Round white pill with blue specks fr

Concept Mapping On Clincal Case Studies For Medical Surgical Nursing

Clinical Reasoning Cases in Nursing

SEVENTH EDITION

Mariann Harding, PhD, RN, CNE Associate Professor, Department of Nursing, Kent State University at Tuscarawas, New Philadelphia, Ohio

Julie S. Snyder, MSN, RN-BC Lecturer, School of Nursing, Regent University, Virginia Beach, Virginia

Table of Contents

Cover image

Inside Front Cover

Brief Contents

Title page

Copyright

Contributors

Reviewers

Introduction

What Is Clinical Reasoning?

What Is New in This Edition

The “How To” of Case Studies

Acknowledgments

1: Perfusion

Case Study 1

Case Study 2

Case Study 3

Case Study 4

Case Study 5

Case Study 6

Case Study 7

Case Study 8

Case Study 9

Case Study 10

Case Study 11

Case Study 12

Case Study 13

Case Study 14

Case Study 15

Case Study 16

Case Study 17

Case Study 18

Case Study 19

Case Study 20

Case Study 21

Case Study 22

2: Gas Exchange

Case Study 23

Case Study 24

Case Study 25

Case Study 26

Case Study 27

Case Study 28

Case Study 29

Case Study 30

Case Study 31

Case Study 32

Case Study 33

Case Study 34

Case Study 35

Case Study 36

Case Study 37

Case Study 38

Case Study 39

Case Study 40

3: Mobility

Case Study 41

Case Study 42

Case Study 43

Case Study 44

Case Study 45

Case Study 46

Case Study 47

Case Study 48

Case Study 49

Case Study 50

Case Study 51

Case Study 52

Case Study 53

Case Study 54

4: Digestion

Case Study 55

Case Study 56

Case Study 57

Case Study 58

Case Study 59

Case Study 60

Case Study 61

Case Study 62

Case Study 63

Case Study 64

Case Study 65

Case Study 66

5: Urinary Elimination

Case Study 67

Case Study 68

Case Study 69

Case Study 70

Case Study 71

Case Study 72

Case Study 73

Case Study 74

Case Study 75

6: Intracranial Regulation

Case Study 76

Case Study 77

Case Study 78

Case Study 79

Case Study 80

Case Study 81

Case Study 82

Case Study 83

Case Study 84

Case Study 85

Case Study 86

Case Study 87

Case Study 88

7: Metabolism and Glucose Regulation

Case Study 89

Case Study 90

Case Study 91

Case Study 92

Case Study 93

Case Study 94

Case Study 95

Case Study 96

Case Study 97

Case Study 98

Case Study 99

Case Study 100

8: Immunity

Case Study 101

Case Study 102

Case Study 103

Case Study 104

Case Study 105

Case Study 106

9: Cellular Regulation

Case Study 107

Case Study 108

Case Study 109

Case Study 110

Case Study 111

Case Study 112

Case Study 113

Case Study 114

Case Study 115

10: Tissue Integrity

Case Study 116

Case Study 117

Case Study 118

Case Study 119

11: Cognition

Case Study 120

Case Study 121

Case Study 122

12: Infection and Inflammation

Case Study 123

Case Study 124

Case Study 125

Case Study 126

Case Study 127

Case Study 128

Case Study 129

Case Study 130

13: Developmental

Case Study 131

Case Study 132

Case Study 133

Case Study 134

Case Study 135

Case Study 136

14: Reproductive

Case Study 137

Case Study 138

Case Study 139

Case Study 140

Case Study 141

Case Study 142

Case Study 143

15: Mood, Stress, and Addiction

Case Study 144

Case Study 145

Case Study 146

Case Study 147

Case Study 148

Case Study 149

Case Study 150

Inside Front Cover

Brief Contents Chapter 1 Perfusion, 1 Chapter 2 Gas Exchange, 99 Chapter 3 Mobility, 187 Chapter 4 Digestion, 247 Chapter 5 Urinary Elimination, 301 Chapter 6 Intracranial Regulation, 339 Chapter 7 Metabolism and Glucose Regulation, 401 Chapter 8 Immunity, 455 Chapter 9 Cellular Regulation, 483

