Mrs. Phillips is an 84 year old female who arrived to the Emergency Department from a nursing home, where caregivers report she has altered mental status, confusion, and weakness that they just noticed this morning. The nurse inserts 2 large bore PIV’s and draws blood for a chemistry and complete blood count, as ordered by the Provider, who is concerned she may be having a stroke.
Critical Thinking Check
Bloom's Taxonomy: Application
What initial nursing assessments should be performed??
Her NIHSS score is 2, CT scan is negative for an intracranial bleed, and the neurologist believes she is NOT having a stroke. The nurse is called into the room by the caregivers as the patient has wet herself. The nurse notes a foul, sour odor to the urine. Mrs. Phillips’ blood pressure is now 88/52. The nurse notifies the Provider.
Urine and blood cultures should always be obtained before antibiotics
Since the patient has peripheral IV’s already, it would be most appropriate to start the STAT IV fluid bolus before obtaining blood cultures. **Note – most facilities do NOT allow blood cultures to be obtained from existing IV lines due to risk for contamination**
However, if no IV access was available – inserting IV’s and obtaining blood cultures with insertion would be the #1 priority.
The nurse obtains 2 sets of blood cultures and the UAP obtains a sterile urine sample via I&O cath. The UAP reports cloudy, foul-smelling urine. The nurse initiates the IV fluid bolus and requests the Vancomycin from the Pharmacy. Mrs. Phillips’ caregiver asks why she is so confused?
Critical Thinking Check
Bloom's Taxonomy: Analysis
Why is Mrs. Phillips presenting with Altered Mental Status?
The brain is very sensitive to changes in circulating bacteria, oxygen levels, and glucose levels. This is especially true in older patients. The presence of an infectious / inflammatory process in the system causes stress to the brain cells – leading to confusion and an altered mental state.
After 3 days of treatment with IV antibiotics, Mrs. Phillips is awake and oriented x 2-3 (she has dementia at baseline and occasionally thinks it’s 1946). She is calm, conversing with staff, and able to ambulate the halls. She will be discharged home with PO antibiotics tomorrow.
Critical Thinking Check
Bloom's Taxonomy: Application
What discharge teaching should be provided to Mrs. Phillips and to the caregivers at Mrs. Phillips’ nursing home?
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 
