t. peters nursing case study project final

Running Head: Nursing Case Study Project

Nursing Case Study

Instructional Design Project

Tara Peters, MSN

Ed Tech 503

Boise State University

Nursing Case Study Project 2

Table of Contents

Synthesis/Reflection Paper 4

Part 1. Topic 51a. Stated learning goal 51b. Description of the audience 51c. Rationale 5

Part 2. Analysis Report 62a. Description of the needs 62a1: Needs assessment survey 62a2: Needs assessment data report 6 Table 1: Student report of mastery of prior learning 72b. Description of the learning context 72b1: Learning context 82b2: Transfer context 82c: Description of the learners 8 Table 2: Students by gender and age 92d: Task analysis flow chart 10 Figure: Learning objectives flow chart 10

Part 3. Planning 123a: Learning objectives 123b: Objectives and assessment matrix table 133c: ARCS Table 15

Part 4. Instructor Guide 18

Part 5. Learner Content 235a: Learning materials 235b: Assessment materials 235c: Technology tool justification 23

Part 6. Formative Evaluation Plan 246a: Expert Review plan 246b: One-to-One evaluationplan 246c: Small Group evaluation plan 246d: Field Trial evaluation plan 25

Part 7. Formative Evaluation Report 267a: Evaluation survey 267b: Report the results of the expert review 297c: Comments on change 29


Part 8. AECT Standards Grid 30

References 32

Appendices 33Appendix A 33Appendix B 34Appendix C 36Appendix D 40


Synthesis Reflection Paper

It occurred to me part way through my final project that the instructional design (ID) process can be compared to an iceberg in that only a small portion of the work of any instructional design process is visible to most observers. While the educated or experienced observer can look at the small visible portion and understand that they are only seeing about 10% of what makes the project work, or of the iceberg, the inexperienced or uninformed observer cannot. The instructional design project I completed is much the same. An inexperienced observer could walk into any of instructional settings described by me or by any of my fellow students and see a polished, smooth-flowing learning process taking place. Little do they know the hours of thought and volumes of written preparation that support the final project, making it float effortlessly before their eyes!

I, too, had no idea just how much work goes into a really well-constructed instructional design project. While I knew when I started teaching that I had much to learn, I simply had no idea how much preparatory work goes into a well-designed learning activity. Our first ID project in this class made me consider how to think about the process and introduced me to multiple approaches to establishing the framework of any instructional design project. Like the person who knows nothing of icebergs and thinks that all they see is all there is, I not only did not know that I needed a framework (“winging it” had served me well up to this point) or that I needed a different framework for different situations. (Gustafson and Branch, 2002)

Our second project really allowed me to see the ID process from multiple viewpoints as I took on a role and then tried to view the entire project and its component parts from multiple perspectives. In addition, I had to defend my position and critique my classmates’ work from a logical, well-grounded position. I have truly enjoyed learning how to systematically approach instructional design. As I stated previously, I had been winging it in the sense that I thought about what I was doing, but at the same time I has a suspicion that I was missing the boat on one or more issues. Now, I feel that I have some theoretical framework to help guide my thinking as I design learning activities.

I am already using what I have learned in this class. I am better prepared to help new instructors prepare lessons and learning activities and I can explain to them why some projects need to be structured as they are. Most have never been exposed to these ideas (they are nurses, not educators, after all) so anything I can offer them in terms of guidance or resources is most welcomed. As I transition to the field of educational technology, I am sure I will utilize what I have learned in this and all of my classes along with my nursing education to develop relevant, efficient and current learning resources. I am particularly interested in making an impact in the area of competency based eLearning because I can see that the brick and mortar time-based educational experience is available to fewer and fewer students over time and is largely dependent on available financial resources, but that education is still the key to progress and achievement. Education is still the great equalizer and it is a pity that so many bright, motivated students of all ages are not able to reach their potential due to lack of access to affordable, quality, non-location-dependent education.


Part 1. Topic

1a. Stated learning goal

Second semester nursing students will be able to accurately apply their knowledge of the underlying causes of, effective nursing care for, and clinical manifestations of Diabetes Mellitus (DM) to a project-based (case scenario) learning activity after 3 hours of classroom instruction.

1b. Description of the audience

The target audience is second semester nursing school students who are currently enrolled in the Medical-Surgical Nursing class at Mountainland Applied Technology College (MATC). These students are approximately four weeks away from graduation and have learned and had the opportunity to apply principles of patient care in a variety of healthcare settings prior to being presented with this learning activity.

1c. RationaleThe case study project will emphasize newly learned information about caring for

patients with DM and will require students to synthesize this new information with previously learned material covering basic patient care, laboratory and diagnostic testing, and the nursing process, or ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation), and any other previously learned material or skills the students find relevant to the case study.

Nurses must have critical thinking skills and must be able to sift through large amounts of information to determine what is relevant and what less so as well how to prioritize relevant information in order to provide appropriate nursing care and improve patient outcomes. While the clinical setting may be the best setting for learning patient care, the concepts behind patient care take time and targeted guidance to learn well. Therefore, allowing students to work through a case study and try to apply both new and previously learned material to an unknown situation is an effective way to teach students prior to allowing them to care for real patients. Students are free to think through problems without the risk of injuring a patient and they can ask questions as they work through the case. In addition, instructors are available for guidance and to correct misconceptions students may have while in a supportive learning environment.

The learning in this project is primarily generative, though a small amount of the new learning, approximately 10%, will be supplantive. Students will be required to memorize a few lab values and basic information about DM but the majority of their learning will be generative because they are not passive learners during this activity. The students will be actively engaged in applying what they know to a previously unknown situation, prioritizing and justifying their actions, and they will be reflecting on their actions and their patient’s outcome based on the choices they have made.

This learning goal is an intellectual skill according to Gagne (Smith and Ragan, 2005), specifically problem-solving, and thus employing a problem-solving instructional strategy by utilizing a case study is appropriate. The case study can be presented as relatively well-defined to begin with but as the instructor provides the class with patient status updates the case can become more complex and ill-defined. This approach will allow the instructor to gauge the students’ level of understanding and help students correct misconceptions as the difficulty of the case increases. In addition, this progression from relatively well-defined to ill-defined will allow the instructor to match the case difficulty to the students’ levels as well as allow the instructor to


spend more time developing concepts the students need to develop and less time working on concepts they clearly understand.

Part 2. Analysis Report

2a. Description of the needsA learning need exists because students will care for many patients with diabetes mellitus

(DM) during the course of their career, so it is essential that they are familiar with the disease and how it impacts patient health. While the students will have been introduced to various aspects of the nursing process and patient care, they will benefit from having the opportunity to apply their learning to an unknown situation in a safe environment prior to having to demonstrate their knowledge and critical thinking skills in the real world context of clinical rotations or their work place.

2a1: Needs assessment surveyThe needs assessment survey (Appendix A) was handed out to 21 second semester

students to complete at the end of their Medical-Surgical Nursing class on March 25, 2013. The students were told the purpose of the survey and that completing it was voluntary and that they should not put their names on the survey form. 18 of 21 students participated in the survey.

While an instructor may know the answers to many of these questions, an instructional designer would not. Not only might the survey tool be useful for gauging the students’ starting point for the planned learning activity, it may also serve as a cue to the students that content requiring this knowledge might be forthcoming in class and, thus, a brush up on areas where they may feel their knowledge or skills are weak would be beneficial to them going in to this project.