Chapter 10 Tissue Integrity, 527 Chapter 11 Cognition, 547 Chapter 12 Infection and Inflammation, 561 Chapter 13 Developmental, 593 Chapter 14 Reproductive, 615 Chapter 15 Mood, Stress, and Addiction, 645

Copyright

CLINICAL REASONING CASES IN NURSING, SEVENTH EDITION ISBN: 978-0-323-52736-1

Copyright © 2020 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or

http://www.elsevier.com/permissions
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2016, 2013, 2009, 2005, 2001, 1996.

Library of Congress Control Number: 2018954100

Executive Content Strategist: Lee Henderson Content Development Specialist: Laura Goodrich Publishing Services Manager: Julie Eddy Senior Project Manager: Tracey Schriefer Design Direction: Margaret Reid

Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors

Meghan Davis, MSN-Ed, CCRN, RN Registered Nurse, Virginia Beach, Virginia

Jatifha C. Felton, MSN-Ed, APRN, ACNCP-AG, CCRN Critical Care Nurse Practitioner, Chesapeake Regional Healthcare, Chesapeake, Virginia

Sherry D. Ferki, RN, MSN Adjunct Faculty, School of Nursing, Old Dominion University, Norfolk, Virginia

Joanna Van Sant, MSN, RN Clinical Nurse Manager–Oncology Unit, Sentara Northern Virginia Medical Center, Woodbridge, Virginia

Reviewers

Heidi Matarasso Bakerman, RN, BA Nursing, MscN Nursing Instructor, Nursing Vanier College, Montreal, Quebec, Canada

Beverly Banks, MSN, BSN, RN Full Time Faculty, Nursing, Alpena Community College, Alpena, Michigan

Mitzi L. Bass, MPH, MSN, RN Assistant Professor of Nursing, School of Nursing and Health Professions, Baltimore City Community College, Baltimore, Maryland

Michelle Bayard, BSN, RN Teacher, Faculty of Careers and Technology: Nursing Vanier College, Montreal, Quebec, Canada

Diana Lynne Burgess, MSN, RN Nursing Faculty—ADN Program, St. Petersburg College of Nursing, St. Petersburg, Florida

Lacey M. Campbell, MSN, RN Program Coordinator Accelerated LPN to RN Program, Texas County Technical College, Houston, Missouri

Diane Cohen, MSN, RN Professor—Nursing, MassBay Community College, Framingham, Massachusetts

Nicola Eynon-Brown, RN(EC), BNSc, MN, NP, CPNP- PC Professor, School of Baccalaureate Nursing, St. Lawrence College, Brockville, Ontario, Canada

Melissa Marie Fischer, MSN, RN ADN Nursing Faculty, Nursing, Blackhawk Technical College, Janesville, Wisconsin

Victoria A. Greenwood, MSN, MSEd, RN-BC Assistant Professor, Nursing, The Sage Colleges, Troy, New York

Rose A. Harding, MSN, RN Coordinator, Standardized Test

Evaluation Committee, JoAnne Gay Dishman School of Nursing, Lamar University, Beaumont, Texas

Antonea Jackson, PhD (c), MSN, RN CNE Clinical Assistant Professor, Nursing, Prairie View A&M University, Houston, Texas

Llynne C. Kiernan, DNP, MSN, RN-BC Assistant Professor of Nursing, Nursing, Norwich University, Northfield, Vermont

Tonie Metheny, MS, RN, CNE Clinical Instructor, Nursing, Fran and Earl Ziegler College of Nursing, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

Kathleen S. Murtaugh, MSN, RN, CNA Assistant Professor, Nursing, St. Elizabeth School of Nursing/University of Saint Francis, Lafayette, Indiana

