Unfolding clinical reasoning case study acute

Unfolding clinical reasoning case study acute

Tonja M. Opioid use disorder OUD will touch the careers of future generations of nurses no matter their chosen setting of work.

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It is critical to incorporate OUD education into the nursing school curriculum to prepare these future nurses. Research has shown that the unfolding case study is a beneficial pedagogical modality. It allows for the building of new information and the expansion of critical thinking by encouraging the student to assess and ask questions to receive further information.

An unfolding case study was created that centered on a person who develops OUD and their family. It includes simulations, activities, and discussion topics. The unfolding case study can be integrated throughout the undergraduate curriculum from assessment to critical care.

The unfolding case study can continue into the graduate program, which allows for interdisciplinary use. Opioid use disorder OUD remains a national epidemic since officially being proclaimed a public health emergency in October U. According to the Centers for Disease Control and Preventionprescription and illegal opioid use is the main factor in overdose deaths, with Americans dying daily.

The sheer number of deaths from opioid overdose is frightening, as is the number of families who become secondary victims of addiction. Secondary victims can happen in the earliest stages of life, such as during pregnancy, which can result in neonatal abstinence syndrome NAS. Approximately 8 million children younger than age 18 live with an adult who has an addiction to opioids; a majority of these children are younger than age 5 Blozen, An individual with OUD will continue to use the substance regardless of work issues, money issues, arguing or violence with those close to them, neglect of those same people, losing relationships, and not meeting household responsibilities, which affects countless others Luke et al.

Due to the multitude of people affected by OUD, most health care professionals are likely to interact with people affected by OUD in some fashion. The reality is that OUD will touch the careers of future generations of nurses no matter their chosen work setting. The incorporation of OUD in undergraduate nursing education is critical for the preparation of the next generation of nurses to address the current and future challenges caused by the opioid epidemic.

Innovative and interesting methods are needed to incorporate this information into the already full nursing curriculum. The unfolding case study is one modality to incorporate opioid education into the curriculum.

An unfolding case study was developed that incorporates the entire family, centered on a person who becomes addicted to opioids after being in a car accident.

The scenario involves an opioid-addicted person along with the ramifications of opioid addiction on the family unit, including both pediatric and geriatric individuals. The unfolding case study includes simulations, activities such as plotting and using growth charts, vignettes, and discussion topics. The scenario begins with all three family members having normal assessments, allowing students to focus on assessment skills and plotting on growth charts at the beginning of the curriculum.

The building blocks of addiction and substance abuse then are provided to prepare students to delve further into the evolving case study. The adult client is involved in a motor vehicle accident that requires surgery for a fractured leg and also results in a back injury. This allows for a simulation of taking care of a postoperative client and providing education for opioid medications. The scenario progresses 6 months, and the adult patient is showing signs of opioid abuse at a follow-up appointment, and his son the pediatric client and mother the geriatric client are showing signs of possible abuse.

The unfolding case study culminates at the emergency room with an addicted person in septic shock and the family members being abused. Because this unfolding case study was built with a timeline, it is unique in that it can be integrated throughout the entire undergraduate curriculum from assessment to critical care Table 1.

The scenario also has the ability to continue into the graduate program by having the acute care nurse practitioner participate as the health care provider, which allows the benefit of having an interdisciplinary functionality.

The comprehensive health assessment course is placed in the third semester of the undergraduate curriculum providing the nursing student with the basic skills needed to perform complete assessments across the life span with a focus on the healthy client.

Clinical Reasoning 02: Illness Scripts

Basic written case study vignettes are used to introduce the three focal characters in the unfolding case study throughout the curriculum. During this course, the vignettes are used to provide healthy persons: a healthy year-old man, a healthy year-old woman who is the adult's mother, and a healthy 4-year-old boy who is the man's child. These three characters are used for nursing students to practice plotting on growth charts and writing assessments of healthy clients; the same three individuals will be used in future semesters to provide a comparison.

