unfolding case study activity 1

38.1 Unfolding Case Study Dissection

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

Unfolding Case Study

Nursing care of a patient who fell.

Mrs. Jackson, a 68-year-old female patient, presents to the emergency department after experiencing a fall at home. Her daughter witnessed the fall and brought Mrs. Jackson to the hospital saying, “My mom has been acting really confused after falling. I’m scared she might have a concussion.”

Mrs. Jackson has been on the neuro unit for two days and is now showing a slight improvement in symptoms. The family has requested to meet with the unit’s social worker to discuss rehabilitation options.

Clinical Decisions Based on Patient Needs

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 the care to provide, then developed and refined the 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 assessing the patient as soon as they arrived at the hospital. The nurse was informed that the patient fell at home and was brought to the emergency department by her daughter, who is concerned that the patient may have a concussion. The nurse immediately performed a general survey, looking for cues that would be indicative of a concussion or injury from the fall. During the general survey, the nurse noticed that the patient appeared anxious and confused. The nurse hypothesized that the confusion could be related to head injury from the fall, but that there may be more going on, and further assessment was indicated. The nurse performed a quick head-to-toe assessment and recognized the following relevant cues:

• Alert and oriented only to self
• Slurred speech
• Slight right facial droop
• Rapid, thready pulse
• Decreased muscle strength in right side extremities
• Decreased sensation to right side of body

The nurse recognized that the patient’s symptoms were consistent with a cerebrovascular accident (stroke) from using the FAST assessment and immediately activated a code stroke, recognizing the importance of initiating interventions in a timely manner. Additionally, the nurse recognized other important cues from the patient’s medical history that increased the probability of a stroke: hypertension , atrial fibrillation , and type 2 diabetes . The nurse also took note of the patient’s current medications, because that information often provides more context for a patient’s situation. In this case, the patient was actively taking two antihypertensive medications, an antidiabetic medication, an anticoagulant, and a daily aspirin .

Recognize, Analyze, and Prioritize Patient Needs

After recognizing symptoms of stroke and alerting the stroke team, the nurse also quickly initiated patient transport to the imaging department for a STAT head CT to determine if the patient was actually experiencing a stroke, and to identify, if necessary, the type of stroke (e.g., ischemic, hemorrhagic). The nurse also recognized the importance of asking the patient’s daughter when the patient was “last seen normal,” as the patient must be in the allotted time window from the onset of symptoms to receive tissue plasminogen factor (tPA), a clot-busting medication that is used to treat ischemic stroke. The nurse then performed important diagnostic tests per the provider’s order, including a point-of-care glucose, CBC, BMP, INR, PTT, HA1C, and 12-lead ECG.

Develop and Refine Interventions

Based on the provider’s orders, the nurse performed a 12-lead ECG and found the patient’s cardiac rhythm to be atrial fibrillation on the monitor. The nurse recognized that this cardiac rhythm is often a risk factor for stroke and hypothesized that it may have been a contributing factor to the patient’s presenting symptoms.

Other nursing interventions included performing frequent neurological checks, frequent vital sign checks, analyzing lab and test results, and initiating NPO orders. The nurse recognized the importance of performing frequent neurological checks, because these checks provide tangible measurements of the subtle changes that may indicate the patient’s status is worsening. While analyzing lab and test results, the nurse recognized that the CT report showed findings that were consistent with an ischemic stroke on the left side of the brain. These findings are consistent with the patient’s right-sided symptoms, as symptoms of a stroke are often exhibited on the opposite side of the body in relation to their location in the brain. The nurse also recognized that the patient’s blood glucose was slightly elevated, consistent with the patient’s diabetes, but was likely not the cause of the patient’s symptoms. Typically, hypoglycemia can mimic symptoms of stroke, not hyperglycemia. Lastly, the nurse initiated an NPO order for the patient because strokes increase the risk of dysphagia. At this point, the nurse should anticipate that the patient will require a bedside swallow screen and possibly future consultation with a speech language pathologist to determine their ability to swallow food, liquids, and medications before the NPO status will be changed.

Application of Nursing Care

Application of nursing care in the case study included the interventions mentioned in the previous section, as well as educating the patient and family about the plan of care. Experiencing a stroke can be stressful for both the patient and family members, so the nurse can help ease some anxiety by keeping everyone informed about what is happening. In this case, it was important for the nurse to let the patient’s family members know that the patient had experienced a stroke, but that typical treatment (tPA) was contraindicated because of the patient’s elevated INR value. The nurse should explain this in simple terms, avoiding complex medical jargon to ensure understanding. For example, the nurse might say, “We would typically give a medication that would dissolve the clot that is causing the stroke, but that medication carries a large risk of bleeding. Because the patient is on a blood thinner medication, she is already at an increased risk of bleeding, so if we gave this medication, it could cause her to experience bleeding in the brain, which is life-threatening. Instead, we are going to watch her closely to make sure her symptoms don’t get worse and do all we can to improve them.”