Karen Noss, MSN, RN Professor, Nursing Department, Luzerne County Community College, Nanticoke, Pennsylvania

Alicia Powell, MSN, RNC Clinical Nurse Educator, Women’s Services, Chesapeake Regional Healthcare, Chesapeake, Virginia

Deborah J. Pumo, MS, RN, EdD Nursing Professor, Nursing Department, Illinois Valley Community College, Oglesby, Illinois

Sandra A. Ranck, MSN, RN Program Administrator, Auburn Practical Nursing Program, Auburn Career Center, Concord Township, Ohio

Cherie R. Rebar, PhD, MBA, RN, COI Professor of Nursing, Wittenberg University, Springfield, Ohio

Alicia N. Rose, ACNS-BC, PMHNP-BC, RN-BC, CSAC Psychiatric Nurse Practitioner, Meridian Psychotherapy, Virginia Beach, Virginia

Jane Tyerman, BA, RN, BScN, MScN, PhD Professor, Trent/Fleming School of Nursing, Trent University, Peterborough, Ontario, Canada

Introduction

To provide safe, quality care, nurses need to have well-developed clinical reasoning skills. As new graduates, you will make decisions and take actions of an increasingly sophisticated nature. You will encounter problems you have never seen or heard about during your classroom and clinical experiences. You will have to make complex decisions with little or no guidance and limited resources.

We want you to be exposed to as much as possible during your student days, but more importantly, we want you to learn to think. You cannot memorize your way out of any situation, but you can think your way out of any situation. We know that students often learn more and faster when they have the freedom to make mistakes. This book is designed to allow you to look at how to solve problems and find answers without the pressure of someone’s life hanging in the balance. We want you to do well. We want you to be the best. It is our wish for you to grow into confident, competent nursing professionals. We want you to be very, very good at what you do!

What Is Clinical Reasoning? Clinical reasoning is not memorizing lists of facts or the steps of procedures. Instead, clinical reasoning is an analytical process that can help you think about a patient care issue in an organized and efficient manner. Five steps are involved in clinical reasoning. Thinking about these steps may help you when you work through the questions in your cases. Here are the five steps with an explanation of what they mean.

1. Recognize and define the problem by asking the right questions:

Exactly what is it you need to know? What is the question asking?

2. Select the information or data necessary to solve the problem or answer the question: First you have to ask whether all the necessary information is there. If not, how and where can you get the additional information? What other resources are available? This is one of the most difficult steps. In real clinical experiences, you rarely have all of the information, so you have to learn where you can get necessary data. For instance, patient and family interviews, nursing charting, the patient medical chart, laboratory data on your computer, your observations, and your own physical assessment can help you identify important clues. Of course, information can rapidly become outdated. To make sure you are accessing the most current and accurate information, you will occasionally need to use the Internet to answer a question.

3. Recognize stated and unstated assumptions; that is, what do you think is or is not true? Sometimes answers or solutions seem obvious; just because something seems obvious does not mean it is correct. You may need to consider several possible answers or solutions. Consider all clues carefully and do not dismiss a possibility too quickly. Remember, “You never find an answer you don’t think of.”

4. Formulate and select relevant and/or potential decisions: Try to think of as many possibilities as you can. Consider the pros and cons of the consequences of making each decision. What is the best answer/solution? What could go wrong? This requires considering many different angles. In today’s health care settings, decision making often requires balancing the well- being needs of the patient, the preferences and concerns of the patient and caregiver, and financial limitations imposed by the reimbursement system. In making decisions, you need to take into account all relevant factors. Remember, you may need to explain why you rejected other options.

5. Draw a valid, informed conclusion: Consider all data; then

determine what is relevant and what makes the most sense. Only then should you draw your conclusion.

It may look as if this kind of reasoning comes naturally to your instructors and experienced nurses. You can be certain that even experienced nurses were once where you are now. The rapid and sound decision making that is essential to good nursing requires years of practice. The practice of good clinical reasoning leads to good thinking in clinical practice. This book will help you practice the important steps in making sound clinical judgments until the process starts to come naturally.

