Critical Thinking to Achieve Positive Health Outcomes

Nursing Case Studies and Analyses

Margaret Lunney

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9780813816012
• eBook ISBN: 9781118701218
• Edition: 2
• Topic: Medicine
• Subtopic: Nursing Skills

This book uses the latest research findings to apply critical thinking processes for the development of diagnostic reasoning and the selection of patient outcomes and nursing interventions.Four chapters describe the meaning of intelligence, critical thinking, and application of critical thinking processes within nursing. The case studies and their ultimate resolution to intervention and outcome illustrate these processes by enabling repeated practice. Case studies are organized into four sections; problem diagnoses, risk diagnoses, health promotion diagnoses, and strength diagnoses. A companion website provides on-line resources.

II

Case Study Application of Strategies

Part II consists of case studies in each of four categories: problem diagnoses, risk diagnoses, health promotion diagnoses, and wellness/ strength diagnoses. Cases with more than one type of diagnosis are categorized by the primary diagnosis. The primary references below were used for each and every case study. These references are not cited with the case studies because it would be redundant.

References

Bulechek, G.M., Butcher, H.K., and Dochterman, J.M. (2008). Nursing Outcomes Classification (NOC) (4th ed.). St. Louis, MO: Mosby.

Moorhead, S., Johnson, M., Maas, M.L., and Swanson, E. (2008). Nursing Interventions Classification (NIC) (5th ed.). St Louis, MO: Mosby.

NANDA International. (2009). Nursing diagnosis: Definitions and classification, 2009-2011. Hoboken, NJ: Wiley-Blackwell.

Use of Critical Thinking with Each Case Study

One way to engage with the case studies for learning is to read the cases, formulate analyses, and compare your analyses with the authors' analyses. It is important to accept that your analyses and those of the authors may not be the same because the author was present with the person or family and may have had additional information that was not identified and recorded. In addition, the words of a case study can never fully represent the complexity of a real person or family or the context of the situation. Written case studies are valuable for learning (Lunney, 2008), but to make the best decision, you have to be there. Accepting the complexity of diagnosis in nursing indicates the personal strength of tolerance for ambiguity.

When you see this icon, do the following:

• After listing the possible diagnoses identified in the case (use flexibility, intuition, and open-mindedness), select the diagnoses with the strongest evidence (use logical reasoning, discriminating, analyzing, information seeking, and/or applying standards).
• Considering the person or family's story, identify the most likely priority issue or concern (use contextual perspective).
• Considering the type of setting (e.g., hospital, home), identify the nurse's likely priority concerns (use contextual perspective and applying standards).
• From the most likely diagnoses, consider possible outcomes (use predicting and transforming knowledge) and select the best outcome (or outcomes) for the diagnosis and this consumer (use analyzing, applying standards, discriminating, information seeking, and/or predicting).
• List the nursing interventions that you would select to address the identified outcomes (analyzing, applying standards, flexibility, contextual perspective, confidence, creativity)
• Compare your selections of diagnoses, outcomes, and interventions with those of the author (use applying standards, logical reasoning, predicting, transforming knowledge, flexibility, inquisitiveness, intellectual integrity, open-mindedness, perseverance, and/or reflection).
• Reflect upon the areas of congruence and incongruence between the author's selections and your own (use discriminating, transforming knowledge, open-mindedness, and reflection).
• Accept that in each case, the author had the best clinical judgment because he or she was present with the consumer and experienced more data than he or she was able to include in the written case study.

References

Lunney, M. (2008). Current knowledge related to intelligence and thinking with implications for the development and use of case studies. International Journal of Nursing Terminologies and Classifications, 19,158‒162.

Abbreviations Used in the Case Studies

ABG	Arterial blood gases
am	Before noon
BID	Two times a day
BP	Blood pressure
BMI	Body mass index
CBC	Complete blood count
CHF	Congestive heart failure
cm	Centimeters
CNS	Clinical nurse specialist
CT	Computerized tomography
D	Dextrose
dl	Deciliter
ED	Emergency department
EKG	Electrocardiogram
F	Fahrenheit
gm	Gram
Hgb	Hemoglobin
Hct	Hematocrit
hg	Mercury
HR	Heart rate
IV	Intravenous
K	Kilograms
L	Left
lb	Pound
m	Minute
meg	Microgram
mg	Milligram
ml	Milliliter
MRI	Magnetic resonance imaging
mm	Millimeter
mm^3	Millimeter to third degree
NS	Normal saline
pm	After noon
QD	Every day
R	Right
RR	Respiratory rate
SaO2	Saturated oxygen
T	Temperature
WNL	Within normal limits

