Elimination Clinical Judgment Case Study with Concept Map

Engage Fundamentals

Elimination

Clinical Judgment Case Study with Concept Map

Case study

A 25-year-old woman who is at 34 weeks’ gestation arrives to the obstetrician’s office for her routine appointment; she is accompanied by her husband. The client informs the nurse that she has some generalized abdominal discomfort and has had firm stools recently that are hard to pass and less frequent than usual. Additionally, the client reports urine leakage that is especially noticeable with coughing, laughing, or sneezing. The client reports managing the symptoms of constipation with increased fluid intake but no other measures. The provider examines the client and determines the client demonstrates an otherwise normal assessment. The provider instructs the nurse to provide the client with directions on constipation management, including an over-the-counter stool softener and urinary incontinence related to pregnancy.

Graded Rubric

· Recognize Cues (Assessment) Identify all relevant subjective (0-10 points) and objective assessment information related to the client’s condition (0-10 points)

20 possible points (20%)

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· Analyze Cues (Analysis)– Form hypotheses Based upon assessment information, identify, and prioritize the top 3 client problems. In other words, which 3 assessment findings are of immediate concern? (0-9 points) Below each client problem, determine and enter 2 relevant assessment information that supports the identified client problem. (0-9 points)

18 possible points (18%)

· Prioritize Hypotheses (Analysis) Identify with rationale the assessment findings that the nurse should address first (0-6 points) State priority framework used for the identification (0-3) and rationale for choice (0-3 points)

12 possible points (12%)

·

· Generate Solutions (Planning) What is the desirable client outcome(s)? State 2 outcomes (0-4 points) Identify 3 possible nursing interventions that can be done for the prioritized problem. (0-9 points) State rationale for each intervention (0-3 points) SMART criteria met for outcomes and interventions (0-4 points)

20 possible points (20%)

·

· Take Action (Implementation) Prioritize with rationales the 3 actions the nurse should take to address the priority assessment finding? (0-9 points) What 2 client factors must you consider when making this decision? (0-4 points) How should the intervention(s) be accomplished (performed, requested, administered, communicated, taught, documented, etc.)? (0-5 points)

18 possible points (18%)

· Evaluate Outcomes (Evaluation) What signs point to: - improving status? (0-3 points) -declining status? (0-3 points) -unchanged status? (0-3 points) What additional interventions or assessments should the nurse implement if expected outcome(s) are not met? (0-3 points)

12 possible points (12%)