Educating Nurses (2010) - Saint Anselm College

5/9/2013

Clinical Reasoning Case Studies Educating Nurses (2010)
Across the Curriculum for NCLEX
 Effective in forming professional
Success identity

Keith Rischer, RN, MA, CEN, CCRN  Clinical laboratory promotes learning
 Not as effective in the classroom
www.KeithRN.com
[email protected] Additive vs. removing
PPT driven-get through the content
False assumption…Abstract knowledge

leads to application

Nursing Ed: Transformation Needed! Nursing Ed: Transformation Needed!

 Teach for salience-situated cognition  Integrate classroom & clinical teaching

Contextualize Content CONNECT classroom & clinical

 CONCEPTS Make classroom rich, ACTIVE learning

Must translate content to the bedside Decrease current fragmentation
What clinical data is RELEVANT
Emphasize APPLICATION of knowledge BRIDGE current clinical/theory divide

 Emphasize clinical reasoning
Grasp the “essence” of clinical situation
Recognize present priorities
Capture trends
Reason as situation changes

 THINK in action

Benner: Novice to Expert (1982) Think Like a Nurse:

 Novice Before Clinical: Clinical Reasoning?

 Concrete learners 1. What is primary problem /pathophysiology?
 No experience-no prior context 2. RELEVANT clinically significant data from chart
 ALL clinical data relevant
to trend?
 Advanced beginner 3. What is your nursing PRIORITY?
4. Nursing interventions/desired outcomes?
 Sees exceptions to concrete textbook data 5. Body system(s) to most thoroughly assess?
 Clinical experience allows to see prior patterns of 6. Worst possible/most likely complication(s) to

relevant recognition anticipate?
 Identifies CERTAIN clinical data as relevant 7. What nursing assessments needed to identify
 Unable to readily recognize priorities
this complication?

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5/9/2013

Think Like a Nurse: NANDA vs. Clinical Reasoning

During Clinical: Clinical Reasoning?  Does not reflect how  Reflects “nurse
nurses think in thinking”
1. RELEVANT clinically significant data practice
from patient to TREND?  Concisely captures
 Unable to capture problem/priority
2. Rationale/expected outcomes physician essence of changing
plan of care? status  Interventions readily
follow
3. Educational PRIORITIES?  No NANDA statement
to identify status  Rescue of pt.
change facilitated

 May contribute to
failure to rescue

What We Can Learn from our History Clinical Reasoning Case
Studies
“Only by constant repetition can you become really familiar
with the work. Only by doing a thing well again and again &
can you obtain confidence, accuracy and precision. It is NCLEX Success
this constant, intelligent practice that constitutes the
difference between the skilled trained professional
woman and the amateur.”

“Despite the common use of the term, the “born nurse”
does not exist…it will always be necessary to take hold
of each task and do it over and over again, being guided
by an intelligent, trained mind.”
Isabel Hampton Robb
Nursing Ethics, 1900

Principles of the NCLEX NCLEX Client Need Categories

 Context is the bedside Fundamental/RR (62% NCLEX) Unfolding Studies (75% NCLEX)
 Management of care:
 Application /Analysis  Management of care:
 17-23%
 Assesses ability to make safe judgments  17-23%
based on clinical reasoning  Medications/IV therapies:
 Medications/IV therapies:
 No NANDA  12-18%
 PRIORITY setting  12-18%
 RATIONALE  Reduction of risk:
 EXPECTED OUTCOME  Reduction of risk:
 RELEVANT data  9-15%
 9-15%
 Labs, VS, assessment  Physiologic adaptation:
 Physiologic adaptation:
 11-17%
 11-17%

 Health
promotion/maintenance:

 6-12%

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5/9/2013

Passive vs. Active Learning Clinical Reasoning Case Studies

Passive (Lecture) Active (case studies) I. Fundamental Reasoning
II. Rapid Reasoning Study
 80% forgotten in 24 hours  Increased engagement III. Unfolding Clinical Reasoning
 After 20” begin to
 Learning promoted
disengage
 Promotes higher level
 Role of student: thinking/learning