5

Case Studies with a Primary Focus on Problem Diagnoses and Associated Outcomes and Interventions

5.1. Woman Admitted for Diagnostic Testing of a Lung Nodule

Fabiana Gonçalves de Oliveira Azevedo Matos and Diná de Almeida Lopes Monteiro da Cruz

Ms. AL, a 72-year-old female, was admitted to a Brazilian hospital for diagnosis of an R lung nodule. Ms. AL is single, has no children, and is a retired nurse.

The admitting nurse conducted an assessment using the eleven functional health patterns (Gordon, 1994). Interviewing and examining Ms. AL, the nurse identified possible problems in six different patterns: (1) nutritional-metabolic (lost 8 Kg last year, BMI = 17.5), (2) elimination (for two months has had constipation), (3) sleep-rest (complained that she awakened during the night and got up tired in the morning), (4) activity-exercise (she took walks but stopped in the middle for tiredness, felt tired all day, was afraid of falling while taking a shower, and had an unsteady gait), (5) perceptive-cognitive (felt pain in the legs for about one year, currently hospitalized for pain in chest and shoulder), and (6) coping-stress tolerance (uncomfortable with the uncertainty of the lung problem and pain, “tired” of going to a number of physicians with no diagnoses, family worried about her physical and emotional condition, and smoked to relieve tension).

The nurse thought it was very likely Ms. AL was worried that her problem was lung cancer. Ms. AL had worked for 30 years in a radiological setting, and would be familiar with situations like the one she was living as a patient. The nurse thought that Ms. AL not mentioning this concern could be a sign of a coping problem. Ms. AL also exhibited signs of anxiety.

In extending the pain assessment, the nurse learned that Ms. AL was treating the chronic pain in her legs for three months with opiates. It was after starting the use of opiates that her intestinal problems began. Ms. AL reported that her last bowel movement was the day before hospitalization and she had no abdominal discomfort.

At present, her leg pain was reported as 7 on the 10-point scale and Ms. AL’s facial expression was tense and contracted. Ms. AL told Sofia that when she started pain treatment for the leg pain, she also started sleeping better, and pain was not disturbing her sleep anymore, but when the lung problem appeared she started awakening during the night again and was keeping herself awake thinking about the problem. Concomitantly, the leg pain also became worse.

The nurse asked Ms. Al what her most important problem was. Ms. AL said “this pain … waiting for this exam … this doubt … I am very worried and distressed about everything … I hope it finishes soon.”

STOP. THINK. Which diagnoses, outcomes, and interventions would you select?

Submitter’s Analysis and Use of NANDA-I, NOC, and NIC

Interpreting Ms. AL’s data to arrive at accurate and priority diagnoses required analysis of the situational context and consideration of the length of time that Ms. AL would be under nursing care in the current event. Although Ms. AL presented with many possible health problems, her hospital stay for diagnostic testing would likely be short, one or two days. In an ideally integrated health system, nursing care in acute care settings would be addressed as an adjustment of the working nursing care plan established in the ambulatory care setting, but this was not the case with Ms. AL.

The nurse noted relevant cues for the nursing diagnoses of anxiety, pain, constipation, impaired walking, risk for falls, fatigue, imbalanced nutrition, and insomnia, and considered that some of these diagnostic hypotheses were associated with each other. The diagnoses of impaired walking, constipation, fatigue, insomnia, and imbalanced nutrition were excluded.

Impaired walking was ruled out because interventions for this diagnosis were not appropriate for this hospitalization. The major concern with Ms. AL’s walking problems in the hospital would be her safety. Constipation was ruled out because it was related to taking opiates for leg pain and, as a nurse, Ms. AL knew how to manage this. Imbalanced nutrition was ruled out because it was not a priority in Ms. AL circumstance. After the current medical problem was diagnosed and medical treatment started, a complete nursing reassessment would be required to identify Ms. AL’s nutritional and other needs.

The nurse encouraged Ms. AL to talk about her worries and at the same time validate the priority diagnoses of acute pain and anxiety. The pain level of 7 was important and had to be managed for Ms. Al’s comfort, so acute pain related to ineffective control of chronic pain was accepted as a nursing diagnosis to guide care. Also, the diagnosis of anxiety was selected, with rumination, facial tension, insomnia, fatigue, diminished productivity, apprehension, and anorexia as the defining characteristics (Young, Polzin, Todd, and Simuncak, 2002). Ms. AL agreed with the nurse that relieving pain and anxiety could positively impact her sleep and fatigue. Risk for falls was the third diagnosis to be addressed because of Ms. AL’s tiredness, muscle weakness, and unsteady gait.

Studies have shown that people who are hospitalized for testing related to a potentially life-threatening illness are likely to develop a higher level of psychological distress than the general population (Fantini, Pedinielli, and Manouvrier, 2007). Ms. AL was probably anticipating a lung cancer diagnosis as a result of the biopsy. Distress and fear of cancer and death were found the major negative aspects of subjects who received screening tests for cancer (McGovern, Gross, Krueger, Engelhard, Cordes, and Church, 2004).

NOC Outcomes

The NOC outcomes that were selected for Ms. AL were anxiety level, pain level, and fall prevention behavior. For anxiety level, the baseline score was determined as 2 (substantial) and the target score was set as 3 (moderate). For pain level, the baseline score was determined as 2 (substantial) and the target score was set as 4 (mild). For fall prevention behavior, the baseline score was identified as 5 (consistently demonstrated) and the goal was to maintain a level of 5.

NIC Interventions

The interventions that were selected to achieve these outcomes and address the nursing diagnoses were anxiety reduction, pain management, and fall prevention. The nurse informed Ms. AL of the intervention focus and Ms. AL agreed with the plan. The nurse obtained information about Ms. AL’s pain medications taken at home and her usual reactions to them, and shared this information with her physician. The physician and nurse collaborated on a different analgesic treatment, including medication on an as needed basis. The nurse administered the analgesic, and told Ms. AL to rest and she would return. She also asked Ms. AL to call a nurse as needed using the bell, particularly to get out of bed. The nurse told Ms. AL how to use the bell and left it near her, and also explained to her that the bedrail must be kept elevated to keep her safe.

Thirty minutes later, the nurse returned to Ms. AL who was sleeping. The nurse thought Ms. AL’s pain had decreased; this was later confirmed by Ms. AL who said she slept deeply for forty minutes after the medication and scored her pain as 3.

While Ms. AL was sleeping, the nurse found out that Ms. AL’s biopsy was scheduled for the next day at 11:00 am. The nurse gave this information to Ms. AL, who agreed to discuss how to manage the expectation until the procedure time. The nurse discussed anxiety with Ms. AL to identify the personal resources that would help her to deal with this stressful situation, and also to give her an opportunity to express her feelings and threats (Fishel, 1998). The nurse listened attentively to Ms. AL, and learned that she was nervous about having lung cancer; that she would like to know the diagnosis as soon as possible, because she had many things to arrange before things got worse. The nurse told Ms. AL she could imagine how difficult it was to deal with the uncertainty and asked her opinion about trying a relaxation technique (Conrad and Roth, 2007). Ms. AL said that when she was young, she practiced progressive relaxation and accepted the nurse’s guidance in remembering how to perform it. Ms. AL asked to be left alone to practice the relaxation technique. The nurse accompanied Ms. AL to the toilet, helped her to return to bed, confirmed that light and noise were acceptable, and left Ms. AL alone. The nurse discussed Ms. AL’s responses with her physician, who decided to consider an anxiety reducing medication in Ms. AL’s prescription after assessing relaxation outcome.

Evaluation

Before shift report, Ms. AL rang the bell and asked for help to position herself for lunch. The nurse noticed that Ms. AL was less tense, and Ms. AL said that she was more comfortable after the relaxation exercise. Ms. AL commented on the details of the relaxation technique and that, in the past, she was able to get better results from relaxation, and that this “was good for body and soul.” As Ms. AL showed interest in the technique, the nurse encouraged her to repeat it in the afternoon, assuring her that retraining would improve the results. Ms. AL agreed to repeat the relaxation techniques but said she was not sure that it could completely relieve her tension.

The nurse also evaluated that Ms. AL was free of pain—her pain level score was 5 (none)—and that Ms. AL consistently demonstrated fall prevention behavior (score = 5). The nurse scored anxiety level at 3 (moderate).

