Help with critical thinking on case study please

athena55, BSN, RN · Apr 5, 2009

I have a case study due for my Med-Surg II class and am stuck on the critical thinking part. They want us to describe a problem identified for our client for which there was more than one possible solution and the different approaches I could have used with the client. It goes on to say we need to identify one evidence based clinical practice guideline that supports my approach.
I'm really confused on this. My pt. is a 25 y.o female with a wound infection and osteomylitis of the foot. She is morbidly obese and a non-compliant type II diabetic. As for identifying the problem with our client, is it something I as a nurse do independently or can it be collaborative or dependent? For example, my client had the choice of having a transmetatarsal amputation or 6 weeks of treatment with antibiotics and then re-evaluation. Can I use that? And for the clinical practice guideline, where do I get that? On line journal articles or from my book?

Gosh I am so not the expert but if I were doing this for my program I would look at why this particular patient is being "non-compliant". Is it because of side effects? Cost of the medications? Inability to adequately care for her wound? Has she been able to self-monitor her blood sugar levels? What are her living arrangements? i.e., does she live alone? How has her HA1c been? Glycemic control would be number 1 on my hit parade before even thinking about surgery or having her undergo rigorous antibiotic treatment.

If this patient were admitted to a hospital then upon admission to your unit you would start the collaborative process by identifying her problems and obtaining consults: endocrinology or the diabetes educator, nutrition, PT/OT. Does she have any other co-mobilities?

If she opted for the six weeks of antibiotic treatments would she need to be admitted or could she have visiting nurse services administer the meds at her home. Is she capable of taking care of, say for example, a PICC line and would she be able to self administer the needed antibiotics? Does she have any limitations in her ability to read, understand? Would she have any physical limitations to aseptically care for her PICC line, if this were inserted?

As for the clinical practice guideline I am not sure....I guess you could do an on-line search. Try, just as ONE example, www.nurse.com and check out their resources. You could go on, from there.

I am sure others with much more experience can guide you...

GCCTX · Apr 5, 2009

Thanks for the reply. The patient being non-compliant is a complicated issue. It depends on the day and who she speaks to as to her reasons. She told the diabetic counselor she is following the 1800 calorie ADA diet and practices carb control, calorie counting etc. She told me she checks her blood sugar regularly and uses the insulin as directed. She told the case manager she would, "eat what I want, when I want and no one will stop me." Her A1C is 10.1, and she gets very defensive when asked about control of the diabetes. She, so far, has chosen to have the long-term antibiotics and is in-patient for the treatment. As of late last week she decided she'd rather have the surgery, though the surgeon is reluctant to do it because of her non-compliance issues.

What do you think of me using the blood sugars as my issue? Saying the options for the elevated blood sugars are to either use sliding scale coverage or to use a strict diet. The action I took was sliding scale coverage and the reason was because I know she is non-compliant and will not adhere to a strict diet. I could use the ADA clinical practice guidelines as my source. Does this sound correct?

Daytonite, BSN, RN · Apr 5, 2009

case studies are care plans. care plans are done using the nursing process to determine the patient's problems. what you need to do with this scenario is begin with step #1 of the nursing process which is assessment. assessment consists of:

reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking
a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)

since this is a non-real patient, you have to work with the information that was given to you. so, that is:

a 25 y.o female
type ii diabetic
osteomylitis of the foot
a wound infection
morbidly obese
non-compliant
choice of transmetatarsal amputation or 6 weeks of treatment with antibiotics and then re-evaluation

what would you diagnose her nursing problems to be based on the above information? once you do that you need to develop nursing interventions for them and that is where you must find evidence based clinical practice guidelines. nursing diagnosis handbook: a guide to planning care by betty j. ackley and gail b. ladwig is very good about listing evidenced based articles to go with the nursing interventions listed with the nursing diagnoses in their book. some of them are listed with the online diagnoses here and they will apply to this patient: http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/, but you need to develop you plan of care first. good luck.