Student Case Study Example, Exams of Nursing

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Running head: WRITTEN CASE PRESENTATION 1

Written Case Presentation

Student A. Sample

Grand Canyon University: ABC-

January 1, 2012

Written Case Presentation

In critical care nursing, close attention must be paid to the patient status post

cardiothoracic surgery in order to prevent the onset of complications and to ensure outcomes are

being met. The nature of the procedure and the patient’s past medical history play important

roles in the postoperative recovery course of the patient, and can set the stage for complications

to occur. The purpose of this paper is to examine a patient undergoing cardiac surgery with

respect to review of subjective and objective data, determination of nursing diagnoses, formation

of outcomes with interventions, evaluation of the outcomes, and presentation of three research

questions that can be identified based on the patient’s scenario.

Subjective Data

L.R., an 81-year-old Caucasian male, was admitted to the Emergency Room at Banner

Good Samaritan Medical Center with the complaint of progressively worsening exertional

shortness of breath for the last 2 weeks. He states that his shortness of breath has been relieved

temporarily by rest, and also notes he has had bilateral extremity swelling develop over the past

week. He also states that he has had to dramatically reduce his activity level over the past week

due to the progressing shortness of breath and lower extremity swelling and that his urinary

pattern has decreased. He denies chest pain, palpitations, orthopnea, cough, fever, or chills. The

patient is currently on the Progressive Care (telemetry) Unit status post aortic valve replacement,

left-sided maze procedure, and excision and removal of left atrial thrombus on 2/2; he is

currently postoperative day 6. The patient’s past medical history includes hypertension, coronary

artery disease status post stent placement to Left Anterior Descending artery and Right Coronary

Artery in 2008, hyperlipidemia, moderate aortic stenosis, sleep apnea (on CPAP at night), and

benign prostatic hypertrophy. His past surgical history in addition to the stent placement also

atelectasis in lower bases with mildly enlarged cardiac silhouette. Post-operative transesophageal

echocardiogram showed an increase in ejection fraction from 25% to 35%, confirming the

presence of systolic heart failure. Current medications include simvastatin, fish oil, fluoxetine,

nicotine patch, vitamin C, multivitamin, docusate, enoxaparin, furosemide, potassium, aspirin,

metoprolol, amiodarone, and warfarin.

Nursing Diagnoses

The first problem concerns the patient’s activity intolerance related to his generalized

weakness and imbalance between oxygen supply and demand as evidenced by shortness of

breath with exertion and fatigue. The second problem concerns the patient’s inappropriate

voiding pattern related to his systolic heart failure as evidence by his decreased urinary output,

increased brain natriuretic peptide level, and increased creatinine level.

Plan and Interventions

The patient’s plan of care will include interventions that maximize the patient’s energy

level, promote rest, control pain levels, promote increased renal function, prevent further

respiratory decline, and increase in complexity in order to practice activities of daily living

before discharge. Interventions will include close monitoring of vital signs during activity, as

increased heart rate can decrease myocardial perfusion and lead to recurrence of arrhythmias.

Administration of antihypertensive and diuretic medications will also be completed, as these

medications promote myocardial perfusion and decrease preload (Gulanick & Myers, 2007).

Having the patient participate with the multidisciplinary team in setting goals will allow for

realistic goals that the patient will be motivated to complete for discharge. Frequent resting

periods in between activities and ambulation is also essential for maximizing energy levels as

well as reducing oxygen demands. Slow progression of activities will also occur as this will

allow for resting periods, preventing myocardial overload and exhaustion (Mullen-Fortino &

O’Brien, 2009).

The patient’s acute renal failure has been attributed to his systolic heart failure and

volume overload conditions, prompting need for interventions that decrease volume status and

promote effective renal clearance. For this condition, interventions will focus on assessing daily

weights, need for supplemental oxygen, placing the patient on a fluid restriction, administering

prescribed diuretic medications, and educating the patient on signs and symptoms of heart

failure, as well as dietary and lifestyle considerations. In order to manage the renal failure

currently occurring, interventions will be focused on maintaining sufficient fluid volume to

prevent cardiac workload (Warise, 2010). The goal of the interventions is to decrease the

patient’s signs and symptoms of heart and renal failure post-surgery, promoting quality of life

and functional status.

Evaluation

Evaluation of the interventions and goals will take place during daily multidisciplinary

rounding at the patient’s bedside. The bedside nurse, clinical nurse specialist, respiratory

therapist, physical therapist, cardiac rehab therapist, clinical pharmacist, case manager, and

social worker participate in goal creation, assessment, evaluation, and revision. The rounding

team also discusses potential needs for successful discharge. Monitoring of the patient’s vital

signs will allow for evaluation of cardiac workload after activities as well as while at rest. Daily

chest radiographs will evaluate the presence of fluid status; the patient’s weight trend will

evaluate the progress of diuresis and need for additional medication regimens. Performing “teach

back” education with the patient through discussion and administration of short quizzes can

assess the patient’s retention of information, providing direction for continued education to take

and family-centered care. Lastly, the thorough execution of care allowed the patient to eventually

be discharged from the hospital to home with home health and physical therapy on postoperative

day 9.

References

Gulanick, M., & Myers, J. L. (2007). Nursing care plans: Diagnoses, interventions and

outcomes (7th ed.). St. Louis, MO: Mosby.

