood pressures were in the low 90s for me Lungs are clear shes on room air They put her on a mechanical soft diet She takes her pills whole in pudding or applesauce The nursing home said her last bowel movement was 3 days ago and that shes incontinent of both bowel and bladder Her urine seems really concentrated and has a strong odor I noticed that there is still an outstanding order to collect a UA but I couldnt get one since she was incontinent all night Maybe you can address that with the doctor today if they still want it Shes got a 22 gauge in her left wrist with LR running at 100 mlshr for a total of one liter I started that at 0200:
- Clinical SignificanceGladys Parker is a sweet little 92yearold lady Shes here because she had a fall at her nursing home that they think was due to dehydration and weakness She was admitted by the night float but Dr Howard will probably be her attending Shes DNRDNI Alert to self and place but definitely disoriented to time and situation Shes really forgetful and doesnt seem to want to bother anyone so she hasnt used her call light all night Id guess shes at least an assist of one for transfers Shes on telemetry because her electrolytes were off when she arrived EKG showed Afib with a heart rate in the 90s Blood pressures are pretty soft her systolic blood pressures were in the low 90s for me Lungs are clear shes on room air They put her on a mechanical soft diet She takes her pills whole in pudding or applesauce The nursing home said her last bowel movement was 3 days ago and that shes incontinent of both bowel and bladder Her urine seems really concentrated and has a strong odor I noticed that there is still an outstanding order to collect a UA but I couldnt get one since she was incontinent all night Maybe you can address that with the doctor today if they still want it Shes got a 22 gauge in her left wrist with LR running at 100 mlshr for a total of one liter I started that at 0200:
- Most Recent Vital Signs 0425:
- What Do You Notice_5:
- :
- Vital Signs_3:
- Q4H with telemetry does not require continuous oximetry:
- Weight_3:
- upon admission:
- IO_3:
- na_3:
- General Orders_3:
- Medications_3:
- cholecalciferol 2000 units PO daily docusatesenna 5088 mg PO BID donepezil 5 mg PO daily metoprolol 125 mg PO BID saline flush 10 ml IV TID Lactated Ringers IV at 100 mlhr for a total of one liter:
- Diagnostics_2:
- Order of PriorityRow1:
- RationaleRow1:
- Order of PriorityRow2:
- RationaleRow2:
- Order of PriorityRow3:
- RationaleRow3:
- Patient 1:
- PRIORITY Body SystemsRow1:
- PRIORITY Nursing AssessmentsRow1:
- Patient 2:
- PRIORITY Body SystemsRow1_2:
- PRIORITY Nursing AssessmentsRow1_2:
- Patient 3:
- PRIORITY Body SystemsRow1_3:
- PRIORITY Nursing AssessmentsRow1_3:
- Order of PriorityRow1_2:
- RationaleRow1_2:
- Order of PriorityRow2_2:
- RationaleRow2_2:
- Order of PriorityRow3_2:
- RationaleRow3_2:
- Text10:
- Text11:
- Text12:
- Text13:
- Text14:
- Text15:
- Text16:
Patient Report:
Vital Signs:
Weight:
General Orders:
Medications:
Diagnostics:
Appointments:
Clinical Significance: