Description
Assessment Description
Use the “Case Study: Mrs. T.” template to complete the assignment.
Case Study: Mrs. T. has indirect care experience requirements. The “NRS-455 – Case Studies: Indirect Care Experience Hours” form, found in the Topic 1 Resources, will be used to document the indirect care experience hours completed in the case study. As progress is made on the case study, update this form indicating the date(s) each section is completed. This form will be submitted in Topic 3.
You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
American Association of Colleges of Nursing Core Competencies for Professional Nursing Education
This assignment aligns to AACN Core Competencies 2.3, 2.4, 2.5, and 2.9.
Attachments
NRS-455-RS-T2-CaseStudyMrsT.docx
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Case Study: Mrs. T.
Directions: Read the case study below. Evaluate the information and formulate a
conclusion based on your evaluation. Complete the critical thinking table and submit this
completed template to the assignment dropbox.
Case Study: Mrs. T.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the
pathophysiological processes of disease, the clinical manifestations and treatment protocols, and
how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mrs. T., presented below.
Health History and Medical Information
Mrs. T., a 42-year-old female, has been living at home with her two high school age children,
husband, and dog. She is a schoolteacher who works full-time teaching at the local grade school.
She tries to be active by walking with her husband and dog for 20 minutes on the weekend but is
starting to add weight as she gets older. She has no known allergies. She is a pack-a-day smoker
and drinks three glasses of wine/per night after work. She tries to eat healthy but likes to eat out
at fast food restaurants to avoid having to cook.
Medical history includes atrial fibrillation controlled with beta blocker, hypercholesterolemia,
mild anemia related to heavy menses, and migraines. Current medications include:
1. Metoprolol 50mg daily
2. Pravastatin 40 mg at bedtime daily for cholesterol
3. Birth control pill Microgestin Fe in the AM
4. Amitriptyline 20 mg/daily for migraines
Case Scenario
You are the school nurse where Mrs. T. works. While at recess duty, another teacher runs up to
you and reports that Mrs. T. is not acting like herself. When you approach, you see her sitting on
a bench mumbling something to the kids gathered around her. She has dropped her cell phone on
the ground, and her right arm appears limp. You try asking her questions and you notice the right
side of her face is slacken, and she does not seem to be making sense when talking. You call an
ambulance, and try to walk her back to your office, but she does not move well. You reassure her
and try to determine if anything occurred prior to her loss of speech and movement. The other
teachers say it came on suddenly, within the last 5 minutes. Mrs. T. shakes her head no to pain.
Objective Data – Completed by Ambulance Personal:
1. Temperature: 36.5 degrees C
2. BP 184/92, HR 101, RR 24, Pox 99%
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3. Blood Glucose = 107
4. Positive FAST & VAN score, NIHSS = 12
5. Height: 62 inches; Weight 89 kg
Laboratory/Test Results – On Arrival to the Emergency Department (Initial Results)
1.
WBC: 9.4 (1,000/uL)
2.
INR – 0.7
3.
CT Head is normal.
4.
Negative pregnancy test
5.
Cholesterol – 247, Triglycerides – 302
Critical Thinking Table
Clinical Manifestations
Describe the clinical manifestations present in Mrs. T., focusing on what is normal and
abnormal and how this relates to her current condition.
Subjective
Objective
Primary and Secondary Diagnoses
Discuss the primary and secondary medical diagnoses that should be considered for Mrs. T.,
and why you chose this diagnosis.
Primary medical diagnosis
and why you chose this
diagnosis.
Secondary medical diagnosis
and why you chose this
diagnosis.
Formulate a nursing
diagnosis from the medical
diagnoses
2
Pathophysiological Changes
Explain the pathophysiological changes in Mrs. T.
What pathophysiological
changes would you expect to
be happening to Mrs. T.?
How will pathophysiological
changes transition in the
subacute phase after
diagnosis and initial
treatment?
Health Status Effect
Describe the effects Mrs. T.’s current health status may have on her.
Describe the physical,
psychological, and emotional
effects Mrs. T.’s current
health status may have on
her.
Discuss the impact it can have
on her role in the family.
Treatments and Support
Discuss treatments and support that can be completed for Mrs. T.
Discuss the immediate
treatments that can be
completed for Mrs. T.
Describe the long-term
support she may need to
return to baseline activity
level.
Explain how the
interdisciplinary team is
utilized to help her family
support and cope with her
diagnosis.
3
Collapse All
Case Study: Mrs. T. – Rubric
Clinical Manifestations of Mrs. T.
6.5 points
Criteria Description
5. Target
6.5 points
Subjective and objective clinical manifestations are thorough.
4. Acceptable
5.79 points
Subjective and objective clinical manifestations are detailed.
3. Approaching
5.14 points
Subjective and objective clinical manifestations are present but lack detail.
2. Insufficient
4.88 points
Subjective and objective clinical manifestations are incomplete or incorrect.
1. Unsatisfactory
0 points
Subjective and objective clinical manifestations are not present.
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Primary Diagnosis
26 points
Criteria Description
5. Target
26 points
Primary medical diagnosis and rationale for this diagnosis are thorough.
4. Acceptable
23.14 points
Primary medical diagnosis and rationale for this diagnosis are detailed.
3. Approaching
20.54 points
Primary medical diagnosis and rationale for this diagnosis are present but lack
detail.
2. Insufficient
19.5 points
Primary medical diagnosis and rationale for this diagnosis are incomplete or
incorrect.
