Case Study Notes: Unfolding Case — Mrs. Bernadette Jackson, 85, Admitted from ED with Weakness, Lethargy, and Abdominal Discomfort

Date Started: April 19, 2026 Student: — Course/Source: Instructor-guided unfolding case

Patient Overview

Bernadette Jackson is an 85-year-old female who presented to the emergency department at 1130 with weakness, lethargy, and abdominal discomfort. Following initial treatment and catheterization in the ED, she was transferred to the medical-surgical unit for further evaluation and care.

Stage 1 — Phase 1, Day 1 (15:00) — EHR Orientation on Assumption of Care

Patient Presentation

• Time: Day 1, 15:00 — nurse assuming care, transferred from ED
• Presenting complaints: Weakness, lethargy, abdominal discomfort
• ED intervention: Initial treatment and urinary catheterization performed prior to transfer
• Student task: Orient to patient via EHR review (H&P, Progress Notes, Provider Orders, Admission History, Patient Card)
• Chart sections: History and Physical · Progress Notes · Provider Orders · Admission History · Patient Card

Patient Card

Provider Orders (General — dated 09-05-2023 14:00)

⚠ Code Status Discrepancy: Patient Card displays Full Code, but Provider Orders dated 09-05-2023 list Do Not Resuscitate (DNR). These orders are from a prior encounter (nearly 2.5 years ago). Current code status must be clarified with the provider and confirmed with the patient/family before any intervention. This is a patient safety issue.

Provider Orders — Action List (18 entries, dated 09-05-2023 14:00)

Note: All orders carry the 09-05-2023 date (simulation artifact). Clinically, these orders align with Mrs. Jackson’s current presentation — urinary catheter placed in ED, I&O monitoring, hydration push, and urology consult are all appropriate for a patient admitted with urinary complaints, weakness, and lethargy.

Miscellaneous Nursing Notes

Braden Scale (09-05-2023 14:30 — S. Walker)

Score of 19 = No risk category (≥19). However, given her age (86), acute illness, weakness, and catheter in place, ongoing skin monitoring remains warranted — risk can shift rapidly with deterioration.

Respiratory Assessment (09-05-2023 14:00 — S. Walker)

Lung fields clear in all auscultated fields bilaterally. Respiratory pattern even. No adventitious sounds (no crackles, wheezes, or rhonchi). Pulmonary involvement not a current concern.

Neurological Assessment (09-05-2023 14:00 — S. Walker)

⚠ Key Clinical Cue: A&Ox2 with disorientation to time — confirmed by both the nursing note (14:30) and this assessment (14:00). Friend corroborates this is new. Combined with anxiety, acute illness, urinary pathology, and advanced age, this pattern is consistent with acute delirium until proven otherwise. Anxiety in an elderly delirious patient is a classic apresentation — do not reassure and move on.

Morse Fall Scale (09-05-2023 14:00 — S. Walker)

⚠ High Fall Risk — Score 90. Interventions required: bed in lowest position, brakes locked, call light within reach (already done), non-slip footwear, fall risk communication to patient/family, hourly rounding, and re-evaluation with any change in condition. The combination of weak/furniture-clutching gait + cognitive impairment (overestimates abilities) + IV tether + catheter tubing creates a compounded mechanical fall risk.

Safety Assessment (09-05-2023 14:00 — S. Walker)

Pain Assessment (09-05-2023 14:00 — S. Walker)

Gastrointestinal Assessment (09-05-2023 14:00 — S. Walker)

Musculoskeletal Assessment (09-05-2023 14:00 — S. Walker)

Integumentary Assessment (09-05-2023 14:00 — S. Walker)

⚠ Dehydration Signs: Skin tenting + pallor + dryness together form a classic triad of significant dehydration in an elderly patient. Note: skin turgor is a less reliable indicator in the elderly due to normal loss of skin elasticity with aging — but tenting (the most severe turgor finding) is still clinically meaningful. Combined with weakness, lethargy, and urinary pathology, dehydration is a confirmed contributing diagnosis. “Push oral fluids” order is appropriate but may be insufficient alone if she is significantly volume-depleted — IV fluid status must be confirmed.