 Absorb knowledge  Adult learning strategy
 Take notes  Role of student:
 Passive “tape recorder”
 Regurgitate content  Participate
 Experience
 Think & discover
 Construct/apply knowledge

Scenario Introduction Scenario Introduction

 Mandy White is an 18 year old woman  Mandy White is an 18 year old woman who has struggled
who has struggled with bulimia since the with bulimia since the age of 14. She was sexually
age of 14. abused by her step father who was convicted and sent to
prison. She lives with her mother and has recently been
 She presents to the ED this evening with engaging in self injurious behavior (SIB) of cutting both
c/o increasing weakness, lightheadedness forearms with broken glass and razors causing numerous
and a brief syncopal episode this evening. scars.
She has been inducing vomiting after
meals for the past 3 weeks. Is 5’ 5” and  She presents to the ED this evening with c/o increasing
weighs 83lbs (BMI 13.8) weakness, lightheadedness and a brief syncopal episode
this evening. She has been inducing vomiting after meals
for the past 3 weeks. Is 5’ 5” and weighs 83lbs (BMI 13.8)
Mandy is brought in by her mother. She does not want to
be treated. You hear her say to her mother, “I am so tired
of living, I wish I were dead!”

Fundamental Reasoning Trending to Rescue…

Identifying Clinical Relationships  Lab values

 Relationship of what current medications are  Creatinine
treating past medical problems?  K+
 Mg+
 Relationship between any problem in their past  Na+
medical history that contributed to the  WBC
development of the current primary problem?  Neutrophils %
 Hgb
 Relationship between the primary problem and
current chief complaint?  All VS

 Relationship between relevant clinical data and  Nursing assessment
the primary problem?

 Relationship between newly ordered
medications and the primary problem?

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II. Rapid Reasoning 5/9/2013

 Set the table: Rapid/Clinical Reasoning ???

 CC 1. RELEVANT CC/VS/assessment data
 PMH
 VS  Management of Care/Reduction of Risk Potential
 Nursing assessment
 Labs/diagnostic results 2. RELEVANT labs/diagnostic tests
 Nursing interventions (immediate)
 Physician orders  Management of Care/Reduction of Risk Potential

3. Primary problem?

 Management of Care /Physiologic Adaptation

4. Cause/pathophysiology of primary problem?

 Physiologic Adaptation

5. Nursing priority(s)?

 Management of Care

Rapid/Clinical Reasoning ??? Caring & the “Art” of Nursing

6. Nursing interventions based on nursing priority w/rationale & 11. What is the patient likely
expected outcomes? experiencing/feeling right now in this
situation?
 Physiologic Adaptation
12. What can you do to engage yourself with
7. Rationale for physician orders/meds & expected outcomes? this patient’s experience, and show that they
matter to you as a person?
 Pharmacological & Parenteral Therapies

8. Body system to focus on based on primary/priority concern?

 Physiologic Adaptation

9. Worst possible complication to anticipate?

(start with A-B-C priorities)

 Reduction of Risk Potential

10. What nursing assessment(s) needed to identify and
respond to quickly if develops?

 Physiologic Adaptation)

Structural Components Structural Components

Unfolding Clinical Reasoning Study: II. Unfolding Clinical Reasoning Study:

 Set the table:  Pharmacology…pharm. class/indications
 F&E/Lab Values Application
 CC  Dosage calculation
 VS
 Nursing  Change in status

assessment  Evaluation ?
 Labs/diagnostic
 Has patient improved or not as expected?
results  What data supports evaluation assessment?
 PMH  Nursing priorities and current plan of care?
 Current meds  Education/DC planning

 QSEN
 National Patient Safety Goals

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“Jason” is still out there… 5/9/2013

