Mr. Devito is a 48-year-old male who presents to his Primary Care Provider with left upper abdominal pain and complaints of weakness and fatigue. The nurse immediately notes how pale his skin is. A full set of vital signs reveals the following:
HR 82 bpm
BP 142/90 mmHg
RR 16 bpm
SpO294% on Room Air
Temp 101.0°F
Critical Thinking Check
Bloom's Taxonomy: Application
What furtner nursing assessments would you perform at this time?
Upon further assessment, the nurse notes a palpable mass in the left upper quadrant, possibly an enlarged spleen, that is tender on palpation. The nurse also notes petechiae and bruising to the patient’s arms and legs. When questioned, the patient says “I seem to bruise so easily these days”. The patient’s lungs have diffuse crackles, heart sounds S1 and S2 present with no murmurs. The patient also reports a slight headache.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What laboratory or diagnostic tests do you anticipate the provider ordering?
Complete Blood Count (to check for wbc – infection and reason for bruising)
Full chemistry to ensure no electrolyte abnormalities or renal involvement
Coagulation studies to determine cause of easy bruising
Chest X-ray and sputum culture to identify source of infection
The provider orders a complete blood count, chemistry panel, and chest x-ray. The chest x-ray shows the patient has a slight pneumonia. He is sent home with a course of antibiotics while awaiting the test results.
The next day, the lab results show the following:
RBC4.2BUN22
Hgb 8.4 Cr0.9
Hct25.2K3.9
WBC144,000Na148
Plt 40,000Ca7.6
Critical Thinking Check
Bloom's Taxonomy: Analysis
Based on the above lab results, what should the nurse be most concerned about?
The patient has EXCESSIVE amounts of white blood cells. It would be expected for them to be slightly elevated because of the infection, but this is WAY beyond that.
The patient is also anemic, with low platelets – this could explain the easy bruising
Critical Thinking Check
Bloom's Taxonomy: Analysis
What do you believe may be going on, physiologically, with Mr. Devito?
A bone marrow biopsy must be done to confirm a leukemia diagnosis
The provider calls Mr. Devito and explains the results. They set an appointment for Mr. Devito to have a bone marrow biopsy. Biopsy results confirm Mr. Devito has Acute Myeloid Leukemia. Mr. Devito’s wife says “I don’t understand, I thought you said he just had pneumonia?”
Leukemia causes the body to make a bunch of immature, non-functioning white blood cells. So when a patient gets an infection, like a respiratory infection, the body’s white blood cells can’t actually fight it off. So it’s common for patients to be prone to infections like pneumonia.
Mr. Devito DID have pneumonia – but it was due to the poor immune response caused by the Leukemia.
Mr. Devito will be started on high-dose chemotherapy.
Critical Thinking Check
Bloom's Taxonomy: Application
What education topics should be included in teaching for Mr. Devito and his wife?
Mr. Devito will have a special port implanted in order to receive his chemotherapy
Mr. Devito will likely also receive medications to manage the symptoms of the chemotherapy
Mr. Devito may lose his hair, depending on the type of chemotherapy used, because chemo also kills healthy fast-growing cells
Mr. Devito May experience something called neutropenia. This means he will be highly susceptible to infections. He should avoid having lots of visitors, avoid fresh flowers, and especially avoid being around anybody who is sick. He can even wear a mask in public if he so desires.
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 