What Is New in This Edition The conceptual approach to nursing education is a new way to manage information and help students develop clinical reasoning skills. In this edition, we chose to reorganize the cases in each section by health-illness concepts. Within each section, you will see the basic principles of that concept applied in exemplars, or models of that concept, that cross care settings, the life span, and the health-illness continuum. For example, you may be enrolled in a course that focuses on gas exchange, including risk factors, physiologic mechanisms, assessment, and interventions to promote optimal oxygenation. Based on prevalence and incidence, exemplars such as pneumonia, influenza, and asthma, are used to show how to apply principles across ages and care settings. To ensure that there are cases that cover common exemplars you may see in class, we added over 20 new cases. Like the existing cases, each of these are adaptations of actual scenarios encountered in the clinical setting—there is no better way to learn than from real patients!

Because nurses play a vital role in improving the safety and quality of patient care, you need to learn interventions you will use to deliver safe care and enhance patient outcomes. To help you learn key principles, you will note questions marked with a

. These questions involve scenarios that typically include inherent

risks, such as medication administration, fall and pressure injury reduction protocols, and preventing health care–associated infections.

The “How To” of Case Studies When you begin each case, read through the whole story once, from start to finish, getting a general idea of what it is about. Write down things you have to look up. This will help you move through the case smoothly and get more out of it. How much you have to look up will depend on where you are in your program, what you know, and how much experience you already have. Preparing cases will become easier as you advance in your program.

Acknowledgments

We would like to express our appreciation to the editorial Elsevier staff, especially Laura Goodrich, Lee Henderson, and Tracey Schriefer for their professional support and contributions in guiding this text to publication. We extend a special thanks to our reviewers, who gave us helpful suggestions and insights as we developed this edition.

Mariann’s gratitude goes to those she loves most—her husband, Jeff, and her daughters, Kate and Sarah. She gives a special thanks to her students, colleagues, and patients; each inspire her passion for nursing and education. Lastly, Mariann praises God, who has graciously bestowed more blessings than could ever be imagined.

Julie thanks her husband, Jonathan, for his love, support, and patience during this project. She is grateful for the encouragement from daughter Emily, son-in-law Randy, and parents Willis and Jean Simmons. Julie appreciates the hard work of colleagues Sherry Ferki, Jatifha Felton, Meghan Davis, Joanna Van Sant, Alicia Rose, and Alicia Powell as contributors and reviewers for this edition. She is especially thankful to the students, whose eagerness to learn is an inspiration. Most importantly, Julie gives thanks to God, our source of hope and strength.

1

Perfusion

Case Study 1 Name_________________________________ Class/Group ______________________________ Date ___________

Scenario M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can’t catch my breath and my legs are as big as tree trunks.” After further questioning, you learn she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds (0.5 to 1 kg) every day since her discharge.

1. What error in discharge teaching most likely occurred? 2. An echocardiogram revealed that her ejection fraction (EF) is

30%, but it was 40% a month ago. What is EF, and what does the decreased number indicate?

Case Study Progress During the admission interview, the nurse makes a list of the medications M.G. took at home.

Chart View

Nursing Assessment: Medications Taken at Home

Enalapril (Vasotec) 5 mg PO bid

Pioglitazone (Actos) 45 mg PO every morning

Furosemide (Lasix) 40 mg/day PO

Potassium chloride (K-Dur) 20 mEq/day PO

3. Which of these medications may have contributed to M.G.’s HF? Explain.

4. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce HF? Select all that apply.

a. Cause systemic vasodilation b. Increase cardiac contractility c. Reduce preload and afterload d. Prevent the conversion of angiotensin I to

angiotensin II e. Block sympathetic nervous system stimulation to

the heart f. Promote the excretion of sodium and water in the

renal tubules

Case Study Progress After reviewing M.G.’s medications, the cardiologist writes the following medication orders.

