CASE STUDY:

APPLYING CRITICAL THINKING AND NURSING PROCESS

Alma Boiko had been in an intermediate care facility since having a stroke that left her
unable to care for herself. When she developed pneumonia, she was transferred to a hospital.
Juan Apodaca, RN, settled her comfortably in bed and briefly interviewed her about her
symptoms. He obtained a temperature of 101 F, pulse 120, respirations 32, and blood pressure
of 100/68. Juan examined Ms. Boikos chart to obtain a history of her illness and a record of her
nursing care. He administered oxygen by nasal cannula, as ordered by the physician. When
performing the physical examination, Juan noticed a reddened area over Ms. Boikos coccyx.

Because Ms. Boiko was unable to move about in bed, Juan wrote a diagnosis of Risk
for Impaired Skin Integrity over coccyx related to constant pressure to bony prominences
caused by inability to move about in bed. From the list on the computer, he chose an outcome
that the skin on Ms. Boikos coccyx would remain intact and that the redness would be gone
within 2 days. He wrote nursing orders for skin care, a schedule for turning Ms. Boiko every 2
hours, and orders for frequent, continued observation of her skin.

Two days later, while bathing Ms. Boiko, Juan observed that her coccygeal area was still
red, a small area of skin was peeling off, and there was some serous drainage. Juan concluded
that the outcome had not been achieved. He was sure his data were adequate, and he changed
his nursing diagnosis to Impaired Skin Integrity over coccyx. The other staff members
assured Juan that they had carried out the 2-hour turning schedule, except for 6 hours at night
when they left Ms. Boiko to sleep undisturbed. Even though turning every 2 hours while awake
was a standard of care on the unit and had been adequate for other clients, Juan concluded that
it was not often enough for Ms. Boiko. He changed the order on the plan of care to read Turn
every 2 hours around the clock.

1. Label the underlined activities A, D, P, I, or E, according to the phase of the nursing

process represented by the activity.

2. List below all the client data (human responses).

3. Circle the activities that show the dynamic/ cyclic nature of the nursing process.

4. List all the nursing orders that Juan wrote. Note that some are summarized here
instead of being fully written out in nursing-order format.

5. Where in the case study do you see the most obvious example of overlapping nursing
process phases?

6. How did the nurse demonstrate creativity?

7. Which characteristic(s) of the nursing process was/were demonstrated when Juan

ordered a turning schedule that was more frequent than the unit routines?