| Primary Concept | ||
| Cognition | ||
| Interrelated Concepts (In order of emphasis) | ||
| StressCopingClinical JudgmentPatient EducationCommunication | ||
| NCLEX Client Need Categories | Percentage of Items from Each Category/Subcategory | Covered in Case Study |
| Safe and Effective Care Environment | ||
| Management of Care | 17-23% | |
| Safety and Infection Control | 9-15% | |
| Health Promotion and Maintenance | 6-12% | |
| Psychosocial Integrity | 6-12% | |
| Physiological Integrity | ||
| Basic Care and Comfort | 6-12% | |
| Pharmacological and Parenteral Therapies | 12-18% | |
| Reduction of Risk Potential | 9-15% | |
| Physiological Adaptation | 11-17% | |
History of Present Problem:
John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure who had a right total hip arthroplasty and is post-operative day one. Since surgery he has been on path, resting comfortably and his pain has been controlled with oxycodone 5 mg PO. When the nurse enters the room to do his
morning assessment, John is agitated, combative and resistive to staff. He pulled out his Foley urinary catheter, his IV catheter and removed his surgical dressing. His legs are swung over the side rails and is trying to get out of bed. John does not know where he is and oriented to self only. He insists that he is at home and yells out, “You get the hell out of my home or I am going to call the police!” His wife is visibly upset and states that she has never seen him behave like this before. With tears in her eyes she asks you, “What is happening to my husband! Please do something to help him!”
Personal/Social History:
John is a retired high school math teacher who lives at home with his wife and lives independently. He is active at the senior center where he attends social activities 3-4 times a week. He attends Catholic Mass every Sunday with his wife. He is a nonsmoker and has a glass of wine 2-3 times a week with dinner.
(Reduction of Risk Potential)
| RELEVANT Data from Present Problem: | Clinical Significance: |
| History of: OsteoarthritisAsthmaDementia (early stage)Heart failure 1 day post-op (r. hip arthroplasty) Prescribed 5 mg oxycodone P.O. Agitated, combative and resistant behavior He insists he is at home and yells, “you get the hell out of my house or I am going to call the police” | Increased risk for activity intolerance (weakness/fatigue) and injury or fall Disrupts patient’s ability to function independentlyAcute confusionDementia is a risk factor for acute deliriumNarcotics/opiates and comorbidities can cause behavior disturbancesSignificant distress to patient and spouse |
| RELEVANT Data from Social History: | Clinical Significance: |
| Retired, married, independent and socially active Religious (Catholic) | Indicates patient is able to complete ADL’s with full/complete independence May want spiritual or religious services involved in pt. careReligious/spiritual practices are adequate coping methods |
| Current VS: | P-Q-R-S-T Pain Assessment: | |
| T: 99.1 F/37.3 C (oral) | Provoking/Palliative: | Pain in his right hip but unable to give details |
| P: 102 (regular) | Quality: | Tenderness to palpation over incision site |
| R: 18 (regular) | Region/Radiation: | Right hip |
| BP: 155/65 | Severity: | Unable to verbalize due to confusion, tenderness to palpation but does not appear to be in acute discomfort based on assessment |
| O2 sat: 95% room air | Timing: | Unable to verbalize |
(Reduction of Risk Potential/Health Promotion and Maintenance)
| RELEVANT VS Data: | Clinical Significance: | ||
| Temperature = 99.1 F B.P. = 155/65 Pulse = 102 | – 99.1 F is a low-grade fever but elderly have a normal body temperature of below 98.6 this can be indicative of infection or underlying condition – Hypertension can cause confusion or pt.’s inability to verbalize | ||
| Current Assessment: | |||
| GENERAL APPEARANCE: | Agitated, attempting to climb out of bed, pulled out Foley catheter and IV catheter, is not grimacing as if he is in pain but does grimace when incision site is palpated | ||
| RESP: | Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort | ||
| CARDIAC: | Pink, warm & dry, slight edema present at incision site, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, no diaphoresis present | ||