1. Unsatisfactory
0 points
Primary medical diagnosis and rationale for this diagnosis are not present.
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Secondary Diagnosis
26 points
Criteria Description
5. Target
26 points
Secondary medical diagnosis and rationale for this diagnosis are thorough.
4. Acceptable
23.14 points
Secondary medical diagnosis and rationale for this diagnosis are detailed.
3. Approaching
20.54 points
Secondary medical diagnosis and rationale for this diagnosis are present but lack
detail.
2. Insufficient
19.5 points
Secondary medical diagnosis and rationale for this diagnosis are incomplete or
incorrect.
1. Unsatisfactory
0 points
Secondary medical diagnosis and rationale for this diagnosis are not present.
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Nursing Diagnosis
26 points
Criteria Description
5. Target
26 points
Nursing diagnosis formulated from the medical diagnoses is thorough.
4. Acceptable
23.14 points
Nursing diagnosis formulated from the medical diagnoses is detailed.
3. Approaching
20.54 points
Nursing diagnosis formulated from the medical diagnoses is present but lacks
detail.
2. Insufficient
19.5 points
Nursing diagnosis formulated from the medical diagnoses is incomplete or
incorrect.
1. Unsatisfactory
0 points
Nursing diagnosis formulated from the medical diagnoses is not present.
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Pathophysiological Changes
6.5 points
Criteria Description
5. Target
6.5 points
Description of the pathophysiological changes expected and how these will
transition over the course of a week after diagnosis and initial treatment is
thorough.
4. Acceptable
5.79 points
Description of the pathophysiological changes expected and how these will
transition over the course of a week after diagnosis and initial treatment is detailed.
3. Approaching
5.14 points
Description of the pathophysiological changes expected and how these will
transition over the course of a week after diagnosis and initial treatment is present
but lacks detail.
2. Insufficient
4.88 points
Description of the pathophysiological changes expected and how these will
transition over the course of a week after diagnosis and initial treatment is
incomplete or incorrect.
1. Unsatisfactory
0 points
Description of the pathophysiological changes expected and how these will
transition over the course of a week after diagnosis and initial treatment is not
present.
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Health Status Effect
6.5 points
Criteria Description
5. Target
6.5 points
Description of the physical, psychological, and emotional effects of the health status
on the patient and the impact the health status has on the family and the ability of
patient to work is thorough.
4. Acceptable
5.79 points
Description of the physical, psychological, and emotional effects of the health status
on the patient and the impact the health status has on the family and the ability of
patient to work is detailed.
3. Approaching
5.14 points
Description of the physical, psychological, and emotional effects of the health status
on the patient and the impact the health status has on the family and the ability of
patient to work is present but lacks detail.
2. Insufficient
4.88 points
Description of the physical, psychological, and emotional effects of the health status
on the patient and the impact the health status has on the family and the ability of
patient to work is incomplete or incorrect.
1. Unsatisfactory
0 points
Description of the physical, psychological, and emotional effects of the health status
on the patient and the impact the health status has on the family and the ability of
patient to work is not present.
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Treatments and Support
19.5 points
Criteria Description
5. Target
19.5 points
Discussion of the immediate treatments and long-term support needed to return
the patient to baseline activity level and explanation of how to help the family
support and cope with the diagnosis are thorough.
4. Acceptable
17.36 points
Discussion of the immediate treatments and long-term support needed to return
the patient to baseline activity level and an explanation of how to help the family
support and cope with the diagnosis are detailed.
3. Approaching
15.41 points
Discussion of the immediate treatments and long-term support needed to return
the patient to baseline activity level and an explanation of how to help the family
support and cope with the diagnosis are present but lack detail.
2. Insufficient
14.63 points
Discussion of the immediate treatments and long-term support needed to return
the patient to baseline activity level and an explanation of how to help the family
support and cope with the diagnosis are incomplete or incorrect.
1. Unsatisfactory
0 points
Discussion of the immediate treatments and long-term support needed to return
the patient to baseline activity level and an explanation of how to help the family
support and cope with the diagnosis are not present.
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Mechanics of Writing
7.8 points
Criteria Description
Includes spelling, capitalization, punctuation, grammar, language use, sentence
structure, etc.
5. Target
7.8 points
No mechanical errors are present. Appropriate language choice and sentence
structure are used throughout.
4. Acceptable
6.94 points
Few mechanical errors are present. Suitable language choice and sentence
structure are used.
3. Approaching
6.16 points
Occasional mechanical errors are present. Language choice is generally
appropriate. Varied sentence structure is attempted.
2. Insufficient
5.85 points
Frequent and repetitive mechanical errors are present. Inconsistencies in language
choice or sentence structure are recurrent.
1. Unsatisfactory
0 points
Errors in grammar or syntax are pervasive and impede meaning. Incorrect language
choice or sentence structure errors are found throughout.
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Format/Documentation
5.2 points
Criteria Description
Uses appropriate style, such as APA, MLA, etc., for college, subject, and level;
documents sources using citations, footnotes, references, bibliography, etc.,
appropriate to assignment and discipline.
5. Target
5.2 points
No errors in formatting or documentation are present.
4. Acceptable
4.63 points
Appropriate format and documentation are used with only minor errors.
3. Approaching
4.11 points
Appropriate format and documentation are used, although there are some obvious
errors.
2. Insufficient
3.9 points
Appropriate format is attempted, but some elements are missing. Frequent errors
in documentation of sources are evident.
1. Unsatisfactory
0 points
Appropriate format is not used. No documentation of sources is provided.
Total 130 points
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