2a2: Needs assessment data report All 18 respondents were able to identify the correct steps of the nursing process and were

able to place them in the correct order, and all students were able to explain why they needed to assess prior to acting. Students were less clear about how elevated blood sugars effect cellular functioning or why it inhibits wound healing, though all were sure that it did and demonstrated at least a partial mastery of the concepts involved. While all the students report caring for multiple patients with diabetes during their clinical rotations, twelve were able to affirm that they had been presented with lab or simulation scenarios involving patients with diabetes as the subject’s primary or secondary medical diagnosis. Of the 18 students who responded to this question, five rated their understanding of proper nursing care for patients with DM as average, 10 rated themselves as very good and 3 rated their knowledge of nursing care for diabetic patients as excellent.


Table 1. Percentage of students reporting experience or mastery of prior nursing school experiences.Total number of respondents 18 (4 male, 14 female)

Male Female0

20

40

60

80

100

120

Prior Case StudiesPatients with DiabetesAble to Utilize MaslowsState Elements of Nursing Di-agnosis

Because case studies are a regular part of their educational experience in the practical nursing program, all the students reported prior experience with case studies and reported that the experience is generally helpful to them because it allows them to collaborate with their group in class, and the case studies provide context for what they have learned. Two students commented that the case studies allowed them the chance to make connections between aspects of the patient’s care they might not have made otherwise, and the majority indicated that case studies in one class had helped them either in other classes or in clinicals.

The remaining questions on the survey dealt with utilizing Maslow’s hierarchy of needs to prioritize care for their patients and developing appropriate nursing diagnoses for their patients. While all the students were able to identify how Maslow’s can help them figure out what is most important or which patient needs to be seen first, they were less adept at explaining why their interventions should be patient-specific, and fewer than half the students gave a satisfactory response to question 15 which asked them to identify the essential elements to a nursing diagnosis. Considering that these concepts have been covered since the second week of the program, the nursing instructors were a bit mystified as to why the students are still having trouble with these concepts and agreed that the results warrant examination. 2b. Description of the learning context

Nursing program instructors have noticed an increasing tendency for students to want to “learn by bullet-point” and favor memorization over in-depth critical thinking. Since the bulk of a nurse’s work is at the application or higher levels, this type of learning will not serve to develop a competent, effective, safe nurse. Instead, nursing students need to be able to think critically, apply what they know to new situations.


The discrepancy model is the appropriate method for conducting a needs assessment in this case because both didactic and clinical instructors have noticed that students want to memorize content but they are increasingly less successful at actually applying what they should know to patient care scenarios in the Sim lab and in the clinical setting. Therefore, there appears to be a discrepancy between what is and what should be. Case studies require learners to apply the content and concepts they have learned to new situations, thereby giving them an opportunity to apply what they know as they consider multiple pieces of information and changing conditions. Discrepancies in performance can be due to failure to master previously taught content and concepts, failure to grasp new content, or it can be attributed to other factors such as motivation or lack of time to complete projects.

2b1: Learning context The learning activity will be conducted in the Practical Nursing program’s second

semester classroom on the MATC campus. The room is well-lit and has adequate seating for up to 30 students, and is equipped with a large white-board, an overhead projector, viewing screen and a computer for use by the instructor. The students may bring their portable electronic devices to class and plenty of electrical outlets are available for students who want to charge their device’s batteries.

All nursing students are adults who have completed prior coursework in anatomy, physiology, English and math as prerequisites to entry into the program, and all have completed their Certified Nursing Assistant (CNA) classes and are certified in the State of Utah. In addition, all nursing students have taken a CPR course and most have worked as a CNA in a hospital or nursing home prior to enrolling in the practical nursing program.

The nursing students have had to compete academically to be accepted into the nursing program and so all appear to be motivated to succeed. However, many students are over-scheduled due to family, work and the ill-advised habit of trying to complete the nursing program while taking prerequisites for more advanced nursing programs to which they hope to gain entry after they complete the practical nursing program. Thus, what is in fact a reasonable amount of work for any entry-level nursing program is felt to be excessive by students because of other issues and demands outside the classroom. Instructors feel these problems can contribute to students’ tendency to fall back on old habits such as being task-oriented rather than learning-oriented, and attempting to simply memorize content rather than master and apply concepts.

2b2: Transfer context The students will be able to apply their knowledge and skills when caring for their

patients and they will be able to utilize the critical thinking skills they are developing when they take the National Council Licensure Examination for Practical Nurses (NCLEX-PN) after graduation. It is not enough that nurses possess knowledge or that they can master the art of taking multiple choice exams such as the NCLEX-PN. Nurses must also be able to apply what they know to patient care. Thus, the learners must be able to apply their learning in two contexts in order to become licensed and in order to function as safe, effective nurses.

2c: Description of the learners All of the current 21 second semester nursing students are adults over the age of 18 who

have completed prior coursework in anatomy, physiology, English and math as prerequisites to entry into the program, and all have completed their Certified Nursing Assistant (CNA) classes and are certified in the State of Utah. In addition, all nursing students have taken a CPR course


and most have worked as a CNA in a hospital or nursing home prior to enrolling in the practical nursing program. While most of the students are females in their 20’s, the class does include several adults over the age of 30, and one in her 50’s, and four males. In addition, the current class consists primarily of white non-Hispanic students who are members of the LDS church though two of the male students are Hispanic, one from Bolivia and the other from Mexico. Six students have associates degrees in another field, 2 have Bachelor’s degrees, and one was an attorney in his home country.

Table 2. Percentage of second semester practical nursing students by gender and by age.

Student Gender

Male - 4Female - 17

Student Age

18-30 years31-52 years

The planned learning activity will take place in week 30 of the 32 week program. As such, the learners will all have already been presented with all the basic skills and concepts they will need to complete this activity successfully by the time they begin working on this case study. However, it is not enough that information and ideas have been presented to the students. They also need the opportunity to apply their knowledge in a safe environment where they can learn from their mistakes and the mistakes of others. The student’s learning will also be enhanced by allowing them to link new information to previously learned information and by allowing them the time to think issues through and make connections.


2d: Task analysis flow chart

Learning Objectives #1 - 4.1

Read Case Study Gather lab data LO #1 ID 5 required lab results

Was lab data correctly Identified?

If yes, continue. If not, seek information.

LO 1.1.1Able to distinguish relevant from

irrelvant lab data?If yes, continue.

If not, seek information.

LO 1.1.2Explain how lab results drive

patient care?If yes, go to LO #2.


LO #2 Explain use of BS checks in

patient care. If yes, go to LO #3.


LO #3 ID critical lab values If yes, continue.

If not seek information

LO #3.1 Predict change in nursing care

If yes, continue.If not seek information

LO #3.2 Give critical lab value report

If yes, go to LO #4If not seek information

LO #4 Prioritize care per Maslow's

If yes, go to LO #4.1If not seek information

LO #4.1 Determine priority nursing diagnosis.If yes, go to LO #5

If not seek information


Learning Objectives #5 - 6.1

How to Seek Information Flow Chart

Part 3: Planning

LO #5 Construct 5 interventions with rationales. If yes,

continue to LO #6. If not, seek

information.

LO #6 Apply interventions and

anticipate results. If yes, continue. If not, seek

information.

LO #6.1 Are interventions patient

specific?

Successful Completion of NIDDM Case Study

Review your notes from this class

Consult your lab and diagnostic handbooks.

Consult your textbook.How to Seek Needed Information

Review your notes from other classes.Consult with your group

membersConsult with your

instructor


3a: Learning objectives

1. Accurately identify 4 of 5 lab results needed for accurate assessment of the diabetic patient in the case study. (This number can be changed up or down to reflect the complexity of the case appropriate to students’ current level.)

1.1. Presented with a list of lab results, students will be able to distinguish relevant labs results from irrelevant lab results.1.2. Students will be able to explain the significance of both relevant normal and abnormal lab results to show how those results drive patient care.

