CASE STUDY WITH CLINICAL JUDGMENT QUESTIONS
Case Study: Hospital Day 1
Nurses’ Notes: 1300
Carrie, a 37-year-old, presented to the Emergency Department with difficulty breathing. They were transferred to the medical surgical unit with a diagnosis of pneumonia. The client reports decreased shortness of breath. Their breath sounds are diminished with crackles right base, and they have a persistent, productive cough. A 20-gauge IV lock is in the right hand. No other past medical or surgical history. No known Drug Allergies.
Vital Signs: 1300
BP 100/62, HR 90, RR 26, T 101.2?F temporally, O2sat 88% on room air.
Labs:
WBC 21.7 TH/uL
Chest Xray: Right lower lobe infiltrate
Medications:
Albuterol Nebulizer 2.5 mg every 6 hours. Acetaminophen 500 mg PO every 4-6 hours Provider Orders:
Titrate oxygen to keep saturations > = 92% Diet as tolerated
Recognize Cues (Assessment)
1. What are the relevant factors contributing to the client’s condition
Analyze Cues (Analysis)
What potential complications is the client at risk for developing?What are the physiological aspects contributing to the client’s condition?Prioritize Hypotheses (Analysis)
What is the client’s three priority problem?Generate Solutions (Planning)
What client outcomes should the nurse plan for related to the three priority problems?What potential provider orders should the nurse anticipate for the client?Take Actions (Implementation)
What actions should the nurse perform based on the client’s priority needs?What should the client be monitored for based on the nursing actions performed?Case Study: Hospital Day 3
Nurses’ Notes: The client reported shortness of breath mostly with activity, breath sounds diminished bilaterally with crackles in right lower lobe.
Vital Signs: BP 100/62, Temp. 100.4?F temporally, HR 85, RR 26, O2 Sat 96% on 2L O2 via nasal cannula.
Evaluate Outcomes (Evaluation)
Explain whether the client met, partially met, or did not meet the expected Support your response with client information provided.Will the nurse need to revise the plan of care? If yes, describe how the plan of care should be?
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