Clinical Scenario

Stacy Gallegos and Stephanie Crowe

Evaluation in Nursing Education 5328
Objectives
1. Demonstrate knowledge regarding respiratory distress and complications
in clinical scenario at simulation lab.
Sinclair and Ferguson (2009) found that students rated their own self-efficacy
ratings higher after participating in simulated learning environments. This idea is
based on Banduras theory of social learning that uses students prior knowledge
and builds upon that in a simulated hands-on setting to promote new learning.
2. Discuss teaching methods and demonstrate strategy of teaching a patient
with acute pneumonia and respiratory distress.
Communication with a client is an essential part of being an effective health care
provider. Communication is the first of five essential community and public health
nursing practices identified by the American Association of College of Nursing
(Callen, et al., 2013). Some teaching and learning strategies to encourage
communication would be to videotape a teaching session with a client and then
watch and critique afterwards. Another effective communication strategy is to roleplay interaction with a nurse and a client in either a hospital or home setting (Callen
et al, 2013).
3. Enhance knowledge by finding evidence based nursing interventions for
acute pneumonia. Discuss before and after clinical.
According to Winters and Echeverri (2012), a strategy used by nursing clinical
instructors is to require students to find evidence based nursing interventions on a
particular disease process and be prepared to discuss with their preceptor the
knowledge gleaned before and after clinical.
4. Compare knowledge of respiratory distress by participating in selfreflection before and after clinical rotation.
In a study that analyzed teaching/ learning strategies for nursing students entering
their psychiatric mental health clinical, it was found that a time of self reflection and
perceptions of clinical care before and after their experience was helpful in reducing
anxiety, promoting self awareness, and served as a valuable tool in the clinical
learning process (Ganzer & Zauderer, 2013).
Case Scenario:
HISTORY: Mr. A is a 68-year-old man who developed a harsh, productive cough four
days prior to being seen by a physician. The sputum is thick and yellow with streaks
of blood. He developed a fever, shaking, chills and malaise along with the cough. One
day ago he developed pain in his right chest that intensifies with inspiration. The
patient lost 15 lbs. over the past few months but claims he did not lose his appetite.

"I just thought I had the flu." Past history reveals that he had a chronic smoker's
cough for "10 or 15 years" which he describes as being mild, non-productive and
occurring most often in the early morning. He smoked 2 packs of cigarettes per day
for the past 50 years. The patient is a retired truck driver who has been treated for
mild hypertension, bronchitis, appendicitis (as a young adult), hemorrhoids and a
fractured femur and splenic injury (motorcycle accident). Patient does not take any
routine medications. No known allergies.
PERSONAL HISTORY: Patient lives alone. He is widowed, spouse died 2 years ago of
breast cancer. He has 1 son, age 45 that does that lives out of town. The patient has a
neighbor that he depends on for help and support. He does not attend church
regularly, but is a Christian. He does not have good sleeping habits since the loss of
his spouse. He has an inside dog that keeps him company. He is a retired truck
driver and lives on a fixed income. He has Medicare insurance, pays a copay and has
to pay for part of his medication costs.
COURSE OF ILLNESS: Chest x-ray reveals an acute pneumonia in the right middle
lobe, and a mass in the right upper lobe. The patient was admitted to the hospital for
IV antibiotics treatment, oxygen therapy, and close monitoring. The patient will also
need follow up studies to diagnose the lung mass.
LABORATORY:
WBC 17,000/mm3
neutrophils 70%
bands 15%
lymphocytes 15%
Sputum cytology demonstrates atypical cells
HOSPITALIZATION: The patient consented to admission because he is feeling so ill,
however, he is worried about the high cost that he will incur for the stay. He is
depressed about being in the hospital alone, however, he has called his son and
neighbor to let them know where he is.
PHYSICAL EXAMINATION: The patient is an elderly man who appears tired haggard
and underweight. His complexion is pale. He coughs continuously. Sitting in a chair,
he leans to his right side, holding his right chest with his left arm. Vital signs are as
follows: blood pressure 152/90, apical heart rate 112/minute and regular,
respiratory rate 24/minute and somewhat labored, temperature 102.0 degrees F.
Oxygen level 88% on room air. Both lungs are resonant by percussion with one
exception: the right mid-anterior and right mid-lateral lung fields are dull.
Auscultation reveals bilateral diminished vesicular breath sounds. Rhonchi and late
inspiratory crackles are auscultated in the area of the right mid-anterior and right
mid-lateral lung fields. The remainder of the lung fields is clear. Percussion and
auscultation of the heart reveals no significant abnormality. Clubbing noted to
patient fingernails.

