Case study - Chronic lymphocytic leukemia: Nursing

Nurse Tracy works on an inpatient oncology unit and is caring for Margie, a 60-year-old with a history of chronic lymphocytic leukemia, or CLL. In collaboration with the registered nurse, RN Lisa, Nurse Tracy goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Margie’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Tracy recognizes important cues, including Margie’s vital signs which are temperature 98.8 F or 37.1 C, heart rate 90 beats per minute, respirations 18 per minute, blood pressure 122/84 mmHg, and oxygen saturation of 98 percent.

Nurse Tracy notes Margie has various small bruises on her back and legs and generalized lymphadenopathy, or swollen lymph nodes.

She notices Margie grimacing with movement, and when asked about pain, Margie reports a pain level of 5 out of 10 in her legs and a pain tolerance level of 3 out of 10.

Nurse Tracy sees a sign on Margie’s door requesting no visitors, so she asks Margie about how she’s feeling.

Nurse Tracy: Margie, I see you don't want visitors today.

Margie: No, I’m very tired. Besides, I’ve been such a burden to them; they probably want a break from me.

Nurse Tracy: You don’t have to have visitors if you aren’t feeling up for it. Have your family or friends mentioned not wanting to visit?

Margie: No, they haven’t, but I’d rather be alone. There’s so much I can’t control right now with my leukemia, and I’m feeling overwhelmed. Also, my pain is bothering me. I have extra doses of pain medicine to take between scheduled doses, but I forget to ask until my pain is too bad.

Next, Nurse Tracy analyzes these cues. She reviews the electronic health record, or EHR, and notes that Margie has scheduled pain medication as well as doses to take as needed, or PRN, for breakthrough pain. The medication administration record shows that Margie hasn’t received any PRN pain medication today.

Nurse Tracy recognizes uncontrolled pain can interfere with effective coping.

Nurse Tracy also reviews documentation from Margie’s previous nurses and notes Margie has become progressively withdrawn over the last week.

Nurse Tracy compares her findings to Margie’s assessment conducted by RN Lisa and realizes Margie needs help with effective coping.

Now, using the information she’s gathered, Nurse Tracy reports her findings to RN Lisa, and they choose a priority hypothesis of ineffective coping.

Then, she collaborates with RN Lisa to generate solutions to address Margie’s ineffective coping that will include pharmacologic and nonpharmacologic interventions. They establish the expected outcome that, after intervening, Margie will demonstrate two new coping strategies prior to discharge.

Nurse Tracy then takes action to implement these solutions. She begins by administering the prescribed PRN pain medication following safe medication administration principles. Next, she sits down with Margie to reinforce the education RN Lisa has provided about coping strategies. Nurse Tracy also uses active listening techniques by leaning forward, making eye contact, and facing Margie, while gently touching her hand.