| NEURO: | Alert & oriented to person only, very agitated, unable to maintain focus when asked questions, PERRL, emotionally labile, not easily re-directed, face is symmetrical, speech is clear | ||
| GI: | Abdomen flat, soft/nontender, bowel sounds hypoactive but audible per auscultation in all four quadrants | ||
| GU: | Foley cather pulled out, 400 mL clear, yellow urine in collection bag from the last eight hours | ||
| SKIN: | Incision to right hip intact, patient removed dressing and incision is approximated with sutures, some minor erythema at the site and minor bruising, no warmth, and scant blood tinged drainage noted on the dressing, no odor present. | ||
(Reduction of Risk Potential/Health Promotion & Maintenance)
| RELEVANT Assessment Data: | Clinical Significance: |
| Very agitated + climbing out of bed Pulled out Foley and IV catheter Grimacing upon palpation | Agitation and unwarranted aggressive behavior is often indicative of fear, pain or major medical problemPatient was not able to verbalize his need/desire to have catheters taken outIncision will likely be tender, but unable to determine if he is in constant pain |
(Reduction of Risk Potential/Physiologic Adaptation)
| RELEVANT Results: | Clinical Significance: |
| No evidence of acute infarction, intracranial hemorrhage, or mass- effect seen. | – No abnormalities or changes detected on head CT no need for further testing |
| Complete Blood Count (CBC:) | Current: | High/Low/WNL? | Prior to Admission: |
| WBC (4.5–11.0 mm 3) | 10.8 | WNL | 6.5 |
| Neutrophil % (42–72) | 74 | High | 55 |
| Hgb (12–16 g/dL) | 10.1 | Low | 12.8 |
| Platelets (150-450 x103/µl) | 225 | WNL | 252 |
(Reduction of Risk Potential/Physiologic Adaptation)
| RELEVANT Lab(s): | Clinical Significance: | TREND: Improve/Worsening/Stable: | ||||
| High Neutrophil % Low Hemoglobin | Neutrophilia can be caused by bacterial/pyogenic infections (fever), heart failure, autoimmune disorders Anemia | Worsening | ||||
| Basic Metabolic Panel (BMP:) | Current: | High/Low/WNL? | Prior to Admission: | |||
| Sodium (135–145 mEq/L) | 134 | Low | 136 | |||
| Potassium (3.5–5.0 mEq/L) | 3.6 | WNL | 3.7 | |||
| Glucose (70–110 mg/dL) | 72 | WNL | 114 | |||
| Creatinine (0.6–1.2 mg/dL) | 1.1 | WNL | 0.8 | |||
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
| RELEVANT Lab(s): | Clinical Significance: | TREND: Improve/Worsening/Stable: |
| Low Sodium Levels | Hyponatremia can be caused by excess water retention and is seen in heart failure, renal failure or inadequate dietary intake | Worsening |
(Reduction of Risk Potential/Physiologic Adaptation)
| Lab: | Normal Value: | Clinical Significance: | Nursing Assessments/Interventions Required: |
| Creatinine Value: 1.1 | Critical value: >2.5 | No clinical significance as the patients Creatinine lab value is WNL | No further interventions required |
- What is the primary problem your patient is most likely presenting? (Management of Care/Physiologic Adaptation)
Acute delirium
- What are the most common signs and symptoms of acute delirium?
Perceptual disturbances (hallucinations, illusions or misinterpretations), agitation/restless/combative behavior, withdrawn, distractible, makes sounds/moaning, slowed movement, disturbed sleep habits
- What signs and symptoms is this patient presenting with that are consistent with acute delirium?
– Hallucinations
- Agitated, combative and resistant behavior
– Disorganized thinking
- Verbally and mentally withdrawn
– Distractible
- What is the underlying cause/pathophysiology of this primary problem? (Management of Care/Physiologic Adaptation)
R. Hip surgery exacerbated by multiple preexisting comorbidities (especially dementia), catheterization and post-op fever
- What is a CAM assessment and how will it help assess delirium in this patient?
The Confusion Assessment Method (CAM) is a standardized evidence-based tool to help non-psychiatrically trained clinicians recognize delirium quickly
- Using the CAM assessment tool, does John meet diagnostic criteria for acute delirium?
Yes John meets the diagnostic criteria for acute delirium using the CAM assessment tool.
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