Chart View

Medication Orders

Enalapril (Vasotec) 5 mg PO bid

Carvedilol (Coreg) 3.125 mg PO twice daily

Metformin (Glucophage)

500 mg twice daily

Furosemide (Lasix) 80 mg intravenous push (IVP) now, then 40 mg/day IVP

Potassium chloride (K- Dur)

20 mEq/day PO

5. What is the rationale for changing the route of the furosemide (Lasix)?

6. You give furosemide (Lasix) 80 mg IVP. Identify at least 4 parameters you would use to monitor the effectiveness of this medication.

7. What lab tests should be ordered for M.G. related to the order for furosemide (Lasix)? Select all that apply.

a. Sodium level b. Potassium level c. Magnesium level d. Coagulation studies e. Serum glucose level f. Complete blood count

8. What is the reason for ordering the beta blocker carvedilol? a. Increase urine output b. Cause peripheral vasodilation c. Increase the contractility of the heart d. Reduce cardiac stimulation from catecholamines

9. You assess M.G. for conditions that may be a

contraindication to carvedilol. Which condition, if present, may cause serious problems if she takes this medication?

a. Angina b. Asthma c. Glaucoma d. Hypertension

Case Study Progress One day later, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added to her orders.

10. What is the mechanism of action of digoxin? a. Causes systemic vasodilation b. Increases cardiac contractility and cardiac output c. Blocks sympathetic nervous system stimulation to

the heart d. Promotes the excretion of sodium and water in the

renal tubules 11. Which findings from M.G.’s assessment would indicate an

increased possibility of digoxin toxicity? Explain your answer. a. Digoxin level 1.6 ng/mL (2.05 mmol/L) b. Serum sodium level of 139 mEq/L (138 mmol/L) c. Apical heart rate of 64 d. Serum potassium level of 2.2 mEq/L (2.2 mmol/L)

12. When preparing to give the digoxin, you notice that it is

available in milligrams (mg) not micrograms (mcg). Convert 125 mcg to mg.

13. After 2 days, M.G.’s symptoms improve with intravenous diuretics and digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate for achievement of a euvolemic state. What will determine whether the oral dose will be adequate for discharge to be considered?

14. M.G. is ready for discharge. According to the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission?

15. After the teaching session, the nurse asks M.G. to “teach back” one important concept of care at home. Which statement by M.G. indicates a need for further education? Explain your answer.

a. “I will not add salt when I am cooking.”

b. “I will use a weekly pill calendar box to remind me to take my medicine.”

c. “I will weigh myself daily and tell the doctor at my next visit if I am gaining weight.”

d. “I will try to take a short walk around the block with my husband three times a week.”

Case Study Outcome After M.G. has been at home for 2 days, the STOP Heart Failure Nurse Navigator calls to ask about her progress. M.G. reports that her weight has not increased since she has been home and she is breathing more easily.

Case Study 2 Name _________________________________ Class/Group _____________________________ Date _____________

Scenario M.P. is a 65-year-old African American woman who comes to the clinic for a follow-up visit. She was diagnosed with hypertension (HTN) 2 months ago and was given a prescription for a thiazide diuretic but stopped taking it 2 weeks ago because “it made me dizzy and I kept getting up during the night to empty my bladder.” During today’s clinic visit, she expresses fear because her mother died of a stroke (cerebrovascular accident [CVA]) at M.P.’s age, and M.P. is afraid she will suffer the same fate. She states, “I’ve never smoked and I don’t drink, but I am so afraid of this high blood pressure.” You review the data from her past clinic visits.

