Associate Degree Nursing Program - Workforce 3 One

Associate Degree Nursing Program 

Complex Health Alterations II 

This three credit course prepares the learner to expand knowledge and skills from previous 

courses in caring for clients with alterations in immune, neuro-sensory, musculoskeletal, 

gastrointestinal, hepatobiliary, renal/urinary and reproductive systems. This course is also 

focused on management of care for client with high risk perinatal conditions, high risk 

newborns and the ill child. Synthesis and application of previously learned concepts will be 

evident in the management of clients with critical/life threatening situations. 

Department of Labor 

Community Based Job Training Grant 

Developed by the Associate Degree Nursing Faculty 

In alignment with the Statewide WTCS Nursing Curriculum 

Waukesha County Technical College 


800 Main Street 

Pewaukee, WI 53072 

Community Based Job Training Grant 

Project Manager, Peggy Brown 

(262) 691-5030 

This product was funded by a grant awarded under the President’s Community Based Job Training 

Grant as implemented by the U.S. Department of Labor’s Employment and Training Administration. 

The information contained in this product was created by the grantee organization and does 

not necessarily reflect the official position of the U. S. Department of Labor. All references to 

non-governmental companies or organizations, their services, products or resources are 

offered for informational purposes and should not be construed as an endorsement by the 

Department of Labor. This product is copyrighted by the institution that created it and 

is intended for individual, organization, non-commercial use only. 

Waukesha County Technical College, Pewaukee, WI.

ASSOCIATE DEGREE NURSING 

Nursing Complex Health Alterations II 

543-113 

Fall 2007 

Developed by WCTC Nursing Faculty 

In alignment with the Statewide WTCS Nursing Curriculum 

2006 

The faculty wish to include persons with disabilities or otherwise qualified persons in this 

course. Please let faculty know if you need any special accommodations. Please make 

sure to provide the faculty with a copy of your Student Accommodation Card. If you do 

not have such a card, contact the Special Service Coordinator at 691-5210 or the 

Counselor for Students with Disabilities at 691-5274.

Table of Contents 

Schedule – Fall 2007 ...................................................................................................................................... 1 

Course Description ......................................................................................................................................... 2 

Program Outcomes ......................................................................................................................................... 3 

Bibliography................................................................................................................................................... 4 

Student Role, Responsibilities and Assessment Process ................................................................................ 5 

Course Assessment Evidence ..................................................................................................................... 7 

Complex Health Alterations Testing Policy................................................................................................... 8 

Tips for Successful Online Test Taking ......................................................................................................... 9 

Critical Life Skills Assessment Rubrics ................................................................................................... 11 

Reading List ................................................................................................................................................. 15 

Learning Plans.............................................................................................................................................. 17 

Learning Plan 1 - Alterations in the Immune System............................................................................... 17 

Case Study - Altered Immunity ............................................................................................................ 19 

Learning Plan 2 - Alterations in Neurological-Sensory Systems ............................................................. 21 

Case Study - Acute Head Injury ........................................................................................................... 23 

Case Study - Basilar Skull Fracture...................................................................................................... 25 

Case Study - Spinal Cord Compression................................................................................................ 27 

Case Study - Spinal Cord Injury........................................................................................................... 29 

Learning Plan 3 - Alterations in the Musculo-skeletal system ................................................................. 33 

Case Study - Fractured Tib/Fib w/ Osteomyelitis................................................................................. 35 

Learning Plan 4 - Alterations with Gastrointestinal/Hepatic Systems...................................................... 37 

Case Study - Gastrointestinal Disorders ............................................................................................... 39 

Learning Plan 5 - Alterations in the Renal/Urinary System ..................................................................... 41 

Case Study – Acute Renal Failure........................................................................................................ 43 

Case Study – End-State Renal Disease................................................................................................. 45 

Case Study – Pediatric Renal Disease and Transplantation.................................................................. 47 

Learning Plan 6 - Critical/Life-Threatening Situations ............................................................................ 51 

Case Study – Burns .............................................................................................................................. 53 

Case Study – MODS ............................................................................................................................ 55 

Learning Plan 7 - Alterations in the Reproductive System....................................................................... 59 

Case Study - Alterations in the Reproductive System.......................................................................... 61 

Learning Plan 8 - Care of the High-Risk Perinatal Client ........................................................................ 65 

Learning Plan 9 - Care of the High-Risk Newborn .................................................................................. 67 

Learning Plan 10 - Care of the Ill Child ................................................................................................... 69 

Written Projects.................................................................................................................................... 71 

Writing a Formal Paper .................................................................................................................... 71 

APA Sample Paper........................................................................................................................... 73 

Care Plan/Case Study Rubric ............................................................................................................... 81 

Care Plan .................................................................................................................................................. 83 

Case Study - Care of the Patient with Esophageal Varices................................................................... 86 

Case Study - Care of the High Risk Obstetric Patient .......................................................................... 87 

Case Study - Care of the Patient with Neuro-Musculoskeletal Disorder.............................................. 88 

Case Study - Care of Patient with Multiple Organ Dysfunction/Shock................................................ 89

1 

8/27-8/31 

Schedule – Fall 2007 

Rooms: Group A B140/Group B102 

Week Monday T W Th Fri 0800-11:10AM 

Course orientation 

Gr. A – Renal-BCW 

Gr. B - Immune-MM 

2 9/3-9/7 QUIZ on both LP’s 

A – Renal/Immune 

B – Immune/Renal 

3 9/10-9/14 A- Immune 

B- Renal 

4 9/17-9/21 Test 1 (LP 1&2) – Renal/Immune 

5 9/24-9/28 Quiz 

Gr. A & B (Room B140) 

High Risk Perinatal-BCW 

6 10/1-10/5 Quiz 

Gr. A & B (Room B140) 

High Risk Newborn-BCW 

7 10/8-10/12 Test 2 (LP 8 & 9) High Risk Perinatal/High 

Risk Newborn 

8 10/15-10/19 Quiz 

A- Alterations in Reproduction/ Musculoskeletal- 

MM 

B- GI-MT 

9 10/22-10/26 Quiz 

A – GI 

B – Alterations in Reproduction/ Musculoskeletal 

10 10/29-11/2 Test 3 (LP 3, 4 &7) Alterations in 

Reproduction, Musculoskeletal, GI 

11 11/5-11/9 State Board Applications: 11:30AM 

Project Due 

Quiz 

A – Critical Life Threatening-ED 

B – Neuro-MM 

12 11/12- 

Quiz 

11/16 

A- Critical Life Threatening/Neuro 

B- