Case study - Leukemia: Nursing

Nurse Tracy works on an inpatient oncology unit and is caring for Margie, a 60-year-old female with a history of chronic lymphocytic leukemia, or CLL.

After settling Margie in her room, 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 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 how 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Nurse Tracy also reviews documentation from Margie’s previous nurses and notes Margie has become progressively withdrawn over the last week.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 realizes Margie needs help with effective coping. Now, using the information she’s gathered, Nurse Tracy chooses a priority hypothesis of ineffective coping.

Then, she generates solutions to address Margie’s ineffective coping that will include pharmacologic and nonpharmacologic interventions.

Nurse Tracy then establishes 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 to talk with Margie about coping strategies. Nurse Tracy uses active listening techniques by leaning forward, making eye contact, and facing Margie, while gently touching her hand.

Nurse Tracy: Margie, I was wondering if we could talk more about how you’re feeling about your diagnosis. You mentioned earlier that you’re overwhelmed.

Margie: I’m sick of feeling tired and being in pain all the time. It feels like there’s nothing I can do about it.

Nurse Tracy: That’s understandable. You can tell me when your pain is a 3 or above and I‘ll administer your PRN pain medication.

As for your fatigue, I recommend balancing rest with activity and spacing out activities throughout the day. You can try doing the most tiring activities, such as showering, when you have the most energy.

Do you have family or friends who can help at home when you’re too tired for tasks, like cooking? Margie: Yes, my husband has been great at taking care of everything.

I worry he’s doing too much now that he has to take care of me. Nurse Tracy: Have you talked to him about how you’re feeling?

Margie: No, I haven’t. Nurse Tracy: Talking with loved ones about how you’re feeling can help them understand your feelings and give you a chance to express difficult emotions.

It gives them a chance to let you know what they are thinking, too. Margie: Okay, I'll try to talk to my family more.

Nurse Tracy also provides Margie with information on support groups, encourages her to think about what she’s hopeful for, and suggests journaling as a way to process her feelings.

One week later, Margie is preparing for discharge, and Nurse Tracy evaluates the outcome of her actions. When she enters the room, Margie is sitting in her recliner having lunch with her husband.

Nurse Tracy asks Margie how she's been feeling. Margie: I’m doing better.

My husband and I talked about our feelings, which really helped. I also started journaling and joined a support group here at the hospital, and I found one online in the resources you gave me.

It’s nice to know I’m not alone. Nurse Tracy also learns Margie has been taking PRN pain medication when her pain is more than 3 out of 10, and Margie reports that her pain is under control.

Alright, as a quick recap…Nurse Tracy recognized and analyzed cues related to Margie’s leukemia, prioritized hypotheses, and generated solutions to address this problem.

Nurse Tracy then took action by implementing pharmacologic and nonpharmacologic measures to address Margie’s ineffective coping, and evaluated Margie’s outcomes, comparing them to the expected outcome.

Since Margie demonstrated two effective coping strategies,