CaseStudiesGroupAssignment.docx

NSG 100

Case Study in-class Presentations Assignment

1): Moral Courage with a Dying Patient

Mr. T. is an 82-year-old widower who has been a patient on your unit several times over the past 5 years. His CHF, COPD, and diabetes have taken a toll on his body. He now needs oxygen 24 hours a day and still has dyspnea and tachycardia at rest. On admission, his ejection fraction is less than 20%, EKG shows a QRS interval of greater than 0.13 seconds, and his functional class is IV on NYHA assessment.
He has remained symptomatic despite maximum medical management with a vasodilator and diuretics. He tells you, “This is my last trip; I am glad I have made peace with my family and God. Nurse, I am ready to die.” You ask about an advance directive and he tells you his son knows that he wants no heroics, but they just have never gotten around to filling out the form. When the son arrives, you suggest that he speak with the social worker to complete the advance directive and he agrees reluctantly. You page the physician to discuss DNR status with the son. Unfortunately, Mr. T. experiences cardiac arrest before the discussion occurs and you watch helplessly as members of the Code Blue Team perform resuscitation. Mr. T. is now on a ventilator and the son has dissolved into tears with cries of, “Do not let him die!”

2): Moral Courage to Confront Bullying

Melissa started on the unit as a new graduate 5 weeks ago. She is still in orientation and has a good relationship with her preceptor. The preceptor has been assigned consistently to Melissa for most of the last 4 weeks, but due to family emergency has not been available in the last week. Melissa has been told that she will be precepted by a different nurse for the remainder of her orientation. The new preceptor has not been welcoming, supportive, or focused on the educational goals of the orientation. In fact, this new preceptor has voiced to all who will listen her feelings about the incompetence of new BSN graduates. The crisis occurs when Melissa fails to recognize a patient’s confusion as a result of an adverse medication effect. The preceptor berates Melissa in the nurses’ station, makes sarcastic comments in shift report about “inability of university educated nurses to recognize the basics,” and informs the nurse manager “that new graduates are a danger to patients.” Melissa tells you that she thinks she should resign and that maybe her previous preceptor was too easy on her. You know her preceptor is an excellent clinician and experienced teacher.

3) Moral Courage with a Family Disruption

Tom has been a clinical nurse on the unit for 3 years and tonight is charge nurse for a fully occupied 30-bed unit. Even though two staff members called in sick, the supervisor was able to pull a RN and a nurse’s aid from another unit. In shift report, Tom had heard again in detail about the Host family. This family has been problematic for the last week, and the staff has complained constantly about their continuous, frequent requests; rudeness; and unwillingness to leave the room when the patient in the other bed requests privacy. The 79-year-old patient in the Host family has COPD and mild dementia, and currently is hospitalized because of diagnosis of cerebrovascular accident (CVA). The CVA has left her with partial paralysis of the left side and inability to speak. The family expects the nurses to do everything for the patient, even though the patient is able and willing to do a number of basic care functions. The crisis occurs when the son comes to the nurses’ station, screaming at the unit secretary about the staff’s incompetence and demanding to see the nursing supervisor. The charge nurse is in the nurses’ station and is able to address the hostile situation.
While this makes you feel somewhat validated in your perceptions, you now wonder what you should do with this information. Afraid of any repercussions, you decide to keep it to yourself because if you tell anyone, Sue will surely find out it came from you and then will really get mad at you. Besides, you need to stay in the nursing program … you’ve worked too hard to get where you are.

4) Student Nurse/Instructor Case Study

You are a student nurse who is assigned to work with an instructor (Sue) that you have heard ‘horror stories’ about. You are really worried about being in her clinical group as she tends to have ‘favorites’ … and based on assignment grades she has given you in previous terms, you are definitely not one of them. You go to clinical and all seems to be going okay for the first few weeks so you assume all of your problems are unfounded. Then you notice a slight shift in your instructor’s demeanor. She seems to only pay attention to the students who she thinks are the ‘smart ones’ of the group. When you have a question about your patient, she looks at you in disgust and tells you she is going to send you home for being unprepared. Frightened you will not be able to pass clinical; you stay in your patient’s room or to yourself on the unit and no longer ask any questions of your instructor. You are so frightened that your instructor will ask you a question about your patient that you cannot answer; you stay up all night before clinical ‘looking up anything and everything’ so that you won’t be caught off guard. During the 5″ week of the term, you overhear some of the staff at the hospital talking about your instructor in the break room.
This is what you overhear … • Thoughts that Sue is an inexperienced clinical instructor … is she capable of doing her job? (You know she has been at the nursing program for about 7 years.) • Sue is not able to assist her students perform skills they have learned in lab … this does not meet the state board requirements for a clinical instructor. • Perceptions that Sue does not adequately supervise her students … brings to question is she doing her job and ensuring patient safety • Professional boundaries are not clear with students (“Sue is more of a friend than instructor”) … some nurses are saying this is not a new issue and Sue has been counseled regarding this in the past. • Sue actually asked one patient if he was ‘okay’ being taken care of by one of her students considering the student is ‘obviously’ gay. • It is obvious that Sue has favorites … those are the only students she talks to and they can do no wrong … others she just chews out whenever they ask a question.

