Video Case Study - Cholecystitis

Nurse Sandy works in the emergency department and is caring for Natasha, a 40-year-old female with a history of obesity who's been diagnosed with acute cholecystitis requiring surgical intervention. While Nurse Sandy prepares Natasha for surgery, she goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Natasha's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Sandy recognizes important cues, including Natasha's vital signs, which are temperature 98.9 F or 37.1 C, heart rate 102 beats per minute, respirations 22 breaths per minute, blood pressure 159/97 mmHg, and pulse oximetry 99 percent on room air. Natasha rates her pain at 3 on a zero to 10 scale. She also notices that Natasha is holding an emesis bag, which contains a small amount of green emesis.

Nurse Sandy performs a focused abdominal assessment, noting active bowel sounds in all quadrants. However, upon palpation, Natasha grimaces and puts her hand over her mouth.

Natasha: Please don't press down on my stomach, I feel like I'm going to throw up again.

Nurse Sandy provides Natasha with a fresh emesis bag and rubs her back as she vomits.

Afterwards, Nurse Sandy analyzes these cues. She reviews the electronic health record, or EHR, and notes that Natasha initially presented to the emergency department with right upper quadrant pain and vomiting that occurred hours after eating fried chicken for dinner. She also notes that Natasha is taking oral contraceptives, which Nurse Sandy recalls increases the risk for developing cholecystitis. Additionally, Nurse Sandy sees that, two hours ago, Natasha received 4 milligrams of ondansetron and 4 milligrams of morphine sulfate IV.

Nurse Sandy then acknowledges the new preoperative orders for Nastasha, including NPO status, and a maintenance infusion of normal saline to run at 100 milliliters per hour. In addition to completing these preoperative interventions, Nurse Sandy will need to provide effective management of nausea while Natasha awaits surgery.

Now, using the information she's gathered, along with Natasha's medical history, Nurse Sandy chooses a priority hypothesis of nausea. Then, she generates solutions to address Natasha's nausea that will include pharmacologic and nonpharmacologic interventions; and she establishes the expected outcome that after intervening, Natasha will report decreased nausea within thirty minutes.

Nurse Sandy then takes action to implement these solutions. She knows that since Natasha received ondansetron two hours ago, she can't have another dose for another four hours. Since Natasha remains nauseated, Nurse Sandy reports Natasha's nausea, vomiting, and current vital signs to the health care provider. The health care provider orders a one-time dose of metoclopramide IV. While Nastasha waits for the metoclopramide to be delivered from the pharmacy, she initiates the normal saline infusion and closes the window shades to promote relaxation. Once the medication arrives, Nurse Sandy administers the metoclopramide through Natasha's IV using the six steps of medication administration and three checks.

Nurse Sandy: Okay, I just gave you some IV nausea medication, and you have some fluids infusing so you don't get dehydrated. I also have a cold compress for your forehead. Do you think that would feel good?

Natasha: Yes, that would be nice.

Nurse Sandy: Okay. I placed the call bell right next to you. Don't hesitate to call me if you need anything.

Natasha: Thank you.

Nurse Sandy assists Natasha to a comfortable position and leaves the room to document her interventions.

Thirty minutes later, Nurse Sandy enters Natasha's room to evaluate the outcome of her actions. She takes Natasha's vital signs and reassesses her pain. Her temperature is 98.6 F or 37.0 C, heart rate is 90 beats per minute, respirations are 16 breaths per minute, blood pressure is 134/78 mmHg, and oxygen saturation is 99 percent on room air. Her pain rating is at 3 on a zero to 10 scale.

Natasha is currently resting and tells Nurse Sandy that she no longer feels nauseated. Nurse Sandy performs an abdominal assessment and notes that Natasha can tolerate palpation without vomiting. Since Natasha's nausea is under control, Nurse Sandy will continue to monitor her as she prepares for surgery.

Alright, as a quick recap… Nurse Sandy recognized and analyzed cues related to Natasha's cholecystitis and prioritized hypotheses and generated solutions to address her nausea. Nurse Sandy then took action, implemented pharmacologic and nonpharmacologic measures to address Natasha's nausea, and evaluated her outcomes by comparing them to the expected outcomes. Since Natasha's nausea has improved, Nurse Sandy determined that the plan of care was successful.