2. Explain how blood sugar checks and glucometer can be used effectively in the care of a patient with NIDDM.3. Accurately identify the critical lab value in the case study.

3.1. Analyze the relevance of the critical value included in the case study.3.1.1. Predict changes in nursing care related to the critical lab value.

3.2. Articulate the procedure for reporting critical lab values including to whom the results must be reported, in what time frame, and the charting requirements.

4. Prioritize patient care based on Maslow’s hierarchy of needs.4.1 Determine the priority nursing diagnosis, written in proper form.

5. Construct five nursing interventions relevant to the priority nursing diagnosis, with rationales.6. Apply the nursing interventions and describe the anticipated results of those interventions.

6.1 Demonstrate how each nursing intervention is patient specific. Include your nursing actions, and the anticipated results.

3b: Objectives and assessment matrix tableLearning Objectives (a)

Bloom’s Taxonomy Classification (b)

Format of Assessment (c)

Description of test form (d)

Sample items (e)

1. Accurately identify 5 labs needed for accurate assessment of the diabetic patient. (This number can be changed up or down to reflect the complexity of the case appropriate to students’ current level.)

Comprehension Written Constructed answer

Given your thoughts at this time, which labs can you anticipate the provider ordering on this patient?

1.1. Presented with Comprehension Written Constructed Given the lab results at this time,


a list of lab results students will be able to distinguish relevant labs results from irrelevant lab results.

Application answer which are relevant to your patient care and why?

1.2. Students will be able to explain the significance of both relevant normal and abnormal lab results and how those results drive patient care.

Application

Analysis

Written Constructed answer

Explain why the lab results, both normal and abnormal, are relevant. How do the labs drive the care for this patient?

2. Explain how blood sugar checks and glucometer can be used effectively in patient care.

Application Written Constructed answer

How will BS checks with a glucometer help you assess your patient? Explain your reasoning.

3. Accurately identify 2 of 2 critical lab values in the case study.

Comprehension Written Constructed answer

Which, if any, lab values are critical?

3.1. Analyze the relevance of the critical values included in the case study.

Analysis Written Constructed answer

What are the potential outcomes to this patient if the critical lab values are not addressed within the next hour?

3.1.1. Predict any changes in nursing care related to critical lab values.

Application

Analysis


Examine how you will change your nursing care of this patient, if at all, based on the critical lab values you have received.

3.2. Articulate the procedure for reporting critical lab values to include to whom the results must be reported, in what time frame, and charting requirements.

Application Written Constructed answer

What are you obligated to do once you receive critical lab values? Include all steps from the time you receive the critical lab value through the final step in the process.


4. Prioritize patient care based on Maslow’s hierarchy of needs.

Analysis

Synthesis


Apply Maslow’s to this patient case and explain your reasoning.

4.1 Determine the priority nursing diagnosis, written in proper form


Based on the facts of the case and Maslow’s, state the priority nursing diagnosis for this patient, written in proper form.

5. Construct three nursing interventions relevant to the priority nursing diagnosis, with rationales.

Analysis

Synthesis


State 5 patient specific nursing interventions relevant to the priority nursing diagnosis and clearly explain your rationales. Be sure to include an explanation of how you would evaluate the effectiveness of your interventions and why you chose these interventions and methods of evaluation for this specific patient.

6. Apply the nursing interventions and describe the anticipated results of those interventions.

Application

Analysis


What results do you anticipate from each intervention? Why?

6.1. Demonstrate how each nursing intervention is patient specific. Include your nursing actions, and the anticipated results.


Did your results differ from what you might expect (textbook patient responses)? If so, how, and what might have been the cause. What might you do differently next time?

While I have stated that these objectives would be met via a constructed answer, it is also quite possible to have students demonstrate mastery of some of these objectives verbally such as reporting their group’s ideas or diagramming a patient on the board for the rest of the class. In other words, the constructed answer may be something other than a written narrative. However, some students may not actively participate in classroom activities to the extent it is possible to really gauge their mastery of the material. In that case it may be best to use a combination of a constructed answer assessment types and compare those results with the students’ clinical performance to get an accurate assessment of the students’ functioning. In addition, students are strongly encouraged to be self-sufficient when seeking information. Not only does this encourage them to learn where to find reliable information but it discourages the over-use of the instructor as their main resource. When the students move from the classroom to the workplace they will no longer have a ready source of answers like their instructor, so requiring the student nurse to exhaust all other resources prior to asking for the instructor’s help will encourage them to retain


previously learned information and will develop their research skills thus enabling them to function effectively, safely, and independently.

3c: ARCS Table

ATTENTION

A.1 Perceptual Arousal

>Announce that today’s class will consist of a short review session followed by collaborative or individual work on a case study. It is assumed that the students have read the relevant materials prior to class as instructed.

>Review pertinent information and concepts covered in previous classes to be covered in the case study followed by the review of diabetes related information covered in their reading materials for this activity.

>Demonstrate via a short example case study how previously learned and newly learned knowledge can be used to solve patient care problems.

A2. Inquiry Arousal

>Students will be asked to answer prompts from the instructor regarding their care of patients with DM in their previous clinical rotations.

>Students will be asked to respond to instructor inquiries regarding previous examples of patient care and how the new information might have helped them provide more competent, patient-specific care.

A3. Variability

>Instructor will intersperse the lecture and review time with any combination of Power Points, NCLEX-style questions, and exemplars requiring “audience-participation” to keep students engaged.

>Learners will have the choice of working in a group or working alone in solving the case study. One paper will be graded for each group and the same score assigned to all regardless of the size of the group (limited to 1-4).

RELEVANCE

R1. Goal orientation

>The instructor will provide the students with the goals for the learning activity, which involves


applying previously learned and new knowledge to a new case study involving an adult patient with DM.

>The students will be provided with the class objectives.

> The instructor will review the goal and objectives and illustrate how this learning activity applies to their future practice as nurses who will care for patients with DM.

R2. Motive matching

>The instructor will conduct a brief survey of the class to determine if the students have any additional related information/concepts they would like to have covered during the class.

>The instructor will give examples of how what the students will learn in this class will apply to future patient care situations the students will likely encounter by giving examples from real-life experiences.

R3. Familiarity

>The instructor will ask students to recall their previous case studies and remember what strategies worked well for them and what did not so they can use their time effectively.

>The instructor will be available during the class to guide students, and students will be reminded they need to be as self-sufficient as possible.

CONFIDENCE

C1. Learning requirements

>The instructor will provide each student with a rubric and a clearly defined set of questions so students will understand the case study requirements clearly.

>Each student will be provided with a copy of the case study for their own use during class. Students can keep as the case study and reference materials for future reference.

C2. Success opportunities

>The instructor will guide students to appropriate resources or will provide assistance when students have questions they cannot immediately answer on their own.

>The instructor will provided feedback to each group or individual at certain predefined steps in the process as well as whenever asked.

>Students are given the opportunity to have their work reviewed prior to turning it in for a score


and will be provided the opportunity to correct any issues before submitting it for a final score.

C3. Personal control

>Students will be reminded that as adult learners they may use their time as they see fit but that they will need to submit their case study for a score within 60 minutes of the end of class.

SATISFACTION

S1. Natural consequences

>All students will have the chance to work alone or in a group as they choose in order to have the greatest opportunity for personal success.

>All students will have an equal amount of time to complete and submit their work.

S2. Positive consequences

>Students have the opportunity to apply important nursing concepts to the care of a diabetic patient in a low-risk environment.

>Students have the opportunity to submit their work after it has been reviewed in order to correct misconceptions or oversights prior to scoring.

S3. Equity

>Instructor feedback will be given based on the rubric which was provided to the students at the beginning of the project.