References

Conrad, A., and Roth, W.T. (2007). Muscle relaxation therapy for anxiety disorders: It works but how? Journal of Anxiety Disorders, 21, 243–64.

Fantini, C., Pedinielli, J.L., and Manouvrier, S. (2007). Psychological distress in applicants for genetic screening for colorectal cancer. Encephale, 33, 117–123.

Fishel, A.H. (1998). Nursing management of anxiety and panic. Nursing Clinics of North America, 33, 135–151.

Gordon, M. (1994). Nursing diagnosis: Process and application (3rd ed.). St. Louis: Mosby.

McGovern, P.M., Gross, C.R., Krueger, R.A., Engelhard, D.A., Cordes, J.E., and Church, T.R. (2004). False-positive cancer screens and health-related quality of life. Cancer Nursing, 27, 347–352.

Young, L.K., Polzin, J., Todd, S., and Simuncak, S.L. (2002). Validation of the nursing diagnosis anxiety in adult patients undergoing bone marrow transplant. International journal of Nursing Terminologies and Classification, 13, 88–100.

5.2. Adaptation to the Pain of a Fractured Hip

Alsacia Pacsi, RN, MS, FNP, CEN, CCRN

Teresa S. is a 55-year-old Hispanic woman who was admitted to the ED following a motor vehicle accident. In the ED, an X-ray revealed a hip fracture involving the intracapsular region of the L femur. She was scheduled for an open reduction and internal fixation the same day. She complained of severe pain.

Her vital signs were: BP 130/88, T 98 °F; P 126 and regular; RR 32/m. Teresa was alert and oriented and verbalized appropriate responses to all questions. Breath sounds were clear bilaterally, respirations were even and unlabored. Peripheral pulses presented at 2+ except for the L pedal pulse, which was +1 (weak and thready), and her capillary refill response was five seconds on the L side. The L leg was shorter than the R leg and external rotation was noted. She had “no known allergies.”

Teresa was crying and fiddling with her fingers during the assessment. She stated that she had never been hospitalized but confided that she had spent a lot of time at the hospital last year when her husband died of cancer. No significant health history was noted. Teresa said that she usually takes one multivitamin a day and no medications.

Based on the nurse’s observation about Teresa’s increased agitation, moaning, grimacing, and crying, the nurse decided that she needed to assess the effects of Teresa’s current situation. She asked, “Teresa, how do you feel about being hospitalized and having surgery?” Teresa stated that the pain she was experiencing to her L hip and groin area, particularly when she attempted to move it, was unbearable and that it was making her very anxious. Teresa’s face was flushed and she stated she was overwhelmed with the severe pain.

The nurse initially asked Teresa to verbally rate her pain using the numeric scale from 0 (no pain) to 10 (the worst possible pain), but she was not able to assign a number to her pain. The nurse then used the Faces Pain Scale—Revised to determine the intensity of Teresa’s pain (Hicks, VonBaeyer, Spafford, Korlaar, and Goodenough, 2001). Teresa was able to easily select a face that reflected her pain.

The results confirmed, along with the physiological parameters, that Teresa was in severe pain. The face she selected was the equivalent of a 10 on the 10-point scale. By using the Faces research-based pain assessment tool, in conjunction with obtaining a complete health history and performing a physical examination, the nurse was able to more accurately assess the intensity of the pain.

STOP. THINK. Which diagnoses, outcomes, and interventions would you select?

Submitter’s Analysis and Use of NANDA-I, NOC, and NIC

Using Roy’s adaptation model, the nurse viewed Teresa’s hip fracture as an event that activated Teresa’s adaptation processes (Roy and Andrews, 2008). Teresa’s responses to this injury were examples of regulator subsystem activity. The regulator subsystem is the adaptive process for physiological stimuli with physiological outcomes and occurs without conscious awareness. First, during the injury process, internal stimuli, both chemical and neural, started endocrine and central nervous system activity to generate physiological responses to the fracture, e.g., local swelling and delayed capillary refi...

Table of contents

• Cover
• Content
• Title Page
• Contributors
• Preface
• Acknowledgments
• How to Use this Book
• I Strategies for Critical Thinking to Achieve Positive Health Outcomes
• II Case Study Application of Strategies
• Appendices
• Index