DIALOGUE:
Nurse,: Hi, Mr. A, how are you doing this morning?
Mr. A: Not feeling very good.
Nurse: Can you describe how you feel?
Mr. A: Well, I hurt all over, especially my chest when I cough. I feel chilled.
Nurse: Coughing can make all your muscles ache. Can you rate your pain, on scale of
0-10? .
Mr. A: Its about a 6.
Nurse: Looks like you have a fever. I will check your chart, and bring you some
medication to make you feel better. Is there anything else I can do for you?
Mr. A: Thank you. I dont need anything else right now.
Nurse: You're welcome, I will get your medication.

Learning Exercises for Clinical Scenario

Exercises

Due Date

Grade

Participate in clinical
scenario with
classmates in simulation
lab. Complete head-totoe assessment (see
attachment)
Complete first part of
self reflection ( see
attachment - KWL chart)
Critique one classmate
on teaching methods
(see attachment)
Find 4 -evidence based
nursing interventions
related to acute
pneumonia or
respiratory distress.
Complete and turn in to
instructor before
clinical . Include a
minimum of 2 APA
references.
Complete KWL chart:
self- reflection. (see
attachment - KWL chart)

Monday before Clinical

rotation

Completion YES or NO

Due the day after clinical

rotation

Submit to instructor for

grade

Monday before Clinical

rotation

Submit to instructor for

grade

Due on morning of clinical

rotation

Submit to instructor for

grade

Due the day after clinical

rotation

Submit to instructor for

grade

Head-to-Toe Assessment
Initial Survey: Check ABCs

LOC (Awake, alert/lethargic/unresponsive)

Orientation (to person, place and time)
Neuro check (PERRLA/Glasgow Coma Scale if
appropriate)

Skin
Skin temp (cool/cold/warm/hot)
Skin texture (dry/diaphoretic)
Skin lesions/pressure
ulcers: color, drainage, odors, LxWxD in cm
Vital signs
VS T (include route), P, R, BP/5th VS = PAIN
Rate
Rhythm (regular/irregular)
Intensity (loud/distant)
Respiratory
O2 and Pulse Ox
Rate and rhythm of respirations
Effort (easy/unlabored)
Depth (deep/shallow/blowing)
Auscultation-ant/lat/post
Symmetry of chest expansion present or absent
Clubbing Present or absent
Cough present or absent, productive or non
productive
Chest tubes/need for suctioning/advanced airway
Circulation Assessment, include: color/warmth/pulse/ capillary
refill/movement and always compare bilaterally.
Upper extremities
if IV present note: gauge, solution, rate and infusion
pump/controller.
Assess IV site for: warmth, redness, edema, drainage or
tenderness.
Abdomen
inspect (round/flat/obese/distended)
Any PEG, G-tube, NG-tube
Auscultate (BS present x 4 quads? rhythm of BS
(normal/hyper/hypoactive and the intensity high/lowpitched)
Palpate (soft/firm/hard/tender to light and deep
palpation?)
Bowel: Last BM (size/color/consistency/odor)

Postop flatus?
Incontinence urinary or fecal or both?
Ostomy - (note condition of stoma and skin surrounding
stoma/contents of ostomy bag-phalange or bag
change/clients adaptation to ostomy)

GU

Void or Foley?
Suprapubic or French and balloon size, amount, color,
presence of mucus/sediment, odor. Note patency and
describe urine in dependent drainage bag tubing.
Lower extremities
Homans sign (negative/positive)
Pedal pulses (Dorsalis Pedis/Posterior tibial, compare
bilaterally,
Grading (0 - +4)/check for edema) pitting (+1 +4)/nonpitting?
Capillary refill (brisk/sluggish-how long, >3 seconds)
ROM
Gait
Dressings, drains or wounds should be assessed and
documented in the order they appear in the assessment
Client Education Patient preference on teaching methods
Teaching given
Client response

Clinical Evaluation
1. What are you on alert for today with this patient?
a. Respiratory statusOxygen level, dyspnea, lung sounds, cough, ABGs
b. Temperaturefever
c. Pain level
2. What are the important assessments to make?
a. Inspectioncyanosis, chest rise and fall, edema, sputum color and
consistency
b. Auscultate the patient lung sounds
c. Vital signstemperature, oxygen level, blood pressure, pulse,
respiratory rate
3. What complications may occur? What could go wrong?
a. Continuing symptoms after the start of medication therapy
b. Sepsisthe bacteria from the pneumonia can make it into the blood
stream causing sepsis