Chart View

Family History

Mother, died at age 65 years of CVA Father, died at age 67 years of myocardial infarction (MI) Sister, alive and well, age 62 years Brother, alive, age 70 years, has coronary artery disease (CAD),

HTN, type 2 diabetes mellitus (DM)

Patient Past History

Married for 45 years, 2 children, alive and well, 6 grandchildren Cholecystectomy, age 42 years Hysterectomy, age 48 years

Blood Pressure Assessments

January 2: 150/92 January 31: 156/94 (given prescription for hydrochlorothiazide

[HCTZ] 25 mg PO every morning) February 28: 140/90

1. According to the most recent guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, M.P.’s blood pressure (BP) falls under which classification?

2. What could M.P. be doing that is causing her nocturia?

Case Study Progress During today’s visit, M.P.’s vital signs are as follows: BP: 162/102; P: 78; R: 16; T: 98.2°F (36.8 ° C). Her most recent basic metabolic panel (BMP) and fasting lipids are within normal limits. Her height is 5 ft, 4 in (163 cm), and she weighs 110 lb (50 kg). She tells you that she tries to go on walks but does not like to walk alone and so has done so only occasionally.

3. What risk factors does M.P. have that increase her risk for

cardiovascular disease?

Case Study Progress Because M.P.’s BP continues to be high, the provider decides to start another antihypertensive drug and recommends that she try again with the HCTZ, taken in the mornings.

4. According to the JNC 8 national guidelines, describe the drug therapy recommended for M.P. at this time.

5. M.P. goes on to ask whether there is anything else she should do to help with her HTN. She asks, “Do I need to lose weight?” Look up her height and weight for her age on a body mass index (BMI) chart. Is she considered overweight?

6. What nonpharmacologic lifestyle alteration measures might help M.P. control her BP? List 2 examples and explain.

Case Study Progress The provider decreases M.P.’s HCTZ dose to 12.5 mg PO daily and adds a prescription for benazepril (Lotensin) 5 mg daily. M.P. is instructed to return to the clinic in 1 week to have her blood work checked. She is instructed to monitor her BP at least twice a week and return for a medication management appointment in 1 month with her list of BP readings.

7. Why did the provider decrease the dose of the HCTZ? 8. You provide M.P. with education about the common side

effects of benazepril, which can include which of these? Select all that apply.

a. Cough b. Dizziness c. Headache d. Constipation e. Shortness of breath

9. It is sometimes difficult to remember whether one has

taken one’s medication. What techniques might you teach M.P. to help her remember to take her medicines each day? Name at least 2.

10. After the teaching session about her medicines, which statement by M.P. indicates a need for further instructions?

a. “I need to rise up slowly when I get out of bed or out of a chair.”

b. “I will leave the salt shaker off the table and not salt my food when I cook.”

c. “I will call if I feel very dizzy, weak, or short of breath while on this medicine.”

d. “It’s okay to skip a few doses if I am feeling bad as long as it’s just for a few days.”

11. Describe 3 priority problems that will guide M.P.’s nursing care.

Case Study Progress M.P. returns in 1 month for her medication management appointment. She tells you she is feeling fine and does not have any side effects from her new medication. Her BP, checked twice a week at the senior center, ranges from 132 to 136 systolic, and 78 to 82 diastolic.

12. When someone is taking HCTZ and an angiotensin-converting enzyme (ACE) inhibitor, such as benazepril, what lab test results would you expect to be monitored?

Chart View

Laboratory Test Results (Fasting)

Potassium 3.6 mEq/L (3.6 mmol/L)

Sodium 138 mEq/L (138 mmol/L)

Chloride 100 mEq/L (100 mmol/L)

CO2 28 mEq/L (28 mmol/L)

Glucose 112 mEq/L (6.2 mmol/L)

Creatinine 0.7 mg/dL (61.9 mcmol/L)

Blood urea nitrogen (BUN) 18 mg/dL (6.4 mmol/L)

Magnesium 1.9 mEq/L (0.95 mmol/L)

13. What lab test results, if any, are of concern at this time? 14. You take M.P.’s BP and get 138/88. She asks whether these BP

readings are okay. On what do you base your response? 15. List at least 3 important ways you might help M.P. maintain