>Students will be reminded that their success as nurses is a primary goal of this learning activity and has such they will be held to the standards indicated in the rubric but they will also be given ample opportunity for research and inquiry prior to submitting their work.

Part 4. Instructor Guide

Introduction (30 minutes)

Gain Attention


Announce that the class is beginning and that everyone needs to shut off their cell phones and give their attention to the instructor. Shut the door to the classroom to minimize outside distractions.

Inform Learners of Purpose

Inform the students that the goal of the lesson is that they, upon completion of the learning activity, will be able to accurately apply their knowledge of the underlying causes of, effective nursing care for, and clinical manifestations of Diabetes Mellitus (DM) to a project-based (case scenario) learning activity after 3 hours of classroom instruction, review, and participation in the active learning activity (case study).

The instructor will explain that in order to prepare them to meet that goal they will be given the opportunity to combine their previous learning with the newly learned material in order to answer questions involving a case study of a diabetic adult patient.

Stimulate Learners’ Attention/Motivation

Let students know that the purpose of the learning activity is to give them the chance to practice what they know by applying their knowledge and critical thinking skills to a case study in a safe environment prior to providing nursing care to similar patients in the clinical setting.

Since all of the students in the class are likely to have cared for diabetic patients at clinicals prior to this class, the students should be asked to think back to any previous experience and then write down two things that they would have liked to have known at that time about caring for a diabetic patient, but did not, that they would like to know now by the end of the lesson.

Tell the students to keep these questions because they will be referring to these questions at the end of the class.

Preview the Learning Activity

Hold up a copy of the case study, the objectives and the rubric and let the students know that they will each receive a copy of these pages so they will have clear instructions and expectations in front of them the entire time they are working on the case study. Do not give these items to the students prior to the content and concept review, however, as this will merely prove to be a distraction and will interfere with their ability to focus on the review.

Let the students know that the instructor will review relevant knowledge and concepts with them prior to starting and that the instructor will also be available during the entire class for guidance. Once the relevant material has been reviewed the students will be allowed to break off into groups or work individually to complete the case study.

Body (1 hour 45 minutes)


Stimulate recall of prior knowledge

Review relevant, previously learned content with the students by asking them questions such as “what is the first step in the nursing process,” “why do we assess before we act” or “who can tell me why Maslow’s helps us prioritize patient care?”

This type of questioning serves two purposes. First, it allows the instructor to assess the classes’ baseline and it serves to get students thinking about the ideas they will need to use in order to answer the case study questions.

Next, the instructor can ask questions about the content from the reading material. The expectation is that the students have read and understood the material and that the instructor is not there to deliver basic content but rather to review it and clarify misconceptions or elucidate pertinent aspects of the material and related concepts.

The instructor should touch on the main points of the materials and related concepts and guide students through the process of understanding how DM affects patients.

Present information and examples

The instructor can then give at least 2 examples of how DM can change the nurse’s care of a specific patient by giving examples of standard patient care that must be changed once the health care team learns the patient has DM.

The conversation should start out with the general concepts being covered and should end with specific examples in order to show students how to apply concepts to specific patients.

The instructor will inform the students that the rubric asks for patient specific, not textbook, answers to questions. The instructor should ask for and answer questions regarding the learning, but should also take care to help the students discover answers for themselves rather than just providing information for them.

Gain & Direct Attention

The instructor should then hand out the rubric, objectives and the case study and go over each item with the students so they will have a clear overview of the assignment and expectations.

Answer any questions they may have.

Remind the students that the expectation is that this case study be completed within 60 minutes of the end of class, no exceptions. This should give them plenty of time to review the case study and answer the questions. This time frame also provides adequate time to research materials, lecture notes, or textbooks as needed and to prepare their work for submission.


Remind students that the expectation is that the instructor is the resource of last resort and that they will need to look in every possible available source prior to asking the instructor for direct answers, though the instructor is always available to help them think a problem through or organize their approach to a problem.

Tell the students that they can work in groups or individually as they choose and that the instructor will review their answers and give them guidance as they work through their case study. Remind the students that there will not be enough time at the end of class for the instructor to check all work from beginning to end nor will there necessarily be enough time for them to correct all errors and still submit their work on time. Students should be told that they are responsible for using their time wisely and efficiently.

Each group will turn in one care plan with the names of all group members and all the members will receive the same score. Individuals will turn in their case study for themselves, and no student may have their name on more than one submission.

If at any time any individual feels that their group members are not working in a collaborative, goal-directed manner, that student can simply inform the instructor they are breaking off from their group and that they will complete the work on their own.

Guide and Prompt Use of Learning Strategies

The students may work on the case study using their own strategies with the understanding that the instructor is available for guidance as needed.

The instructor should check in with each group or individual multiple times during class and assess whether or not the students are utilizing effective strategies for answering the case study questions. The instructor should offer guidance, encouragement and reinforce their successes.

If the students are struggling then the instructor can assess exactly where the students may be getting off track or where their problem-solving strategies are not effective and offer guidance.

Remind the students to think through problems using the nursing process, the ABCs and Maslow’s because consistent and appropriate application of these principles will help students deal with previously unknown issues in the real world of nursing.

Remind students, too, that if they are having difficulties with problem-solving because they do not have enough information, they need to stop and get the needed information before they move on in the case study.

Provide for and Guide Practice


The students will work on their case study for as long as it takes for them to complete the task, up to 1 hour and 45 minutes.

Students are not allowed to rush through their work and leave early. If students want to leave early they must submit their final product prior to leaving class.

Collect student work as individual or groups finish and compare the work to the rubric. The students can finish early and have their work checked for major errors so they will have time to make corrections. Make it clear to the students that their work is being reviewed for major errors, and that it is not carefully scored at this time.

If the work is lacking then return it with comments for review and correction. Provide guidance as needed. Remind the students to review the assignment and rubric as needed.

Provide Feedback

Review the students’ work at several points during class as described above. The instructor should circulate among the groups to increase accessibility and approachability.

The instructor should make major corrections during class, but certainly within 30 minutes of the end of class in order to give all students time to make corrections prior to submitting their work if needed.

No sooner than one hour after the end of class, the instructor will score the submissions and assign points according to the rubric and then enter the scores in the LMS.

Conclusion (30 minutes)

Provide summary and review

Prior to dismissing class, the instructor should review the students’ questions they were asked to write down at the beginning of class. Were those questions answered? Allow the students time to answer. One very effective method of formative assessment and positive reinforcement is for the instructor to read representative questions to the class and ask for input from the class. If questions still remain, ask the students to research the questions and present their findings at the beginning of the next class.

The instructor can assess whether or not the students were able to learn what they wanted to know, and can also ask if they discovered anything that they now realize was important but may not even have known to ask at the beginning of the class.

Allow approximately 15-20 minutes for this discussion, or more if time allows.

Transfer learning


Remind students of what was learned and how this new knowledge will translate to their workplace once they graduate and are working as nurses.

Provide Remediation and Closure

Opportunities for remediation have been provided throughout the class, but students may benefit from more discussion now if time permits, and are also invited to speak to the instructor individually if desired.

Once all the case studies have been reviewed for major errors the students may leave with the understanding that their final product must be submitted within 60 minutes of the end of class.

Assess Learning

Learning will be assessed based on the written case study and rubric as discussed above.

Provide Feedback and Remediation

The students’ work, the graded rubric, and comments should be completed and returned to each student within one week.

Meet with any students who were exhibiting difficulties grasping or applying the information so they can receive guidance or remediation as needed.

