Case study...

Guests · Jul 10, 2014

This is a thread that is billed as an invitation to develop a nursing plan of assessment and care, but is almost 100% focused on medical diagnoses and assessment.

Therefore you will perhaps understand why I sit here and yell, "NURSING!!! NURSING!!!"

Well, I don't do the whole nursing diagnosis thing.

For me, the salient points were...

How do you get an intoxicated patient to and from the scanner safely?

I suppose one could do the "risk for injury," "risk for ineffective ventilation," etc... I just don't approach it that way.

I just think, "what could go wrong and what will I do?" and "what is the likelihood of this going bad?"

I think I've approached it 100% from a nursing perspective... though I don't mind the medical stuff since, IMO, nursing and medicine are not the separate entities that so many proclaim so vociferously.

Esme12, ASN, BSN, RN · Jul 10, 2014

This is a thread that is billed as an invitation to develop a nursing plan of assessment and care, but is almost 100% focused on medical diagnoses and assessment.

Therefore you will perhaps understand why I sit here and yell, "NURSING!!! NURSING!!!"

I was not looking at this from a "nursing diagnosis"/care plan standpoint per se....but how to process care of the patient when you are the nurse.

I think in order to process a nursing diagnosis and care one needs to have medical diagnosis knowledge and understanding and understanding of the possible sequence of events that accompany that sequence of events in order to develop a nursing plan of care.

For example...all MCA or MVC are NOT the same. One that has encroachemnt into the vehicle has a higher likelihood of increased injury than one that pulled a bumper off. A Starred windshield means that driver was not wearing a seal belt or the belt broke and more indicative of a head injury. Someone with ribs fractures on the left anterior chest are highly suspect for great vessel injury....I now need to think xy....they are at risk for decreased cardiac output, bleeding sand shock....now I need to take the B/P in both arms...check heart tones...be sure the MD gets a stat AP chest and look at the mediastinum/thorasic arch. The patient with abdominal blunt trauma has sever shoulder pain...that might be the spleen...they are at risk for bleeding....I need to watch for....hypotension. I go through a check list in my head of potentials (my assessment) and actual and develop my pan of care.

Now if I were to write them down...risk of bleeding, pain, decreased cerebral perfusion, acute confusion.

From here I plan my care.

I think students are lacking the clinical experience and train of thought that accompany disease processes. It is gained from experience. You and I see a critical patient and we check off things in our head...this patient has xyz...this includes abc....they are showing me RST...I need to EFG because RST is life threatening for this patient. Students are not getting this experience.

IMHO I think going over case scenarios is important....teach them the important assessment and why some physical sign is important over another (critically think)...THEN and only THEN can they develop the nursing plan of care based on that assessment.

smf0903 · Jul 10, 2014

I get where GrnTea is coming from, but I also agree with what you're saying Esme12. I also agree with .[COLOR=#003366]♪♫ in my ♥ ..heck, I apparently agree with all of you LOL.

What I mean is that, like [COLOR=#003366]♪♫ in my ♥ said, I believe you really can't have medical dx info and nursing info separate by-and-large. Can we do nursing dx without the medical dx? Sure we could, but I think knowing the medical dxs allows for anticipation of needs, etc. On the flip side of that coin, as can be seen here on AN all the time, many people try to make nursing dxs and car plans SOLELY from the medical dxs, and that's not the way to make a nursing dx or plan of care...the I-came-up-with-a-dx-first-and-now-need-to-make-info-fit deal. Maybe that sounds contradictory to what I said earlier, but I think they are two separate things.

And Esme12, oh my gosh if I could a thousand times "like" the part about students not doing enough case studies, I would!!! Other than actually dealing with patients, I think it's the best way to learn. That is why I love when these case studies are posted on here. I know things will start to come together more as I am exposed to these situations in the hospital setting, but for now, reading the text is like learning about the ocean by standing on a cliff over the Atlantic. Sure you see it, you know there's water, maybe you see a fish pop up out of the water, but 99.99% of what there is to learn you will never know until you're in the thick of it. That's what case studies are to me. I can spend literally hours upon hours on one case study, looking up meds, looking up s/sx, looking up worst-case scenarios, looking up dx procedures, you name it! I answer these on here from what I may already know or think I may know, but later I spend tons of time looking stuff up based on what you all give as guidance. I have learned a lot just from the couple of case studies that have been posted on here. Learning the ABCs from the text is vastly different from real life cases. And in all honesty, sometimes I think how far I've come since starting school but then I read one of these case studies and think holy cow, I know nothing!!! I really wish nursing school was like back in the day when you spent tons of time in the clinical setting. I think that type of curriculum would turn out students much better prepared to be nurses (just my opinion).

Hope everyone has a great day

Esme12, ASN, BSN, RN · Jul 10, 2014

GrnTea and I agree of aessentially everything...we would make a bag up nursing team and instructors...maybe we should look into a mentoring/teaching joint venture....hummmmm.