Mullen-Fortino, M., & O’Brien, N. (2009, January). Caring for a patient after coronary artery

surgery. Nursing2009CriticalCare , 22-27.

Warise, L. (2010). Update: Diuretic therapy in acute renal failure: A clinical case study.

MEDSURG Nursing , 19 (3), 149-152.

Written Case Presentation Rubric

1. Unsatisfactory 2. Less Than

Satisfactory

3. Satisfactory 4. Good 5. Excellent Total

Content 80%

Subjective Data

• Chief complaint
• Past medical history
• Family history
• Social/Spiritual history
• Focused review of systems
• Functional health pattern assessment
• Cluster the data and determine/modify differential diagnoses Objective Data
• Complete focused physical exam including related systems.
• Identification of diagnostic data. 0 - 10 points Minimal to no subjective or objective data. 11 - 14 points Insufficient subjective and/or objective data 15 - 16 points Includes all the elements of subjective and objective data but lacks in comprehensiveness 17 - 18 points Includes all the elements of subjective and objective data in a moderately comprehensive manner. 19 - 20 points Includes every element of the subjective and objective data in a comprehensive detailed manner for each element. Assessment Determined nursing diagnosis(es) and collaborative problem(s). Plan For each nursing 0 - 10 points Does not clearly include assessment, plan and interventions. Interventions are not 11 - 14 points Includes incomplete assessment, plan and/or interventions Interventions loosely 15 - 16 points Adequately includes an assessment, plan and interventions. Interventions are evidence-based for 17 - 18 points Includes assessment, plan and interventions. All interventions are 19 - 20 points Clearly includes and articulates assessment, plan and interventions. All interventions are

diagnosis or collaborative problem, determined at least two specific measurable patient outcomes. (refer to examples in assignment description) The plan also includes nursing interventions that are evidence-based with rationale and target specific etiologies of illness or risk behaviors. Interventions integrate the unique needs of the patient. clearly evidence-based and do not include rationale. Interventions do not target specific etiologies of illness or risk behaviors. Interventions do not integrate the unique needs of the patient. supported by evidence with minimal rationale. Some interventions target specific etiologies of illness or risk behaviors. Interventions do not clearly integrate the unique needs of the patient. . the most part with rationale provided. Interventions target specific etiologies of illness or risk behaviors. Some interventions integrate the unique needs of the patient. evidence-based through 1 EBP article and a standard of care that is evidence-based. Rationale for each intervention apparent Targeted etiologies of illness or risk behaviors present. Interventions integrate most unique needs of the patient. evidence-based by > EBP articles and standards of care that are evidence-based. Rationale for each intervention is clearly identified with comprehensive rationale provided and targeted etiologies of illness or risk behaviors are clearly present in a comprehensive manner. Each intervention integrates the unique needs of the patient. Evaluation Describe the methods used to evaluate each of the patient outcomes. 0 - 10 points Evaluation does not clearly describe the methods used to evaluate each patient outcome. 11 - 14 points Incomplete description of the methods used to evaluate each patient outcome. 15 - 16 points Some detail in describing the methods used to evaluate each patient outcome. 17 to 18 points Moderate detail in describing the methods used to evaluate each patient outcome. 19 - 20 points Comprehensive detail in describing the methods used to evaluate each patient outcome.

Conclusion Identify three research questions based on the case study. Support the three research questions with a 0 - 10 points Less than 2 research questions based on the case study are without EBP/descriptive 10 - 14 points Identifies 2 research questions based on the case study. Less than two EBP 15 - 16 points Identifies 3 research questions. Two EBP resources and one descriptive resource. 17 - 18 points Identifies 3 research questions based on the case study. Two EBP resources and one 19 - 20 points Identifies 3 research questions based on the case study. Three EBP resources and

Language Use and Audience Awareness (includes sentence construction, word choice, etc.) 1 Point Inappropriate word choice and/or sentence construction, lack of variety in language use. Writer appears to be unaware of audience. Use of “primer prose” indicates writer either does not apply figures of speech or uses them inappropriately. 2 Points Some distracting and/or inconsistencies in language choice (register), sentence structure, and/or word choice are present. Sentence structure may be occasionally ineffective or inappropriate. 3 Points Sentence structure is correct and occasionally varies. Language is appropriate to the targeted audience for the most part. 4 Points The writer is clearly aware of audience; uses a variety of sentence structures and appropriate vocabulary for the target audience. 5 Points The writer uses a variety of sentence constructions, figures of speech and word choice in unique and creative ways that are appropriate to purpose, discipline, and scope. /

APA Format

References 0 Points No references. 0.5 Points Insufficient use of references. 1 Points References are loosely used. 1.5 Point References are correctly utilized, but not often. 2 Points Correct references. Headings 0 Points Headings are not used or only one heading is identified. Reading is impeded without use of headings. 0.5 Points Headings are incorrect. Headings are appropriate to subsequent written information. Uses at least 2 headings that 1 Points Headings are partially incorrect. Headings are correlated with subsequent written information that 2 Point Headings are usually correct. Headings reflect assignment description for the most part. Headings 3 Point Headings are used correctly. Headings reflect assignment description and are appropriate to their subsequent written

reflect assignment description. reflects assignment description for the most part. guide the reader along. information clearly guiding the reader along with ease. / TOTAL / Strengths Areas To Improve Additional Comments: Revised 9/