Part 5. Learner Content

5a: Learning materials

The case study will be provided to the students, along with an answer sheet in both printed and electronic form in order to accommodate students who prefer to work with paper or who do not have a portable device available during class. Students are required to complete their work and submit it electronically. The case study, along with its worksheet and the rubric, is attached as Appendix X.

The students have access to their textbooks and their lab manuals which were purchased at the beginning of the school year, and they have their class notes from this or previous classes to use as reference materials as well. The students are required to read the assigned materials prior to class and come to class prepared to apply what they have learned to the case study. In addition, the instructor will spend some time at the beginning of class reiterating the main points of the reading, making connections to clinical practice by drawing from their own experiences as a nurse, and answering questions and correcting any misconceptions that the students might have. Instructors are free to use lecture notes, Power Points, outside resources or to simply speak extemporaneously.


5b: Assessment materials

The case study answer sheet will serve as the main assessment. Once the students have completed the case study and the accompanying work sheet in the allotted time period they will turn in their final product according to the directions. The instructor will grade their submissions according to the rubric, enter their scores in the LMS and return the students’ work no later than the beginning of the next class period the following week.

5c: Technology tool justification

This case study requires students to complete and submit their work online via email to their instructor. Experience has taught the faculty that this method is more reliable than submitting the assignments within the current LMS and that the time and date stamp is accurate. In addition, should the instructor not receive an email, it is relatively easy for the student to show when it was sent. Students are encouraged to store all of their work “in the cloud” in addition to on their hard drives in order to protect against loss of data for any reason. In terms of preparing students for the workplace, most facilities do not use paper records or are steadily moving away from paper. Students must be able to use computers, email, and the Internet in order to be effective at their jobs and competitive in the marketplace if they hope to obtain and retain employment in almost any setting. All students will have access to their assigned Google Chromebook computers and the Internet while in the classroom, though the Chromebooks cannot leave the nursing department classrooms. Additionally, students can use the computer labs at our school.

Other than the expectation that students will complete and submit their work online, this project is relatively low-tech in that it relies heavily on textbooks, lab manuals, previously received materials from any class, and the students’ own notes. Students can utilize outside resources they locate independently, but that is not required for this learning activity at this time, though the SME suggested the students be allowed to utilize the Internet to search for sources and as a way for instructors to reinforce ideas of evidence-based practice. Please refer the SME’s comments in Section Seven beginning on page 25 for details.

Part 6. Formative Evaluation Plan

6a: Expert Review plan

Tamra Carley served as the subject matter expert (SME) reviewer for this project. Tamra is a Masters-educated registered nurse with an extensive background in both nursing and education. Not only does Tamra have a background in nursing education, curriculum development, and instructional design but she is currently a PhD candidate in education. She has


graciously agreed to review this plan and the associated materials, and to complete the questionnaire I have provided her. Her responses are summarized in Part 7 below. The lesson would be revised based on the SMEs comments prior to presenting it to the one-on-one evaluators.

6b: One-to-One evaluation plan

I would provide the course materials to our two medical-surgical instructors and two to four students, one or two from the top 25% of the class and one or two from the bottom 25% of the class, and speak to them each individually in private one-to-one meetings in order to gain the perspective of both learners and instructors regarding a number of main points. I would like all of the participants to speak to issues such as completeness and clarity of the materials and instructions, if they felt the time allotted for the various tasks is appropriate, and whether or not they feel as though the learners should be able to accomplish this learning activity when their previous learning and the current learning materials are combined. Do students feel that their prior coursework coupled with the current lesson adequately prepares them for the learning activity? If not, what do they think is lacking or what suggestions might they have for making certain students are properly prepared? Have the materials been presented but not learned, or has the missing material(s) or concept(s) not been presented at all? If deficiencies are noted, the faculty can review the curriculum map and make adjustments as needed. The lesson will be revised as needed prior to presenting it to the small group evaluators.

6c: Small Group evaluation plan

A small group of four or five students would be provided the instructions and materials and then allowed to work through the case study on their own without interference. I would select students representing the top 25% and the bottom 25% of the class in order to get a variety of perspectives from students of varying abilities. Just as the learning activity is written, a faculty member could be present to help guide students as needed, but the emphasis would be on self-reliance and the students’ own efforts. I would not act as the faculty member and would not be present in order to allow the process to unfold without interference from the designer. While having the instructional designer present to observe would be beneficial, it must be remembered that I am also the program director and as such my presence could make students self-conscious and impact their behaviors. However, I would like to film the process in order to have the raw footage and dialogue available to me for analysis later on.

Just as with the one-on-one participants, I would ask the small group members if they felt adequately prepared for the activity, if the time allotted was appropriate, and if they felt the instructions were clear. Did you understand how you would be scored and were the instructions clear about when and how to submit your work for evaluation? Have you learned in your previous classes what you needed to know in order to successfully complete this case study? If not, what information or concepts did you feel were lacking? The instructor would observe, as


well, and note how the students appeared to be doing, if they noticed any issues regarding critical thinking, the students’ ability to apply the nursing process, the inability to apply general knowledge to a specific patient case and so forth. The students would be asked to complete the case study questions just as they would if this were a class lesson, and this information along with the instructor’s observations and the film should provide an abundance of useful information to the instructional designer. Any issues noted at this stage would be corrected prior to moving on to the field trial evaluation.

6d: Field Trial evaluation plan

Once adjustments are made to the learning activity, based on the input from the SME, the individual evaluators and the small group participants, I would then conduct a field trial on the revised lesson plan. The lesson would be conducted in the Medical-Surgical classroom of 24 students by the medical-surgical nursing instructor in Week 14, just as intended once implemented. I suspect that the dynamics of a large group might change how people interact while working on their case study because students often take cues from others in the room or get distracted. Therefore, I would provide separate rooms or lab areas for groups or individuals to use if they preferred, but in all cases the working areas would be within short distance (less than 50 feet) of the main classroom and the instructor.

Once the lesson was completed and the case study answers submitted for scoring, the students would be asked to answer an online survey anonymously. In addition, the instructional designer would interview selected students and the instructor for comments and more in-depth input than the survey might provide. After gathering that information, additional revisions would be made to the lesson as needed. Students and the instructor would be asked about the effectiveness and value of the learning activity as well as how well their prior learning and experiences prepared them to participate in and learn from this lesson.

Part 7. Formative Evaluation Report

7a: Evaluation survey

The SME survey is included below and shows the questions asked of the SME, her responses, and my comments regarding her observations and needed changes. The questions covered the effectiveness of the lesson, the quality of the materials and her overall evaluation of the project.

QUESTIONS REVIEWER COMMENTS RESPONSE


Goals and ObjectivesClear?

Properly written?

Aligned with Bloom’s?

Understandable?

Achievable?

Relevant to the students?

Additional comments?

Objectives are clear statements of what is specifically expected of the learner and provides guidelines for the teacher to measure learner progress.

Objectives follow the SMART format: specific, measureable, achievable, realistic and timely.The level of cognitive behavior is aligned with the ability for the learner to apply prior knowledge of a patient with diabetes.

Communicate to students what they are expected to learn and how they will be evaluated.

Written at appropriate levels of learning domains and are will easily be understood by students.

The objectives are well written and lend themselves to be used in evaluating higher cognitive skills.

Glad to see the goals and objectives are well written, appropriate, and relevant.

Learning MaterialsAdequate and appropriate?

Supportive of the learning

goals and objectives?

Aligned with the goals and

Objectives?


Learning materials are accurate and up-to-date. Learning materials are appropriate for characteristics of the learners and complexity of the behaviors that are required.

The learning materials are supportive and consistent with meeting the identified goals and objectives.

Case study is an accurate and realistic depiction of a patient with diabetes.

