Mr. Sampson is a 62-year-old male who presents to the Emergency Department (ED) complaining of severe right knee pain x 3 days. His gait is unsteady and he is limping and guarding that right leg. When the nurse walks in the room, he tells the nurse he has a history of Hepatitis C and HIV.
Critical Thinking Check
Bloom's Taxonomy: Application
What initial nursing assessment should be performed at this time?
OLDCARTS pain assessment, especially when the pain comes on, if anything triggers it, and what makes it better or worse.
Full set of vital signs, especially temperature in case of joint infection
Assess for mechanism of injury and find out if there are other injuries or pain anywhere else
Assess range of motion and assess for crepitus in the painful joint
Upon further assessment, Mr. Sampson’s right knee is very swollen, reddened, and warm and tender to the touch. Mr. Sampson reports that his joints swell up like this all the time, and proceeds to show the nurse his hands, where she notes a swollen nodule on the left wrist, and two swollen nodules on the proximal knuckles of the right hand.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What are the possible diagnosis that should be explored for Mr. Sampson at this time?
CBC to check white blood cell count for infection, as well as CD4 count to assess the status of his HIV
ESR and CRP to determine presence of inflammation
BMP to get a baseline for kidney function
X-rays of the joints in question
Possibly an arthroscopy, but that may come later
The provider orders X-rays of the right knee and bilateral hands, as well as some basic laboratory tests, including an ESR and CRP. When the nurse goes to draw blood, she notes another swollen nodule over the patients left elbow that is shiny and has two white spots on it. She now knows that she needs to recommend one more test for the provider to order.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What is the significance of the finding on the patient's elbow?
This is a tophi – it is indicative of Gout. Gout flares are treated differently than osteoarthritis or Rheumatoid Arthritis, so it’s important that this finding is reported to the provider to confirm the diagnosis.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What other lab test should be added to confirm this diagnosis?
The joint x-rays show crystal deposits around the swollen joints, and Mr. Sampson’s uric acid level is elevated significantly. When asked if he has a history of gout, Mr. Sampson replies “oh yeah, that, too.” He reports that he drinks wine daily.
Critical Thinking Check
Bloom's Taxonomy: Analysis
Explain what is going on with Mr. Sampson physiologically.
Gout is inflammation and swelling of the joints due to deposits of uric acid crystals. This happens when the patient has too much uric acid in their system
Uric Acid could build up due to excess consumption of purines, increased purine synthesis, or decreased renal excretion of purines.
Critical Thinking Check
Bloom's Taxonomy: Application
What medications do you anticipate the provider ordering for Mr. Sampson?
Probably corticosteroids or NSAIDs for the acute inflammation
Analgesics
After 2 days of anti-inflammatory treatments and physical therapy assistance, Mr. Sampson’s joint swelling has decreased and he is able to walk easily without pain and will be discharged home today. The nurse is concerned that he may not understand what triggers his gout flare ups, considering how frequently he reports that they happen.
Critical Thinking Check
Bloom's Taxonomy: Application
What discharge teaching should be included for Mr. Sampson to help him reduce the frequency of his flare-ups?
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 