Most Common “Jasons”…

1. Chest pain
2. Increased resp distress/O2 sats <90%
3. Hypotension
4. Change in LOC or neuro status
5. Patient fall

RISENo Student will to LOW Practical Application in Classroom

Expectations  Come to class PREPARED

 Read textbook
 APPLY reading

 Work through clinical reasoning study BEFORE theory

 CONCEPTS not content

 Cut PPT content in half!
 Limit to 20-25” for each 50” lecture block

 Group DIALOGUE of case study

 Faculty facilitates/directs/emphasizes salient points

Sepsis/Septic Shock Sepsis Overview
Rapid Reasoning Activity
 1,000,000 cases annually of sepsis
Keith Rischer, RN, MA, CEN, CCRN  500 deaths a day

 Similar to out of hospital MI deaths

 Expected to increase as population ages
 Mortality rate 23-50% based on severity

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Who’s at Risk? 5/9/2013

 Extremes of age Sepsis Patho

 <1 yr & >65 yrs  Precipitating event

 Chronic illness  Activation of inflammatory response
 Vasodilation
 DM  Maldistribution of volume
 CRF  Decreased venous return
 Decreased CO
 Malnourishment  Decreased tissue perfusion

 ETOH

 Invasive/surgical procedures
 Immunosuppression

Shock Defined Shock Patho: Common Themes

 Perfusion to the cells is inadequate to  Hypoperfusion of tissues
deliver O2 & nutrients to support vital  Activation of inflammatory response
organs & cellular function  SNS stimulation

 Hypovolemic
 Cardiogenic
 Distributive

 Neurogenic
 Anaphylactic
 Septic-SIRS
 Multiple Organ Dysfunction Syndrome (MODS)

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Stages of Shock Essential Labs to Trend

 Compensatory  CBC
 WBC
 BP WNL  Neutrophils
 Tachycardia  Bands
 SNS stimulation
 BMP
 Progressive  K+
 Creatinine
 Hypotensive  CO2 (Bicarb.)

 SBP <90 or decrease >40mm baseline  LFT
 ALT/AST
 Irreversible
Lactate
 Hypotensive despite fluids/vasopressors
 Acidosis/MODS

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5/9/2013

Importance of Lactate UA Interpretation

 Lactate production associated with  UA  Micro
insufficient O2 delivery
 Color  RBC
 Clear association with lactic acidosis and  Clarity
mortality  Sp. Gravity  WBC
 Protein
 Mortality rates  Glucose  Bacteria
 Ketones  Epithelial
– Norm.<2.0 = 4.3%  Blood
– 2-4 mmol/L = 9%
– > 4 mmol/L = 28.4%  Nitrate
 Leukocyte

esterase

RED FLAGS for Sepsis Medical Management Priorities

 SIRS Criteria  Clinical Sx EARLY IDENTIFICATION!!

 Temp >100.4 or <96.8  Hypotension SBP<90  Trend temp/HR/BP
 HR >90  New confusion/LOC
 RR >20  Narrow pulse pressure  Trend labs…WBC/neuts/Lactate/creatinine
 WBC >12,000 or
 u/o <30 mL/hr  Fluid replacement…early/aggressive
<4000  Decr. cap refill
 Bands >10%  Gluc. >120  Crystalloid: 20 mL/kg bolus over 30”
 Change in LOC  MAP >65 or SBP >90
 Creatinine incr.
 IV Abx
 >2.0 men  Vasopressors/tx to ICU
 >1.4 women

Alice Kelly: Chief Complaint 12 Hours later… Last VS 4 hours
ago…
 Alice Kelly is an 82 year old woman who is  Admitted to med/surg unit 12  T: 101.8 (o)
widowed and lives alone in assisted living who hours ago with a diagnosis of  P: 110 reg.
has been feeling more fatigued for the last 3 urosepsis.  R: 20
days and has had a fever the last 24 hours.  BP: 128/82
 Received a total of 2 liters of  O2 sats: 98% RA
 She reports painful, burning sensation when she 0.9% NS and Ceftriaxone 1 g
urinates as well as frequency of urination the last IVPB.
week.
 Remains confused to date
 Her daughter became concerned and brought and place.
her to the ED when she did not know what day it
was and unable to get off the couch. She is  100 mL u/o the last 8 hours
mentally alert with no history of confusion.
 Assessment is otherwise WNL.

