Video Case Study - Cognition and Sensation

Nurse Eric works on a medical-surgical unit and is caring for Maria, an 80-year-old female who was admitted for pneumonia.

Maria’s husband, Leo, is at the bedside. Nurse Eric goes through the steps of the Clinical Judgment Measurement Model or CJMM to make clinical decisions about Maria's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Eric recognizes cues, by reviewing Maria’s electronic medical record, noting she has no personal or family history of dementia or mental illness.

Then, he assesses her vital signs, which are blood pressure 118/72 mmHg, heart rate 90 per minute, temperature 101.4 F or 38.6 C, respirations 18 per minute, and oxygen saturation 97 percent on room air.

He auscultates Maria’s lungs and notes rhonchi bilaterally, and he notices Maria is coughing up thick, green sputum. During his assessment, Maria is slow to respond and appears confused, so Nurse Eric asks some basic orientation questions.

Nurse Eric: Maria, can you tell me what year it is? Maria: It’s 1983.

Do you see those horses in my room? Leo: Maria, I told you there aren’t horses here.

I don’t understand, she wasn’t confused until this morning. Nurse Eric continues his assessment by performing a neurological assessment to rule out life-threatening concerns.

He performs a stroke assessment, which is negative for slurred speech, facial drooping, and asymmetrical weakness; and a Mini Mental State Examination reveals Maria has cognitive deficits in orientation, attention, calculation, and memory.

Nurse Eric also reviews her most recent laboratory test results to check for other conditions associated with confusion in older adults, and notes Maria’s electrolytes and glucose are within normal limits, her urinalysis is negative for a urinary tract infection; but her white blood cell count is elevated Next, Nurse Eric analyzes these cues.

After reviewing Maria’s test results and considering the results of his assessment, he determines that Maria’s altered cognition is likely due to pneumonia.

Now, using the information he’s gathered, Nurse Eric selects the priority hypothesis of delirium. Then, he generates solutions to help Maria regain her baseline cognition, and establishes the expected outcome that after intervening, Maria will be oriented to person, place, and time within 24 hours.

Nurse Eric then takes action to implement these solutions. First, he promotes safety by instituting fall precautions, and then orients Maria to her surroundings using simple terms.

He administers an antipyretic to treat Maria’s fever, and an antibiotic to treat her infection, as prescribed. Next, Nurse Eric sits down with Leo to discuss Maria’s care.

Nurse Eric: I’m sure it’s scary to see your wife like this. Leo: Yes, I don’t know what’s happening!

Nurse Eric: Being in a new environment, like the hospital, can be disorientating for most people, and so can infections, like pneumonia.

I talked with Maria’s health care provider, who has ordered an antibiotic. Hopefully, once her pneumonia is treated, she’ll be more like herself again.

In the meantime, there are some things we can do to help her. Leo: Okay.

Nurse Eric: It’s best to speak to her in a calm voice and avoid asking her too many questions. Having a familiar object in the room can help too.

Leo: Okay, I’ll have our daughter bring in her favorite blanket. Nurse Eric: Great!

It’s also good to get some rest yourself. Perhaps when your daughter comes you could step away and have lunch?

Leo: You’re right, a break sounds nice. I could use some time away.

Next, Nurse Eric updates the charge nurse. They plan to keep the same staff members assigned to Maria to establish consistency and encourage familiarity.

The next day, Nurse Eric reassesses Maria to evaluate outcomes of his actions. He notes her temperature is 98.9 F or 37.2 C, her lung sounds are improving, and she’s coughing up less sputum.

Also, Maria is now oriented to person and place and is no longer having visual hallucinations. Despite these improvements, Maria remains disoriented to time.

Nurse Eric recognizes the expected outcome hasn’t been fully met, so he’ll revise the plan of care accordingly. Nurse Eric also remembers that the night nurse reported Maria was awake all night and he realizes that the blinds in Maria’s room have remained closed.

He understands the dim light could encourage her to sleep in the day instead of the night, furthering her confusion. So, Nurse Eric collaborates with assistive personnel to promote natural light during the day and close the blinds at night.

When Nurse Eric returns the next morning, he’ll reassess Maria’s cognition, vital signs, and sleep, and update the plan of care.

Alright, as a quick recap.... Nurse Eric recognized and analyzed cues related to Maria’s altered