I know you all have sim/lab time...however the focus is on pass/fail and being judged. I volunteer my time at a nursing program to sit in the sim lab and run scenarios. No grade. No points. No judging. You show up we learn. The students tell me what they would do. I discuss what they should/could do and consider and why or why not. It gives me such joy to watch the students have that...moment... when it all clicks.

Carpediem1012, BSN, RN · Jul 10, 2014

Maybe we need a "case study" study group in the student forum..... :)

smf0903 · Jul 10, 2014

Maybe we need a "case study" study group in the student forum..... :)

Heck yeah!!

smf0903 · Jul 10, 2014

We do have sim lab in our third semester. It's rather lacking though (and we've said that on our class reviews). There was a sim lab CLASS offered last year, which I took, and it was far better than the biweekly sim labs we had third semester. We told the instructors of the sim lab that that class should be required for the nursing program, it was that good. We had some days that med students came in and presented as patients after the sim lab, days in post conference when we had to rate patients according to priority and give reasons why we put in said order...it really was a great experience. Our school has a beautiful sim lab, and I think it's a shame that they don't utilize it more throughout the program.

nurseprnRN, BSN, RN · Jul 10, 2014

What many people forget, too, is that there is no rule against using a medical dx as a causative factor for many nursing diagnoses. I know there are lots of faculty who lie to their students about that (or, to be charitable, perhaps they forgot), but it's a trivial matter to look it up. Many, many, many nursing diagnoses include medical diagnoses as related/causative factors.

I'm also all for case studies-- lord knows that a lot of nursing learning is experiential, and as Shakespeare said (I can quote Shakespeare, right?), "Experience holds a dear (meaning, "expensive")school, and a fool will learn in no other." We've all learned a lot from just being there and doing it. Book/class learning is critical, but it's not the end of our education.

I just hate to see students reinforced in the idea that medical diagnosis comes first and is of primary importance, and that we can't do anything well without knowing it, and we are supposed to figure it out. They hear that enough, even if unintentionally, in their patho classes and being assigned those handbooks that list nursing interventions under medical diagnoses. And yes, I can give you a bazillion examples of medical diagnoses I figured out before physicians, so no need to sing me that song. But those same physicians don't know squat about nursing expertise, and that's what students need to know and internalize.

That's my objection to putting NURSING!! in second position in a nursing forum.

Carpediem1012, BSN, RN · Jul 11, 2014

My thought is this: the more info I have, the better nursing implementation I can perform. If I know the med dx, the patho, the anatomy, my interventions are more likely to be appropriate to the patient's response to their condition. Too many nursing students come up with valid, yet less priority nsg dx when they don't understand the whole picture. As well, to advocate for the pt, one must be able to speak "doctor"(lol) to be heard.

thehumbleRN · Jul 14, 2014

I'm also thinking cautions for seizures. If coming down off alcohol is there a concern for drug use too. I think the glucose was a throw off. Often drinking will decrease BS levels. At least they do in pts with hx of DM. Like the O2, airway precautions mentioned, and my favorite above mentioned was the possibility of aspirating if he vomits.

....is there an answer to this or are we just brainstorming?

Guests · Jul 15, 2014

I'm also thinking cautions for seizures. If coming down off alcohol is there a concern for drug use too. I think the glucose was a throw off. Often drinking will decrease BS levels. At least they do in pts with hx of DM. Like the O2, airway precautions mentioned, and my favorite above mentioned was the possibility of aspirating if he vomits.
....is there an answer to this or are we just brainstorming?

There's nothing about this patient that puts him at high risk for seizures... though it's not out of the question if it turned out that he had a rapidly blooming bleed... the concern for which is why they wanted to buzz him so quickly.

I don't know what you mean by "I think the glucose was a throw off" -- obviously we always check sugars on anyone who's altered; his was normal... meaning it had no bearing on the case.

You spotted one of the pearls in the story... drunk people puke... and laying on their back, strapped to the scanner table, with a nonrebreather in place put him at very high risk... which is why I (a) had the sxn set up, turned on, and sitting next to the scanner and (b) was watching him like a hawk.

This wasn't an academic exercise, it was a case study formed from my personal experiences in the ED. Therefore, it doesn't have a 'correct' answer... except that we were unable to buzz him until we paralyzed and intubated him.

thehumbleRN · Jul 15, 2014

Thank you so much for all the info! I LOVE to be challenged to think. I'm so new that I don't have the experience yet I believe would be valuable but this really helps.

I was thinking seizures if he drinks alot, thinking DT's but I realize that it's probably not an immediate threat. I wasn't sure why you brought up BS other than to r/o hypoglycemia so I thought you may have been testing....they did that alot in school. Thank you again and give me more!!!