5): The case of the Nurse Addict

Judy Boise and Claire Temple had been colleagues for a long time. They have worked together at the same hospital for 6 years. Since obtaining her divorce however, Ms Temple personality has changed. She often makes silly comments or giggles at inappropriate times. At other times, Ms Temples is very irritable and resorts to taking medication for her nerves. Ms Boise suspects that her friend is developing a drug dependence. Her suspicion is confirmed one day when Ms Temple asks Ms Boise to work for her while she sleeps off the effects of some medication. Ms Boise confronts her friend with her suspicions. Ms Temple acknowledges that she has been taking cocaine but asks Ms Boise not to tell other nurses about the nature of her problem. Ms Boise promises not to tell. The next day, however Ms Boise finds Ms Temple asleep in a chair in an empty room when she should be taking care of a patient.

6): Brandon and Marilyn Case Study

Justin Tyme – a registered nurse joins the unit after successfully completing new employee and unit orientation. He had worked for 10 years in a similar unit at St Elsewhere but grew tired of the 2 hour daily commute. He is thrilled to be working closer to home. The staff is ecstatic as the unit has been shorthanded and the census is high. The staff likes working with Justin. He is friendly fellow and frequently brings hot donuts and a huge thermos of Peets coffee for the staff. He is always willing to help with lifting and turning patients and often in the first one to respond to patients lights. Justin does not always follow through on his observations and physician s; he often misses giving routine meds. The staff has taken to routinely double checking Justin’s s and the following shift often dispenses the missed meds. One morning, Dr. Tauk comes in to review the speech consult he ed the day before on his patient, Mrs. Dee Phagia, prior to ing her a diet. Dr Tauk cannot find the consult and asks Charity N. Able RN to locate it and call him. Charity discovers that the had never been placed.
On follow up, Charity discovers not to her surprise- that Justin was the nurse who noted the . Charity does not talk to the manager but does point out the error to Justin who feels terrible about it. Over the next month, Justin continues to make intermittent “small” mistakes which cause no harm to patients and the staff continues to cover. Today, Dr. L. Ovin comes in and notices that her patient, Mr. hart is in atria fibrillation. She s stat IV digoxin and cancels the scheduled diagnostic procedures. Mr Hart remains in atria fib and as you review his chart, you discover that Justin missed the last two routine digoxin doses.

7): Shyla and Gloria Case Study

Mrs. Lyons was a 27 year old woman who recently gave birth prematurely to a set of twins. The infants were doing well but Ms Lyons hemorrhaged and required emergency surgery resulting in a hysterectomy. Severe loss of blood dropped her hemoglobin to 6.0. Because the patient and her husband were Jehovah’s witnesses, they refused blood transfusions as treatment for the low hemoglobin level. Chris Moore was the nurse caring for Mrs. Lyons after her surgery. Although he did not personally believe that patients should refuse blood transfusions, especially new mothers with dependent infants, he supported the rights of others to decide their health care in accordance with their religious beliefs. Shortly after admission to Mr. Moore’s unit, Mrs. Lyon’s hemoglobin began to drop. It was suspected that the patient was hemorrhaging from an unknown site in her body. Vasoactive drug therapy was begun to help maintain adequate perfusion of her body tissues and her cardiac output was constantly monitored. Mr. Lyons remained at his wife’s bedside and supported her repeated desire not to be transfused, even though to not do so might result in his wife’s death. Over the next 24 hours, Ms Lyons drifter in and out of consciousness and remained very close to death despite a slight rise in her hemoglobin level. As Mr. Moore was leaning over the patient, adjusting the IV tubing, he heard Mrs. Lyons whisper, “Please I don’t want to die– please don’t let me die.” Mr. Moore quickly asked Mr. Lyons if he heard what his wife said. He was on the other side of the room and had not heard his wife’s word. Even though the nurse believed that his wife was apparently changing her mind about receiving blood products, Mr. Lyons was reluctant to believe this and did not want to reserve her previous decisions. Mr. Moore knew that the patient condition required a rapid response to avert her death

8): Claudia and Nicole Case study
Sarah was promoted to nurse manager because of her excellence in delivering patient care and recognizing leadership ability. She was a preceptor excellent charge nurse, outstanding patient advocate and chair of the practice council. Sarah has been a medical surgical nurse for over 10 years and loves the variety of patients under her care. She only recently completed her BSN degree and earned her certification in medical surgical nursing. When Sarah was in her position for less than 3 months, her immediate supervisor moved to another stated because of his wife’s promotion. This person had been a mentor, confidant, and recognized leader in the organization. Sarah tried to make the best of the situation and follow the direction of her new supervisor. However, right from the beginning, she found this person to be very focused on the negative.
As an optimistic person, Sarah found this approach counter to her basic instinct about people. Every time she tried to discuss this approach, her director would say she was naive and that the staff was taking advantage of her good nature. The director used several of her recent projects failures to justify her position. However Sarah understood that these disappointments had been the results of staff illness and institutional reorganization. The crisis point was reached when the director told her to get rid of two staff members who were the most vocal in their dissatisfaction with the reorganization. These individuals are excellent clinical nurses, well-liked by staff and each has over 12 years of seniority in the organization. Sarah knew that the director did not like these nurses for reasons unrelated to reorganization and their performance.