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5/9/2013

What data from CC is RELEVANT that must be Your Nursing Assessment…
recognized as clinically significant?
Last VS 4 hours ago…  RESP: breath sounds clear with
(NCLEX Client Need Category: Management of T: 101.6 (o) equal aeration bilat.,
Care/Reduction of Risk Potential) P: 98 reg. tachypneic/labored effort
R: 20
RELEVANT: Rationale: BP: 130/88  CARDIAC: pale, cool mottled
O2 sats: 98% RA extremities, S1S2, no edema,
pulses 2+ in all extremities

 NEURO: remains confused to
place and time

Current VS…  GI/GU: active BS in all quads,
T: 102.8 (o) abd. soft/non-tender, no u/o in
P: 122 reg. the last 4 hours
R: 28
 MISC: denies pain, appears
anxious and restless

BP: 88/50

O2 sats: 90% RA

1. What data from VS & assessment is RELEVANT SBAR:Nurse to MD
that must be recognized as clinically significant?
(QSEN-Teamwork & Collaboration/Safety)
(NCLEX Client Need Category: Management of (NCLEX Client Need Category:Management of Care)
Care/Reduction of Risk Potential)
Situation:
RELEVANT: Rationale: Background:
VS: Assessment:
Recommendation:
Assessment:

Priority Nursing Interventions Physician Orders:

 O2 to maintain sats >92%  0.9% NS 1000 mL
 Establish second large bore IV  Blood cultures x2 sites
 Stat CBC, BMP, Lactate
 Vancomycin 1 g IVPB (after bl. cx. drawn)
 Start Norepinephrine (Levophed) IV gtt if

SBP<90 after NS bolus
 Transfer to ICU

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5/9/2013

Lab Results 2. What lab/diagnostic results are RELEVANT that must
be recognized as clinically significant?
CBC Current Most Recent (NCLEX Client Need Category: Management of Care/Reduction of Risk Potential)
13.2
WBC (4.5-11.0) 18.8 90 RELEVANT Relationship to primary
Neuts. % (42-72) 96 2 Diagnostic problem:
Bands (<10%) 12 11.0 results:
Hgb. 11.2
WBC: 18.8
Basic Metabolic Panel Current Most Recent Neuts: 96%
Sodium (135-145) 142 Bands: 12%
Potassium (3.5-5.1) 138 3.8 K+: 5.9
Lactate (<2.0) 5.9 2.2 Creatinine: 2.8
Creatinine (0.5-1.3) 4.5 1.5 Lactate: 4.5
2.8

Think Like a Nurse: 7. What is the rationale & expected outcomes of nsg.
interventions/physician orders?
Clinical Reasoning ???
NCLEX Client Need Category: Pharmacological & Parenteral Therapies
3. What is the primary problem that your patient is
most likely presenting with? Nsg. Interventions/MD orders: Rationale: Expected
Outcome:
 (NCLEX Client Need Categories:Management of Care •O2 to maintain sats >92%
/Physiologic Adaptation) •Establish 2nd large bore IV
•0.9% NS 1000 mL
4. What is the underlying cause /pathophysiology of •Blood cultures x2 sites
this concern? •Vancomycin 1 g IVPB
•Stat CBC, BMP, Lactate
 (NCLEX Client Need Category:Physiologic Adaptation) •Start Norepinephrine

5. What is your nursing priority(s)? (Levophed) IV gtt if SBP<90

 (NCLEX Client Need Category:Management of Care) after NS bolus
•Transfer to ICU
6. What interventions will you initiate based on this
primary priority/rational/expected outcomes?