c. Shock, Atelectasis, pleural effusion, confusion

d. Respiratory arrestpatients oxygen level could drop if he were to take
off oxygen, lungs are weak from pneumonia
e. Patient fallpatient could fall if he were to get up without assistance
and was too weak to walk on his own
4. What interventions will prevent complications?
a. Continuous pulse oxygen monitoring, closely monitoring patient
respiratory status
b. Evaluate for the effectiveness of administered medications.
c. Teaching the patient importance of wearing oxygen if level is low
d. Teaching patient turn, cough, deep breathing exercises
e. Monitor patient fluid intake and output
f. Create a comfortable environment for the patient.
g. Explain all procedures to the patient and family.
5. How will you prioritize implementation of nursing interventions? Explain.
a. #1assess respiratory status, oxygen level, respiratory rate, lung
sounds
b. #2assess other vital signs-temperature, blood pressure, heart rate,
pain level
c. #3assess mental status, head to toe assessment of all other systems
d. #4assess IV site and patency
e. #5Instruct patient on safety with oxygen use, ambulating with
assistance, turn-cough-deep breathing exercises
6. What actions will you take for potential complications?
a. Closely monitor patient for respiratory statusknow where all oxygen
supplies are including masks, non-rebreather
b. Assist patient to maintain proper airwaypatient should have head
elevated to allow for secretions to drain properly
c. Promote rest and relaxation for the patientto prevent exacerbation of
symptoms
d. Promote fluid intake and proper nutritionimportant for patient to
stay hydrated, and eat several small meals instead of large meals, drink
protein shakes or Gatorade
e. Know patients code statusFull code or Do not resuscitate
f. Inform the charge nurse of patient condition, notify physician
immediately if patient status declines

Critique on Teaching Methods

1. Did the nurse ask the client their preferred teaching

method?_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2. Did the nurse provide information appropriate to the clients learning
preference?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3. Was teaching appropriate for clients education level?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4. Did nurse assess client for understanding?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
5. Did the client verbalize understanding?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Self- reflection
KWL chart

Complete the first two columns before starting clinical simulation ( Know and Want
to know). The last column is to be completed after all other exercises and clinical
rotation are completed.
Know
List some clinical findings
that you know about acute
pneumonia and
respiratory distress.

Want to know
List some additional
information that would be
helpful to know before
taking care of someone
with acute pneumonia or
respiratory distress.

Learned
What new information or
clinical findings did you
learn that would help you
take care of a patient with
acute pneumonia or
respiratory distress?

Grading Rubric to Predict and Manage Potential Complications

Performance
Criteria

NI

Able to identify the potential

complications.

Clearly identifies potential

complications.

Description of potential
complications for this
patient is scant.

Unable to identify potential

complications.

Able to identify the

important assessment data
to monitor for this patient.

Clearly identifies the

important assessment data
to monitor for this patient.

Description of the important

assessment data to monitor
for this patient is scant.

Unable to identify the

important assessment data
to monitor for this patient.

Able to identify all factors

influencing the most
important data to monitor.

Clearly identifies all factors

influencing the most
important data to monitor.

Description of all factors

influencing the most
important data to monitor is
scant.

Unable to identify the most

important data to monitor.

Able to prioritize planned

interventions.

Clearly identifies ways to

prioritize planed
interventions.

Superficially discusses
ways to prioritize planned
interventions.

Unable to prioritize planned

interventions.

Able to plan actions to take

if complications occur.

Clearly identifies actions to

take if complications occur.

Superficially discusses
actions to take if
complications occur.

Unable to discuss actions

to take if complications
occur.

NI, needs improvement; S, satisfactory; U, unsatisfactory

References:

Callen, B., Smith, C. M., Joyce, B., Lutz, J., Brown-Schott, N., & Block, D. (2013).
Teaching/Learning Strategies for the Essentials of Baccalaureate Nursing Education
for Entry-Level Community/Public Health Nursing. Public Health Nursing, 30(6),
537-547. doi:10.1111/phn.12033
Ganzer, C. A., & Zauderer, C. (2013). Structured Learning and Self-Reflection:
Strategies to Decrease Anxiety in the Psychiatric Mental Health Clinical Nursing
Experience. Nursing Education Perspectives, 34(4), 244-247.
McDonald, M. E. (2014). The Nurse Educators Guide to Assessing Learning Outcomes,
Third Edition. Burlington, MA: Jones & Bartlett Learning.
Oermann, M. H. (2013). Teaching in Nursing and Role of the Educator: The Complete
Guide to Best Practice in Teaching, Evaluation and Curriculum Development. New
York: Springer Publishing Company.
Sinclair, B., & Ferguson, K. (2009). Integrating simulated teaching/learning
strategies in undergraduate nursing education. International Journal Of Nursing
Education Scholarship, 6(1), 1-11. doi:10.2202/1548-923X.1676
Winters, C. A., & Echeverri, R. (2012). Academic Education. Teaching Strategies to
Support Evidence-Based Practice. Critical Care Nurse, 32(3), 49-54.
doi:10.4037/ccn2012159