Sensory/Pupillary Assessment (09-05-2023 14:00 — S. Walker)

Genitourinary Assessment (09-05-2023 14:00 — S. Walker)

⚠ Significant Urinary Findings: Amber urine with visible precipitates and sediment is consistent with concentrated, infected urine — a hallmark of UTI, dehydration, or both. In a well-hydrated patient, urine should be pale yellow and clear. Amber + sediment + precipitates in an 86-year-old with urethral burning, weakness, and new cognitive changes = UTI with systemic involvement (probable urosepsis) until proven otherwise. Foley to gravity drain confirms catheter placed in ED remains in situ. Baseline occasional incontinence is important context — this was not a new problem, but the acute infection has likely worsened her urinary symptoms significantly.

Cardiovascular Assessment (09-05-2023 14:00 — S. Walker)

🚨 Critical Finding — Poor Peripheral Perfusion: Capillary refill >3 seconds in ALL four extremities + bilateral 1+ thready/weak radial pulses = significant circulatory compromise. Normal capillary refill is ≤2 seconds. This finding, combined with dehydration (skin tenting), amber sediment-laden urine, new-onset delirium, weakness, and suspected UTI, elevates the concern from “complicated UTI” to possible early urosepsis / septic shock. The body is shunting blood centrally — peripheral perfusion is failing. Vital signs (especially BP, MAP, and temperature trend) are now critical data we still need.

Student Thinking (Recorded)

(To be populated after student responds)

Instructor Insights

(To be populated after stage debrief)

CJMM Checkpoint

Assessment Questions (Stage 1)

Key Teaching Points (Running Log)

• Polypharmacy cascade: Oxybutynin → urinary retention → UTI → dehydration → delirium. One medication caused a system-wide cascade in a frail elderly patient.
• Delirium is a systemic sign: New-onset A&Ox2 with anxiety in an 86-year-old = acute delirium until proven otherwise. Never attribute altered mentation solely to age or “new environment.”
• CRT >3s in all extremities is a red flag: Signals compensatory peripheral vasoconstriction — early sepsis or severe dehydration. Vital signs are essential to differentiate.
• 620 mL retention is severe: Exceeds normal bladder capacity; explains abdominal discomfort, infection risk, and systemic symptoms.
• Chart review must be complete: IV fluids were ordered but not visible in the partial chart extract — a reminder to verify all active orders, especially IV access and infusing fluids, at every hand-off.
• Code status must be clarified: Discrepancy between Patient Card (full code) and prior orders (DNR) is a patient safety issue requiring immediate provider and patient/family clarification.

Student Strengths Noted

• Correctly identified oxybutynin as the incontinence medication and connected it to retention (Q1)
• Correctly identified 620 mL as the catheterized volume and understood its clinical significance (Q2)
• Strong pattern recognition across multiple assessment findings pointing to dehydration and UTI

Areas to Revisit

• Chart completeness: missed that IV fluids were ordered alongside oral hydration (Q5) — practice verifying all order categories during EHR orientation
• Reinforce: always check IV fluid orders and pump settings as part of assumption-of-care

Stage 2 — Phase 2, Day 1 (15:20) — Genitourinary Assessment and Foley Catheter Assessment

Patient Presentation

• Time: Day 1, 15:20 — nurse enters room, introduces self, proceeds with genitourinary assessment
• Genitourinary findings:
  • Foley catheter to gravity drain
  • Urine: cloudy, dark yellow — no odor noted
  • External genitalia: no problems observed
• Foley catheter assessment:
  • Tube: patent, draining well
  • Insertion site: no redness, no swelling
  • Catheter: secured to patient’s leg
• Student task: Document genitourinary assessment in Genitourinary Assessment chart; document Foley assessment in Drains/Tube chart; mark Phase 2 as done

Student Thinking (Recorded)

(To be populated after student responds)

Instructor Insights

(To be populated after phase debrief)

CJMM Checkpoint

Assessment Questions (Phase 2)