I would suggest encouraging students to use the Internet for

I was glad to read the suggestions regarding using the internet as a way to get up to date information and as a way to reinforce the idea of evidence based practice. We have just received approval for Google ChromeBooks in our nursing program classrooms, so we will be able to implement this suggestion.


collection of information. This would allow the student to obtain the most up-to-date information.

This would also be a great opportunity to provide guidance for evaluating and utilizing reputable sources.

Excellent development of case study.

Instructions and RubricClear?

Accurate?

Appropriate for learners?

Provide adequate guidance for

instructors?

Rubric provides guidance for

both content and quality?


Instructions are clear, accurate, and appropriate.

Instructions to the student clearly articulate the instructor’s expectations for the assignment.

Rubric communicates expectations about high-quality versus lower-quality work.

Rubric serves as an appropriate guideline to structure the feedback provided by instructor.

Allows for the assessment of specific student objectives.

I am glad to see that the instructions and the rubric are clear, accurate and appropriate.

AssessmentsAdequate opportunity for

formative assessment

provided?

Summative assessment

measures achievement of goal

and objectives?


Instructor is allowed adequate amount of time for formative assessment throughout student completion of case study.

Students have numerous opportunities to ask questions and provide input.

Encouraging questions from the learner is a way to assess student’s learning and ability to apply the content.

This will also allow identification

I was glad to see that the SME also thought the time allotted for the case study and instructor comments and assessment of students was adequate.


of any difficulties that may arise.

As the instructor works with each group, adequate time is allocated for formative evaluation.

Opportunity for students to record questions prior to experience and allowing review time at end of the activity is an ideal strategy for evaluation to determine the effectiveness of the instructional activity.

Summative evaluation appraises the student learning outcomes and determines the effectiveness of instructional strategy.

Through the use of case studies which promote in-depth thinking and problem-solving short-answer questions can be used as a future testing/evaluation strategy.

ProjectLogical and sequential?

Tables and graphs provide

useful information?

Objectives Table easy to use?

ARCS Table easy to use?

Do you have any additional

comments you would like to

make about any aspect of this

project?

Project logical and sequential.

A clear, concise description of the purposes, objectives, and competencies are provided.

Case study provides in-depth analysis and applies didactic content and theory to a real-life scenario.

Table and graphs were easy to use and illustrated objectives and assessment.ARCS Table easy to use and well-developed.

Project for development of case study will stimulate critical thinking, retention and recall.

I appreciate the SME’s comments. It is easy to assume that the meaning and intent has been adequately conveyed to learners when in fact it has not. The SME was helpful in that I felt I could trust her expertise and suggestions for improvements.


In a rapidly changing health care field, critical thinking skills are especially relevant to students who will enter a practice profession.

Activity is especially good for the adult learner by providing peer interaction and validation of thinking.

Well-done.

7b: Report the results of the expert review

Tamra Carley served as the Subject Matter Expert (SME) for this project. I chose her because of her knowledge of both nursing and nursing education but also because of her background in instructional design. I asked Tamra to review the project both from the standpoint of both the nursing content and the design of the learning activity because if one aspect of the project was lacking in any way, the entire project would be ineffective for students. By utilizing the Instructional Design process that is detailed in the Smith and Ragan’s book, Instructional Design, I was able to construct a comprehensive and apparently effective learning activity. The SME’s comments confirmed that the process I learned was an appropriate process for this type of project.

7c: Comments on Change

Tamra did suggest that I consider incorporating computers into this learning activity by allowing students to use the Internet to search out the most current information, and I completely agree with this suggestion. While the students do not have access to computers in the classroom at the moment, we have decided to purchase Google ChromeBooks for the nursing program so every student will have one available to them in the classroom beginning in the Fall of 2013. Not only will these be useful for taking notes and so forth, the students can use them for a variety of projects and activities such as this case study. As the SME points out, this is also a great way to give the students guidance about what constitutes a reliable source and gives instructors one more tool to use when teaching and reinforcing the concept of evidence-based learning.

Part 8. AECT Standards Grid

Standards Assignments meeting standard in whole or part


Standard 1: DESIGN 1.1 Instructional Systems Design (ISD) X ID Project 1.1.1 Analyzing X ID Project; ID Case Analysis 1.1.2 Designing X ID Project 1.1.3 Developing X ID Project 1.1.4 Implementing X ID Project 1.1.5 Evaluating X Selected Discussion Forums; ID Project 1.2 Message Design 1.3 Instructional Strategies X ID Project 1.4 Learner Characteristics X ID Project

Standard 2: DEVELOPMENT2.0 (includes 2.0.1 to 2.0.8) X ID Project 2.1 Print Technologies X Reading Quiz; ID Project 2.2 Audiovisual Technologies 2.3 Computer-Based Technologies X (all assignments) 2.4 Integrated Technologies

Standard 3: UTILIZATION3.0 (includes 3.0.1 & 3.0.2) 3.1 Media Utilization X (all assignments) 3.2 Diffusion of Innovations 3.3 Implementation and Institutionalization

X ID Project

3.4 Policies and Regulations

Standard 4: MANAGEMENT4.0 (includes 4.0.1 & 4.0.3) 4.1 Project Management 4.2 Resource Management 4.3 Delivery System Management 4.4 Information Management

Standard 5: EVALUATION 5.1 Problem Analysis X ID Project 5.2 Criterion-Referenced Measurement X ID Project 5.3 Formative and Summative Evaluation X ID Project 5.4 Long-Range Planning


References

Gustafson, K. L., & Branch, R. M. (2002). Survey of instructional development models. (4th

Ed.).Syracuse, NY: ERIC Clearinghouse on Information and Technology.

Smith, P. L., & Ragan, T. J. (2005). Instructional design. Hoboken, N.J: J. Wiley & Sons.


Appendices

Appendix ANeeds Assessment Survey Questions

1. What are the steps, in order, of the nursing process?2. Why do you assess before you act?3. Briefly recall what, if anything, you remember about diabetes and its effect on the human body from the anatomy and physiology classes you took as prerequisites to this program.4. Describe how elevated blood sugars effect cellular functioning?5. Explain why elevated blood sugars cause end organ damage.


6. Explain your understanding of the link between diet and diabetes mellitus (DM).7. Why does DM inhibit wound healing?8. Have you had any experience caring for patients with diabetes in your previous clinicals?9. Have you been presented with scenarios in Sims or labs that involved a patient with DM?10. How would you rate your understanding of nursing care for patients with diabetes?11. What would you like to know more about regarding diabetes and the care of patients with diabetes?12. Have you been assigned a case study in any nursing class previously? 13. What did you find beneficial (or not) about engaging in a case study as a learning activity in class?14. Do you have any experience in determining a priority nursing diagnosis for a patient under your care?15. What are the essential elements of a properly written nursing diagnosis?16. Are you familiar with Maslow’s hierarchy of needs as it relates to nursing care?17. Explain how Maslow’s help you to prioritize the nursing care you provide to patients.18. Why should nursing interventions be patient specific?

Appendix BCase Study and Answer Sheet

Note: This case study will be provided electronically and can serve as your answer sheet. Simply type in your answers after each question.

A.B. presents to the ER where you are employed complaining of chronic fatigue, increased thirst and urination and almost constant hunger. She denies any pain and is not being treated for any other conditions at this time, and does not have a regular healthcare provider because she does not have any insurance. A.B. states she decided to come to the ER because she feels so much worse than normal, plus she does not think she could be seen anywhere else.