Incorporated Factors Affecting Patient Care

Caring for a patient who is having a stroke involves a lot of physical nursing tasks and skills, but it is also important to recognize the need to provide emotional support to the patient and their family members. Experiencing a stroke can cause a lot of anxiety, especially in this case, as the patient was unable to receive standard pharmacological treatment because of contraindications. The nurse should remain available to the patient and the family to discuss concerns and answer questions about the plan of care. It is important for the nurse to ask what kind of support or resources would help them cope with the diagnosis and, if possible, provide them. After being in the hospital for a few days and experiencing an improvement in symptoms, the nurse in the case study connected the patient and family to a social worker to help them transition from the hospital to home or to a rehabilitation facility.

Revising the Plan of Care

Even though the patient was not actively receiving treatment for the stroke, the nurse was still closely monitoring and assessing for subtle changes in health status that would indicate the need for a revised plan of care. Specifically, the nurse monitored the patient’s vital signs and neurological status, looking for improvement or worsening of symptoms. As the patient progressed through the hospital stay, the plan of care required revision to account for discharge and possible rehabilitation.

Evaluate Outcomes

After performing interventions, the nurse evaluated outcomes by reassessing the patient’s vital signs and neurological status. The patient’s vital signs remained stable, and the neurological status improved. Also, the nurse must evaluate the patient and family’s understanding of provided education. The nurse can do this by using the “teach back” strategy, which asks the learner to repeat the information in their own words to verify the message was received.

Evaluate Nursing Actions

In this case study, the nurse initially evaluated the patient’s neurological status every 15 minutes, looking for worsening or improving of symptoms. Because the patient was unable to receive tPA, the nurse did not administer a specific treatment for the stroke, but closely monitored the patient’s neurological status. This is an action that can be evaluated. For example, if the nurse notices that the patient’s neurological status is worsening, they might hypothesize that the stroke has expanded or the patient may be experiencing a hemorrhagic transformation and would relay this information to the provider to determine the next course of action, which may involve a surgical intervention. Thankfully, in the case study, the patient’s symptoms showed improvement a few days after the onset of the stroke, and the nurse began facilitating physical, occupational, and speech therapies to help the patient restore function and work toward discharge home. Additionally, the nurse facilitated communication between the patient and family and the social worker to initiate the process of leaving the hospital, either to home or to an appropriate rehabilitation facility for the patient to continue her journey of healing.

Another important way that the nurse monitored outcomes was ensuring patient and family understanding of the education provided. Specifically, the nurse provided information about the importance of taking the clopidogrel as prescribed to decrease the risk of subsequent strokes. To evaluate the patient and family’s understanding, the nurse should consider asking them to “teach back” the information. This process helps the nurse feel confident that they understand the significance of adhering to the medication.

Revised Plan of Care

The nursing interventions were successful, as indicated by the improvement in the patient’s neurological symptoms. If the symptoms 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 and/or requesting alternative treatment options, as available. 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. This continuous assessment occurs until the patient is discharged.

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• Authors: Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt
• Publisher/website: OpenStax
• Book title: Medical-Surgical Nursing
• Publication date: Oct 16, 2024
• Location: Houston, Texas
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• Section URL: https://openstax.org/books/medical-surgical-nursing/pages/38-1-unfolding-case-study-dissection

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Why KeithRN Unfolding Case Studies Can Transform the Virtual (and Traditional) Clinical (1/2)

Principle #2: Contextualize ALL aspects of nursing practice

Case-based simulation such as Skinny Reasoning provides a comprehensive experience of what a nurse must understand and apply to provide safe patient care by addressing the following core nursing content:

• pathophysiology
• pharmacology
• nursing process and care planning
• holistic care priorities
• nursing assessment
• critical thinking that emphasizes understanding and application of essential content
• clinical reasoning that captures the thinking in action required at the bedside
• clinical judgment, which is the outcome when a student can both critically think and clinically reason!

Multiple levels of complexity

Just as any nursing program curriculum is leveled from simple to complex as students progress from novice to advanced beginner in their development, KeithRN case studies have multiple levels of complexity to bring the case study to the level of the student.

For example, Skinny Reasoning is the shortest and most concise level of a KeithRN Unfolding Case Study with only four pages. Still, it captures the essence of a global clinical patient care experience.

Unfolding Reasoning is the most complex KeithRN case study and is 8 to 10 pages in length but provides higher level clinical reasoning questions that emphasize priority setting. Unfolding Reasoning includes an unfolding change of status that must be recognized by the nurse.

Different levels of case studies provide faculty with the flexibility to use the best level based on the student’s semester and professional development.

Principle #3: Emphasize and practice clinical reasoning.

To develop the clinical judgment that students require for safe practice, they must be able to reason in action at the patient’s bedside as new data is collected and correctly interpreted by the nurse.