 (NCLEX Client Need Category:Physiologic Adaptation)

Think Like a Nurse: Caring & the “Art” of Nursing

Clinical Reasoning ??? 11. What is the patient likely
experiencing/feeling right now in this
8. What body system will you most thoroughly assess situation?
based on the patient’s chief complaint and
primary/priority concern? 12. What can you do to engage yourself with
this patient’s experience, and show that
(NCLEX Client Need Category:Physiologic Adaptation) they matter to you as a person?

9. What is the most likely/worst possible complication
to anticipate?

 (NCLEX Client Need Category:Reduction of Risk Potential)

10. What nursing assessment(s) will you need to
initiate to identify this complication if it develops?

 (NCLEX Client Need Category:Physiologic Adaptation)

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5/9/2013

One Student’s Perspective… Educator’s Perspective…

“I didn’t feel like I was memorizing for the “This format helps students to apply
test. I felt like I was able to apply the
information. It helped put knowledge into information and look at the big picture. I had
practice and made it clear why it was
relevant.” so much fun teaching in this way and didn't

see anyone nodding off in the back of the

class!” Janet Miller,Hibbing, MN

“I am seeing a difference in my students
regarding their ability to identify relevant labs
and understanding the disease process. I
really think it is from the case studies.”

Karen Flatt, Pryor, OK

Strengths Barriers

 Bridges current theory & clinical divide  Change
 Promotes “thinking like a nurse” in practice  Faculty buy in
 Time commitment
 Emphasizes clinical reasoning NOT content  Clinical currency
 Open ended vs. multiple choice

 Practice thinking (ruts) & common change of status
 Active learning strategy

 Promotes student engagement…20” lecture MAX

 NCLEX principles reinforced
 Integrate QSEN and National Safety Goals

Next Steps… Transforming the Classroom

 Required Reading:  Responsibility of nurse educators
 Educational best practice
 Educating Nurses: A Call for Radical Transformation
 Clinical Wisdom & Interventions in Acute/Critical Care  Patient outcomes impacted
 Lisa Day: Using Unfolding Case Studies in a Subject-

Centered Classroom
 Dorothy del Bueno: A Crisis in Critical Thinking

 Collaborate as a team/department

 Take first steps with one clinical reasoning case
study

 Choose one lecture/key content area
 Start next semester!

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5/9/2013

It’s Time for a Transformation Revolution!

 Decrease content…emphasize CONCEPTS
 Contextualize content to the bedside
 Engage students w/active learning activities
 Embrace clinical reasoning as nurse thinking
 Allow other ways to prioritize than NANDA
 Expect students to identify RELEVANT

clinical data and worst possible complication

My Journey… The Choice is Yours…

“Don’t ask yourself what
the world needs. Ask
yourself what makes
you come alive, and
do that.

Because what the world
needs is people who
have come fully
alive.”

Contact Information Bibliography

 Email  Benner, P., Hooper-Kyriakidis, P. & Stannard, D.(2011).Clinical
wisdom and interventions in acute and critical Care: A thinking-in-
 [email protected] action approach. Second ed. NY: Springer.

 Web  Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010) Educating
nurses: A call for radical transformation. San Francisco, CA:
 www.KeithRN.com Jossey-Bass

 Cell  Benner, P. (1982). From novice to expert, American Journal of
Nursing, 82(3), p.402-407.
 763.227.1773
 Benner, P., & Wrubel, J. (1989). Primacy of caring: Stress and
coping in health and illness. Menlo Park, CA: Addison-Wesley
Publishing Company.

 Day, L. (2011)., Using unfolding case studies in a subject-
centered classroom, Journal of Nursing Education, 50 (8), p.447-
452.

 Del Bueno, D. (2005). A crisis in critical thinking, Nursing
Education Perspectives, p. 278-282.

 Griffin, M. (2004). Teaching cognitive rehearsal as a shield for
lateral violence:An intervention for newly licensed nurses, The
Journal of Continuing Education in Nursing, 35, 257-263.

 Swanson, K.M, (1991). Empirical development of a middle range
theory of caring. Nursing Research, 40(3), 161-166.

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