Your patient goes on to report that she works as a cashier about 30 hours per week and stands almost the entire time she is at work, and has noticed over the last few months that her feet are increasingly painful by the end of the day, almost like she has burning and “pins and needles,” though she has not been at work today so her feet do not hurt right now. A.B. denies chest pain, shortness of breath, or weakness or headaches, but does state again just how tired she feels all the time and how hungry she is as well. She goes on to tell you that she thinks she has gained 30 pounds or more this year due to the combination of lack of exercise due to her fatigue and her constant hunger. A.B. sounds frustrated when she states that she just cannot seem to get a handle on either problem and has begun to think she may really have a problem.

After gathering more of the patient’s history you move on to the physical assessment. Her vitals as are follows: BP 160/94, HR 82, R 24, T 99.6. As you are speaking to her you notice that her breath is rather fruity smelling and overall her color does not look good.

1. Given your thoughts at this time, what labs can you anticipate the provider ordering on this patient?

2. Are there any other nursing actions you should take right now, even before she is seen by a provider?

3. Did you check the patient’s blood sugar? Why is this action important and how does it relate to the care of this specific patient? (Your instructor will provide you with the patient’s BS.)

The provider arrives and does a quick assessment of the patient and orders labs as you anticipated, and asks that they be done STAT. Your patient asks for a glass of water while she waits for the results.

4. Do you give it to her? Why or why not?

The lab results come back as follows:

Get the labs from your instructor after you have completed questions 1-4.

5. Which of the recent labs are relevant? Why?6. How do the labs drive the care for this patient?7. Are any of the lab values critical?8. What should you do next and how soon?9. What do those lab values mean, anyway? Why are they relevant in this case?10. How might this new information change your nursing care?

You now have a little bit better idea of what is going on with this patient and what you can anticipate in terms of treatments.

11. What medical diagnosis do you suspect?12. Given your patients current condition you begin to formulate your current, working nursing

diagnosis. You recognize that this may change as new information comes in, but what is your priority nursing diagnosis right now, written in complete and proper form?

13. Using Maslow’s, explain why you chose the priority nursing diagnosis you did.


14. Give three patient-specific nursing interventions relevant to your priority nursing diagnosis, with rationales and expected outcomes. Remember to make certain that your nursing interventions are:

a. Patient specificb. Relate to the nursing diagnosisc. Are something you can dod. Can be done by you while the patient is under your caree. Can be evaluated by you in the time the patient is under your care.

You recognize that the patient may be admitted, but you decide to go ahead and begin providing nursing care to this patient on the assumption that you will be her nurse for the next few hours.

15. Why is this or is this not the correct thing to do?

The ER provider returns, states his medical diagnosis and admits the patient. What was the medical diagnosis and were you correct when you made your best guess earlier? What do you think confirmed it for the provider? Think about it, and then go confirm your answer with your instructor.

Bonus points!!

For 5 extra points on this assignment answer the following questions:

16. What should you do next?17. Why? Give the three most important reasons you can think of.

Appendix CCase Study and Answer Guide

A.B. presents to the ER where you are employed complaining of chronic fatigue, increased thirst and urination and almost constant hunger. She denies any pain and is not being treated for any other conditions at this time, and does not have a regular healthcare provider because she does not have any insurance. A.B. states she decided to come to the ER because she feels so much worse than normal, plus she does not think she could be seen anywhere else.


Your patient goes on to report that she works as a cashier about 30 hours per week and stands almost the entire time she is at work, and has noticed over the last few months that her feet are increasingly painful by the end of the day, almost like she has burning and “pins and needles,” though she has not been at work today so her feet do not hurt right now. A.B. denies chest pain, shortness of breath, or weakness or headaches, but does state again just how tired she feels all the time and how hungry she is as well. She goes on to tell you that she thinks she has gained 30 pounds or more this year due to the combination of lack of exercise due to her fatigue and her constant hunger. A.B. sounds frustrated when she states that she just cannot seem to get a handle on either problem and has begun to think she may really have a problem.

After gathering more of the patient’s history you move on to the physical assessment. Her vitals as are follows: BP 160/94, HR 82, R 24, T 99.6. As you are speaking to her you notice that her breath is rather fruity smelling and overall her color does not look good.

1. Given your thoughts at this time, which labs or other diagnostics can you anticipate the provider ordering on this patient? CBC, A1c, CMP (sodium, potassium), BUN and creatinine, serum glucose, ketones, ABGs, bicarbonate, pH.

2. Are there any other nursing actions you should take right now, even before she is seen by a provider? Blood sugar check with a glucometer.

3. Did you check the patient’s blood sugar? Why is this action important and how does it relate to the care of this specific patient? (Your instructor will provide you with the patient’s BS.) Student must provide a brief but accurate explanation of why checking this patient’s BS with a glucometer now is good nursing practice. (Baseline, serial BS, monitor status, provide relevant information to provider)

The provider arrives and does a quick assessment of the patient and orders labs as you anticipated, and asks that they be done STAT. Your patient asks for a glass of water while she waits for the results.

4. Do you give it to her? Why or why not? Has the provider made the patient NPO? Is there a standard protocol for all ER patients? Will providing the patient with water to drink impact her labs? Student needs to provide reasoning and answer based on Maslow’s and standards of nursing care.

The lab results come back as follows:Serum Glucose - 250mg/dLPotassium – 6.5 mEq/L *criticalBUN - 43Creatinine – 2mg/dLHCT – 56%Sodium – 160 mEq/L * criticalSerum Ketones - PositivepH 7.1Bicarbonate - 13mEq/LAnion gap - >12A1c – 9.3Albumin – 4.8 g/dL


Serum total protein – 7.3 g/dLChloride – 110 mEq/LALP – 90 units/LALT – 31 IU/LAST – 33 IU/LTotal Bilirubin – 0.7 mg/dLWhich of the recent labs are immediately relevant? Why?Serum Glucose - 250mg/dLPotassium – 6.5 mEq/L *criticalHCT – 56%Sodium – 160 mEq/L * criticalSerum Ketones - PositivepH - 7.1Bicarbonate - 13mEq/LAnion gap - >12All indicate dehydration and/or DK.How do the labs drive the care for this patient?Medical emergency, patient will be admitted to ICU or IMC.

5. Are any of the lab values critical?Sodium and potassium.

6. What should you do next and how soon?Report to RN so s/he can notify provider within 30 minutes. Provide vitals and LOC Document that you reported.Follow up and make certain the values were reported. Document that.Monitor RR and LOC.Notify RN of any changes in patient condition.

7. What do those lab values mean, anyway? Why are they relevant in this case?Potassium – hypokalemia is common in DK so monitoring cardiac and muscular function (can impact breathing). May notice malaise, palpitations, muscle weakness, hyperventilation to compensate for acidosis.Sodium – Lethargy, irritability, weakness, edema can occur with hypernatremia, can progress to seizures and coma. Must immediately report any change in LOC.HCT – not an immediate concern medially, but an indication of dehydrationBicarbonate, ion gap and pH all indicate acidosis, so student should mention this and give a brief explanation of the lab values.

8. How might this new information change your nursing care? Medical emergency, vigilance, constant care, ECG, vitals, muscle tone, LOC all must be monitored, prepare to transfer patient to higher level of care such as ICU or IMC. Notify RN of any changes in condition.

You now have a little bit better idea of what is going on with this patient and what you can anticipate in terms of treatments.

9. What medical diagnosis do you suspect? DK


10. Given your patients current condition you begin to formulate your current, working nursing diagnosis. You recognize that this may change as new information comes in, but what is your priority nursing diagnosis right now, written in complete and proper form? Students may come up with a number of priority nursing diagnoses here so rather than state that we have only one we are looking for, consider whatever the student presents and look at the rationale. If they have utilized the ABCs and Maslow’s they should arrive at a reasonable conclusion. If not, help direct them to the point at which their thought process was derailed and guide them to the priority considerations and allow them to work through the problem again. They should be considering the critical lab values such as the potassium and would be concerned with the results of hypokalemia, for example, or they may be concerned with the patient’s dehydration. Since in the real world we would not limit ourselves to just one nursing diagnosis, multiple priority nursing diagnoses may be acceptable here as long as the student can support their choice.