Tanner’s Clinical Judgment Model

Chris Tanner’s clinical judgment model captures the essence of the four clinical reasoning steps required to make the correct outcome of a clinical judgment and must be understood by every nurse educator to develop clinical judgment in your students.

These four steps are:

• NOTICING. What clinical data is detected as important or significant by the nurse?
• INTERPRETING. What is the meaning or clinical significance of relevant clinical data that was noticed?
• RESPONDING. How will the nurse respond with a nursing priority and plan of care based on the clinical data that was noticed and interpreted?
• REFLECTING. After responding, what is the evaluation, reflecting on the clinical data noticed by the nurse?

Tanner’s clinical judgment model was published in 2006 and remains a research and evidence-based clinical judgment model that every nurse educator must be familiar with. These four steps of Tanner’s framework align with the nursing process to develop the nurse thinking that every student must possess.

It is not a coincidence that Tanner’s clinical judgment model is also the essence of the NCSBN model of clinical judgment that is the basis for Next Generation NCLEX. When Tanner’s model is understood and then integrated into your curriculum using KeithRN Unfolding Case Studies, there is no reason to fear the upcoming Next Generation NCLEX!

Just as the nursing process is a repetitive framework and sequential process that a nurse uses to think like a nurse, the clinical reasoning questions and underlying framework of KeithRN case studies do not change, regardless of the scenario topic.

This is because the essence of clinical reasoning that captures nurse thinking is consistent; it does not change, irrespective of the clinical practice setting.

How to Use in Traditional Clinical Setting

Got downtime in clinical?

Some students get a robust experience, while other students patient was discharged early or is not as busy. Use the concise SKINNY Reasoning format as a resource to provide a meaningful, clinical-based alternative activity!

Print up extra copies of the case study and have an individual or group of two students work through a relevant topic seen most commonly in your clinical and present it in post-conference.

To strengthen and innovate how nursing is taught, it does not require a change in the curriculum but only changing HOW nursing is taught.

By using the educational best practice principles of replicating the clinical setting as closely as possible and utilizing a practice-based framework of clinical reasoning such as Tanner’s clinical judgment model, student learning can be strengthened despite the challenges posed by the current pandemic.

As a result, students will be better prepared for clinical practice and licensure, including the much more difficult Next Generation NCLEX coming in 2023!

Related Blogs

How to Use a COVID-19 Case Study to Develop Clinical Judgment Online

Online Teaching for the First Time? What Every Nurse Educator Needs to Know

• How to Use Unfolding Case Studies as a Clinical Replacement Activity

Keith Rischer – Ph.D., RN, CCRN, CEN

As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…

The Ultimate Solution to Develop Clinical Judgment Skills

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Helping graduate nurses transition to practice, recommended for you.

Quality and Safety Education for Nurses

Strategy submission, using unfolding case studies to develop clinical forethought in novice nursing students.

Brenda Moench

RN, MS, CNE

Nursing Instructor

Institution:

University of Wisconsin Milwaukee

[email protected]

Competency Categories:

Patient-Centered Care, Safety

Learner Level(s):

Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s):

Strategy Type:

Case Studies

Learning Objectives:

Strategy Overview:

Submitted Materials:

Teaching-Strategy-QSEN-TS-241-1.docx - https://drive.google.com/open?id=1AECA5dGZdE6YPXxF0DmMMC8M9maipFe5&usp=drive_copy

Additional Materials:

Benner, P., Hughes, R.G., & Sutphen, M., (2008). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, 204-211.

Evaluation Description:

• NLN Certification
• Assessment Services
• CNEA Accreditation
• NLN Foundation
• Mission & Core Values
• History & Archives
• Board of Governors
• Senior Management
• Consultants & Speakers Bureau
• NLN Nominations
• Career Center

How to Use an Unfolding Case

ACE unfolding cases were written so that they can be modified to meet the needs of diverse curricula. Since preparation is key to a successful simulation experience, faculty should plan to read through each unfolding case before using it.

These cases were designed so that students can use the ACE Knowledge Domains and Essential Nursing Actions as a framework for thinking about the care and planning of their nursing interventions. Students should be introduced to these concepts before implementing the cases. They will be more successful in the simulation scenarios if they review the introductory monologues and the recommended resources and tools prior to the simulation.

We have included best practices but realize that treatments vary by region. Faculty may wish to include medications, treatments, and standards of care that are current practice in their own geographic areas.

No intentional errors were included in these cases, such as incorrect treatments or medication doses. However, in the Alzheimer's cases, the patient may have multiple providers and medication orders. An objective for some of the simulations is to use the Beers criteria to identify potentially inappropriate medications or combinations of medications for older adults. Faculty may wish to increase or decrease the complexity of the scenario depending on the level of students participating. Faculty may also wish to modify scenarios to provide an interprofessional educational experience for students. When redesigning for this purpose, we urge you to include the other health care professional(s) in the process to insure that the simulation accurately reflects their scope of practice.