Promoting Healthy Populations and Pathophysiology-Pharmacology are two courses that occur in the fourth semester of the undergraduate curriculum. Because students need to acquire an understanding of substance use and addiction before proceeding further into the evolving case study, the characters are not incorporated this semester as the nursing students learn the basic building blocks of understanding substance use disorders.

In the Pathophysiology-Pharmacology course, the basic information regarding substance use and addictions is discussed; opioids are included but are not the sole focus.Clinical reasoning involves the use of both analytical and nonanalytical intuitive cognitive processes. Fostering student development of clinical reasoning skills and evaluating student performance in this cognitive arena can challenge educators.

The use of Web-based unfolding cases is proposed as a strategy to address these challenges. Unfolding cases mimic real-life clinical situations by presenting only partial clinical information in sequential segments. Students receive immediate feedback after submitting a response to a given segment.

For the example case given, the approaches used to evaluate individual components of clinical reasoning are provided. Possible future uses of Web-based unfolding cases are described. The authors gratefully acknowledge support from the U. The use of Web-based unfolding cases is proposed as an active learning strategy to both enhance student development of clinical reasoning skills and provide faculty with the ability to evaluate individual student capabilities.

It involves determining what information or data are needed; interpreting that data; generating, testing, and verifying hypotheses; and assessing both the benefits and risks of potential actions to achieve positive outcomes Eva, ; Kassirer, Analytical processes include making conscious causal links between data e. Nonanalytic or intuitive processes, often subconscious, include first impressions and pattern recognition Bowen, ; Kassirer, Use of clinical case studies is an effective method to teach clinical reasoning to advanced practice nurses.

Effective case studies must be sufficiently complex to be engaging, to realistically mimic actual clinical situations, and to challenge students to build on and apply prior knowledge Kim et al. Case studies also provide opportunities for students to accumulate a mental database of illness scripts to help facilitate the development of pattern recognition and intuitive methods Bowen,which can be used to ensure exposure to essential clinical situations Brykezynski, ; Zary et al.

The Web-based unfolding case is a variation of the case study method that addresses these limitations. Using these components, the Web-based unfolding case is structured in distinct segments, such as history, physical examination, assessment, and plan.

New information about the clinical situation is provided at each segment; however, the information is purposefully incomplete Reese, Questions posed at the end of each segment prompt the student to use clinical reasoning skills and apply knowledge relevant to the clinical scenario to identify the additional information needed and how to obtain it. After the student submits a response to a segment, the desired response is provided, along with the information for the next segment.

In this way, all students move through the segments with the same information.Learner Setting s Classroom. Strategy Type Case Studies. The student will describe patient-centered care as applied to the home and long-term care settings.

Knowledge The student will identify safety interventions to protect patients from falls in the long-term care setting. The student will explain how clinical forethought is used to predict potential complications. Skills and Attitudes. Unfolding case studies as a teaching strategy are ideal for novice learners in a pre-licensure nursing program.

The author has used unfolding case studies to illustrate principles of patient-centered care and safety in a Health and Illness course in a concept-based curriculum. First semester students develop knowledge, skills, and attitudes about patient-centered care as they identify salient features in the case study that are opportunities to intervene with patient-centered care. Clinical judgment is required to interpret the complex clinical situations found in current nursing practice Tanner, Lack of clinical judgment poses a risk to patients and can lead to negative patient outcomes.

Clinical judgment requires forethought, which is the process of looking ahead to the needs of the patient to prevent problems before they occur. Nurse Educators are challenged with writing case studies that require students to see how clinical judgment could facilitate safety and patient-centered care. Including aspects of health aids students in understanding the context of the story.

To begin this learning process, students receive the first narrative of the unfolding case study and are asked to underline words that stand out as important. Novice student nurses, limited by lack of experience, tend to focus more on the physical aspects of the patient and less on patient preferences and values.

As students encounter additional case studies throughout the semester, they begin to recognize patient-centered care as an integral part of patient care. The advantage of unfolding case studies is that they reveal information incrementally, which mirrors nursing practice. In unfolding case studies, students are asked to use clinical forethought to predict what could happen next. Reflecting backward on the patient trajectory highlights what clinical forethought might have predicted.