11. Using Maslow’s, explain why you chose the priority nursing diagnosis you did.Is the student’s rationale sound and supported?

12. Give three patient-specific nursing interventions relevant to your priority nursing diagnosis, with rationales and expected outcomes. Remember to make certain that your nursing interventions are:

a. Patient specific – not textbook or typical, have they made a reasonable effort to speak to this patient’s situation rather than the average patient?

b. Relate to the nursing diagnosis. Interventions must relate to the nursing diagnosis or they are wrong and must be rewritten.

c. Interventions are something you can do. Nurse does not rely on others for patient care.

d. The intervention can be completed by you while the patient is under your care. Intervention can be completed while the patient is under the nurse’s care rather than at some point in the future.

e. Can be evaluated by you in the time the patient is under your care. Can the student be reasonably sure that they will have the patient long enough to evaluate their intervention?

You recognize that the patient may be admitted, but you decide to go ahead and begin providing nursing care to this patient on the assumption that you will be her nurse for the next few hours.

13. Why is this or is this not the correct thing to do? The student needs to recognize that this patient has a medical emergency and needs care now regardless of where she may be treated or by whom in the future.

The ER provider returns, states his medical diagnosis (diabetic ketoacidosis) and admits the patient. Were you correct when you made your best guess earlier? What do you think confirmed it for the provider? Think about it, and then go confirm your answer with your instructor.

Bonus points!!


For 5 extra points on this assignment answer the following questions:

14. What should you do next? Chart or document.15. Why? Give the three most important reasons you can think of.

a. Continuity of care – others will know what was done alreadyb. If you do not document it, it did not happenc. Legal document, protects you, patient, others in courtd. Proper and complete billinge. Patient protection – complete medication and health information helps

provide for patient safety.f. Proves you addressed problems and that you followed up on your

interventions

Appendix DDiabetes Case Study Rubric

Points Question

5Excellent

3Average

0Does not Meet Expectations

1. ID 5 necessary labs.Student

Correctly identifies 5 or more labs needed to accurately assess the diabetic patient. (A1c,

Correctly identifies 3-4 labs needed to accurately assess the diabetic patient.

Correctly identifies fewer than 3 labs needed to accurately assess the diabetic


Learning Objective (SLO) #1

Blood Glucose, patient.

2. Nursing ActionsSLO # 4

Lists 3 or more priority nursing actions/interventions based on Maslow’s.

Lists 2 priority nursing actions/interventions based on Maslow’s.

Lists fewer than 2 priority nursing actions/interventions based on Maslow’s.

3. Blood sugar checks and glucometer.SLO #2

Gives a detailed, accurate, patient-specific explanation of how BS checks and the glucometer are used in patient care.

Gives a detailed, accurate, non-patient-specific (general patient care or textbook) explanation of how BS checks and the glucometer are used in patient care.

Fails to give adequate details or provides inaccurate information AND fails to provide patient-specific explanation of how BS checks and the glucometer are used in patient care.

4. Do you give her water?SLO #4

Provides a well thought out rationale for the decision and cites Maslow’s and standard nursing care to support the decision.

Provides a rationale for the decision that is lacking in detail and cites standard nursing care to support the decision.

Provides rationale that is lacking in specificity and support.

5. Able to identify relevant labs?SLO #1.2

IDs all relevant labs, states why they are important to this patient.

IDs 5 or more relevant labs, but fails to give clear explanations about the importance of each.

IDs fewer than 5 relevant labs, or fails to state why they are important to this patient.

6. How do labs drive patient care?SLO #1.2

Provides logical explanation for how labs will drive care for this specific patient.

Provides incomplete explanation for how labs will drive care for this specific patient, or answer is not patient specific.

Fails to provide an explanation for how labs will drive care for this specific patient.

7. ID critical lab values.SLO # 3

Able to identify 2 critical lab values.

Able to identify 1 critical lab value.

Unable to identify any critical lab values.

8. Understands how to handle critical lab values.SLO # 3.2

Clearly states 3 nursing duties related to critical lab values. (To whom reported, in what time frame, and what does the nurse do next?)

Clearly states 2 nursing duties related to critical lab values. (To whom reported, in what time frame, and what does the nurse do next?)

States 1 or fewer nursing duties related to critical lab values.

9. What do critical labs mean and why are they relevant?

Gives clear, complete, logical, patient-centered explanation regarding the meaning and relevance of the critical lab values.

Gives explanation regarding the meaning and relevance of the critical lab values but the explanation lacks details, logic, or is

Explanation regarding the meaning and relevance of the critical lab values is


SLO #3.1 not patient-centered. absent or lacks sufficient details as to be illogical, or is a textbook answer that applies to all patients generally but does not address this patient’s situation.

10. Anticipate changes in nursing care based on critical lab values.SLO #3.1.1

Provides a logical, complete, patient-centered explanation of anticipated changes in nursing care relative to critical lab values.

Provides an adequate, but incomplete, patient-centered explanation of anticipated changes in nursing care relative to critical lab values.

Fails to provides a an explanation of anticipated changes in nursing care relative to critical lab values, or the explanation lacks sufficient details as to be illogical, or remarkably incomplete.

11. Not graded.12. Priority

nursing diagnosis.SLO #4SLO #4.1

Provides accurate, complete, properly written priority nursing diagnosis based on Maslow’s.

Provides accurate, priority nursing diagnosis based on Maslow’s, but the nursing diagnosis is missing 1 required element.

Provides and inaccurate nursing diagnosis, or the ND is accurate but is incomplete and missing multiple required elements.

13. Reasoning behind your priority nursing diagnosis.SLO #4SLO #4.1

Provides a logical, patient-specific explanation of why priority nursing diagnosis was chosen, and shows how Maslow’s was applied in this case.

Provides an adequate, patient-specific explanation of why priority nursing diagnosis that lacks details or logic, or is unclear about how Maslow’s was applied in this case.

Provides no patient-specific explanation of why priority nursing diagnosis was chosen or fails to address how Maslow’s was applied in this case.

14. Nursing interventions.SLO# 6SLO # 6.1

Provides 3 nursing interventions that are:

a. Patient specific

b. Relate to the nursing diagnosis

c. Are something you can do

Provides 2 nursing interventions that meet all requirements (a-e) or provides 3 nursing interventions but 1-3 total elements (a-e) across all three interventions are missing or inappropriate.

Provides fewer than 2 nursing interventions that meet all requirements (a-e) or provides 3 nursing interventions but 4 or more total elements (a-e)


d. Can be done by you while the patient is under your care

e. Can be evaluated by you in the time the patient is under your care.

across all three interventions are missing or inappropriate.

15. Patient is admitted.SLO #3.1.1SLO #4SLO #1.2

Provides a logical and complete analysis of whether or not this patient should be admitted to the hospital, and the explanation considers 3 critical aspects of patient care as indicated in the SLOs listed under item 15.

Provides an adequate analysis of whether or not this patient should be admitted to the hospital, or the explanation properly considers only 2 critical aspects of patient care as indicated in the SLOs listed under item 15.

Fails to attempt an answer.

16. Now that the patient has been transferred out, what do you do?

Gives the proper response. Not applicable. Fails to respond or the response is incorrect.

17. Give three reasons for your answer in item 16.

Lists three priority reasons behind your response to item 16.

Lists 2 priority reasons behind your response to item 16.

Lists fewer than 2 reasons.

t. peters nursing case study project final

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