The American Association of Colleges of Nursing (AACN) promotes educational approaches that actively engage learners to better prepare them for today’s challenging health care environment. More specifically, the AACN (2009) encourages opportunities or assignments for students to engage in case study discussions to improve critical thinking skills that will ultimately improve patient health outcomes.
Similarly, as a means of helping students understand the “big picture,” Billings and Halstead (2009) and Levin and Feldman (2005) support the pedagogical value of using evidence-based teaching methods, such as case scenarios, to improve clinical decision making skills and abilities among students. This article describes a teaching method using a case scenario that supports both of these perspectives.
An 87-year-old woman with type 2 diabetes mellitus was admitted to the hospital with a diagnosis of hyperglycemia secondary to an infected ulcer of her lower leg. She is 5 feet 4 inches tall and weighs 215 pounds. Her blood sugar has been elevated >400 mg/dL for the past week, and she has a fever of 101°. Her prealbumin level is 10.2 mg/dL. Her medical history documents an allergy to penicillin. Current home medications include Glucotrol® (glipizide), Glucophage® (metformin), Neurontin® (gabapentin), Vasotec® (enalapril), Benicar® (olmesartan medoxomil), Lopid® (gemfibrozil), a daily aspirin, and over-the-counter calcium. The health care provider’s orders are brief and include: intravenous ½ normal saline at 75 mL/hour, Ancef (cefazolin) 1 g intravenous piggyback every 8 hours, blood sugar level monitoring, and methicillin-resistant Staphylococcus aureus contact precautions.
Description of Learning Activity
Multiple variables such as age, polypharmacy, and comorbidities influence the management of older adults. Correspondingly, multiple variables may impact availability of patient assignments in the clinical environment.
During times of low patient census, an alternative plan to engage students in assessment, data collection, and prioritization was implemented using the case scenario described in this article. The setting was a large conference room within the hospital. Eight junior-level nursing students were provided the case scenario as a group assignment. Textbooks and PDA resources were allowed. The clinical instructor served as facilitator of the learning activity while encouraging independent thinking among students to foster comprehension of critical concepts.
Goals and Objectives
Students were instructed to view the patient described in the case scenario as though assigned within the clinical unit. Performance expectations were for students to prioritize patient diagnoses, describe assessment criteria consistent with an expected knowledge base, plan appropriate nursing interventions, and identify significant educational needs. Additional areas of educational focus included drug therapy, nutritional status, monitoring of laboratory values, and infection control issues.
The assignment promoted use of the nursing process and incorporated multiple areas of learning, including thorough collection of historical data, refinement of geriatric physical assessment skills, and prioritization of care delivery in an elderly patient with multiple inter-related health problems. Because historical data in the case scenario were incomplete and the physician’s orders were insufficient to properly manage the patient’s care, students were challenged to critically analyze the information provided and identify missing or incomplete patient data.
Incomplete data identified by students included duration of diabetes and history of prior glycemic control, the patient’s management regimen for treatment of type 2 diabetes mellitus (oral medications, insulin dependence, or both), and current laboratory data (glucose measurement, hemoglobin A1c level, and urine or serum ketones) suggesting possible ketoacidosis. Students prioritized patient diagnoses and identified a number of coexisting conditions, including hypertension, dyslipidemia, peripheral neuropathy, and venous insufficiency with risk for neurovascular compromise.
Aggressive management of uncontrolled hyperglycemia was determined to be the primary intervention. Students described educational needs, noted the importance of health promotion related to chronic disease management, and identified the need for regular follow-up examinations regarding hypertension, cardiovascular disease, and peripheral vascular disease.
Use of a case scenario with a geriatric component was more aligned with “real-life” patients. Students discussed care of the fictional patient as though she was an actual patient assignment. Several students reflected on previous clinical learning experiences, whereas others talked of aging grandparents’ declining health.
Care-related changes made by the family and community resources to accommodate older adults’ needs were focal points of discussion. One idea mushroomed another. Interactivity, brainstorming, and sharing of ideas among group members promoted the development of creative solutions to patient problems. Desired goals and expected outcomes replaced actual ones; therefore, implementation and evaluation steps of nursing process were maintained.
Eight students benefited from one patient assignment in a collaborative learning environment. The assignment engaged students in case study discussion. Enhanced critical thinking skills were evidenced by students’ application of knowledge in the clinical setting. This teaching method provides relevant information that can be replicated in the classroom, outside the classroom, and in online education.
Vicki Hannah, MSN, RN, FNP-BC
Shelton State Community College
JoAnn S. Oliver, PhD, RN, CNE
The University of Alabama
Capstone College of Nursing
- American Association of Colleges of Nursing. (2009). Faculty tool kit for the essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/Education/pdf/BacEssToolkit.pdf
- Billings, D.M. & Halstead, J.A. (2009). Teaching in nursing: A guide for faculty (3rd ed.). St. Louis, MO: Saunders Elsevier.
- Levin, R.F. & Feldman, H.R. (2005). Teaching evidence-based practice in nursing A guide for acadmic and clinical settings. New York, NY: Springer.