Students are asked to reflect on steps they might have taken to accommodate patient preferences patient-centered care in the case study. Students get a glimpse of the power of informed prediction to prevent adverse outcomes. Instructions: This strategy can be used with individual students or with groups of students. For both clinical and classroom settings, each stage is presented on one slide or on an individual piece of paper at incremental intervals beginning with Stage I and ending with Stage III.

Answers are written in the Learning Management System used by your college, on paper, or on a notecard and turned in after each stage. The instructor may choose to add course content during the time between each stage.

Web-Based Unfolding Cases: A Strategy to Enhance and Evaluate Clinical Reasoning Skills

Students cannot change their answers to previous stages. Student knowledge, attitudes, and skills are assessed using the rubric at the end of the assignment and during class discussion. Stage I Unfolding Case Study: Jean is an year-old widow with four grown sons and numerous grandchildren. She was living alone, caring for her own home for the past 35 years since her husband died. At home, Jean could make meals, take care of her hygiene, pay her bills, and use the bathroom on her own.

She had enjoyed being at home and continued to take care of herself and her home. One day she developed mild abdominal pain. She thought it was related to something she ate, but it persisted, so she decided to go to her family doctor. Jean was taken to the clinic and underwent lab tests and a CT scan, for which her doctor concluded she had ovarian cancer. Since the treatment would not provide a cure, she opted to let cancer take its course.

The clinic nurse told Jean to call if she needed anything. Jean was a strong independent woman, as she had to be after becoming a widow at such a young age.

But now, she was facing an unexpected diagnosis of cancer.Learn More. Transform the way you teach. Hit enter to search or ESC to close. Unfolding Reasoning. Case studies suited for advanced nursing students. Key Components Recognizing Clinical Relevance Identify clinically significant data from the medical history and lab results. Analyzing Nurse-Collected Clinical Data Identify clinically significant data from vital signs and nursing assessment.

Practicing Clinical Reasoning 12 sequential questions to develop nurse-thinking. Caring and the Art of Nursing Reflective questions to encourage empathy, engagement, and caring. Select any topic below for additional info. Never pay extra for another case study. All-inclusive membership is your best value, with unlimited access to over case studies, exclusive topics, and video teaching aides.

Exclusive Topics Only Inside Membership. Back to Case Studies Overview. Browse Can Caring Be Taught? Subscribe Sign up now to receive the latest updates and offers from KeithRN! This field is for validation purposes and should be left unchanged.An year-old man with diastolic heart failure, coronary artery disease, TIAs, chronic obstructive pulmonary disease COPDhypothyroidism, chronic kidney disease, aplastic anemia, and benign prostatic hypertrophy with chronic indwelling catheter was transferred to the neurocritical care unit for acute encephalopathy.

The patient initially presented to an outside facility with progressive lethargy evolving over 12 hours from a fully functional baseline. At the outside hospital, he was febrile Empiric IV vancomycin and cefepime were started.

CT scan of the chest, abdomen, and pelvis was unrevealing of an infectious source. MRI of the brain was also unremarkable.

unfolding clinical reasoning case study acute

His mental status declined further over the following 4 days, prompting an EEG that revealed generalized periodic discharges GPDs. The patient was treated with levetiracetam and transferred to our hospital out of concern for nonconvulsive status epilepticus NCSE. He was mumbling unintelligible words and withdrew all 4 limbs antigravity to pain. The differential diagnosis for our patient with subacute encephalopathy and unremarkable MRI included NCSE, sepsis, infectious or autoimmune encephalitis, metabolic derangement, and drug-related cefepime toxicity.

To investigate these possibilities, video-EEG monitoring was performed, and MRI of the brain and CT of the chest, abdomen, and pelvis were reviewed and were unrevealing.

Broad-spectrum antibiotics were continued. Admission laboratory studies revealed thrombocytopenia, anemia, a normal leukocyte count 5.

Thyroid-stimulating hormone, thiamine, ammonia, and vitamin B 12 were normal. Urine cultures grew pan-susceptible Klebsiella oxytoca. Blood cultures were negative. Cefepime was streamlined to ceftriaxone 48 hours after admission 5 days after presenting to the outside facilityand a day course of antibiotics was completed to treat sepsis secondary to urinary tract infection UTI.

In the absence of focal pathology seen on imaging, unremarkable toxic-metabolic workup, nonfocal EEG, and persistent obtundation in spite of appropriately treated sepsis, lumbar puncture should be considered to rule out CNS infection.

Prior to proceeding with this, however, further history revealed that the patient had been hospitalized at least twice yearly for COPD exacerbations, during which he was treated with high-dose prednisone.

He had a remote history of chronic daily prednisone use that was discontinued more than 10 years prior to admission, but he continued to use a combination budesonide-formoterol inhaler daily. Morning cortisol was checked and was low at 3. Standard dose adrenocorticotropic hormone ACTH stimulation test resulted in a cortisol level of 9.

The patient's persistent encephalopathy in the setting of appropriately treated sepsis, hypotension, hypoglycemia, peripheral eosinophilia, low morning cortisol with inappropriate response to ACTH stimulation, and EEG semiology consistent with toxic-metabolic encephalopathy TME is consistent with the diagnosis of adrenal insufficiency AI.

AI can be characterized as primary affecting the adrenal glandssecondary affecting the pituitary glandor tertiary affecting the hypothalamus. Most crises are precipitated by infection. Another characteristic feature of adrenal crisis is the rapid reversal of symptoms in the setting of glucocorticoid administration.

While clinical improvement is often demonstrated within 24 hours, full recovery has been reported to take up to 1 week. The EEG findings of TME are nonspecific for AI and are expected to resolve upon treatment figure 2 ; however, there are reports of bifrontal predominance of rhythmic high-amplitude sharp and slow wave complexes in the setting of hypocortisolism, as depicted in our patient's EEG.Recommend Documents.

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unfolding clinical reasoning case study acute

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It is critical to incorporate OUD education into the nursing school curriculum to prepare these future nurses. Research has shown that the unfolding case study is a beneficial pedagogical modality. It allows for the building of new information and the expansion of critical thinking by encouraging the student to assess and ask questions to receive further information.

An unfolding case study was created that centered on a person who develops OUD and their family. It includes simulations, activities, and discussion topics. The unfolding case study can be integrated throughout the undergraduate curriculum from assessment to critical care. The unfolding case study can continue into the graduate program, which allows for interdisciplinary use. Opioid use disorder OUD remains a national epidemic since officially being proclaimed a public health emergency in October U.

According to the Centers for Disease Control and Preventionprescription and illegal opioid use is the main factor in overdose deaths, with Americans dying daily.

The sheer number of deaths from opioid overdose is frightening, as is the number of families who become secondary victims of addiction.

unfolding clinical reasoning case study acute

Secondary victims can happen in the earliest stages of life, such as during pregnancy, which can result in neonatal abstinence syndrome NAS. Approximately 8 million children younger than age 18 live with an adult who has an addiction to opioids; a majority of these children are younger than age 5 Blozen, An individual with OUD will continue to use the substance regardless of work issues, money issues, arguing or violence with those close to them, neglect of those same people, losing relationships, and not meeting household responsibilities, which affects countless others Luke et al.

Due to the multitude of people affected by OUD, most health care professionals are likely to interact with people affected by OUD in some fashion. The reality is that OUD will touch the careers of future generations of nurses no matter their chosen work setting. The incorporation of OUD in undergraduate nursing education is critical for the preparation of the next generation of nurses to address the current and future challenges caused by the opioid epidemic.

Using Unfolding Case Studies to Develop Clinical Forethought in Novice Nursing Students

Innovative and interesting methods are needed to incorporate this information into the already full nursing curriculum. The unfolding case study is one modality to incorporate opioid education into the curriculum. An unfolding case study was developed that incorporates the entire family, centered on a person who becomes addicted to opioids after being in a car accident. The scenario involves an opioid-addicted person along with the ramifications of opioid addiction on the family unit, including both pediatric and geriatric individuals.

The unfolding case study includes simulations, activities such as plotting and using growth charts, vignettes, and discussion topics.


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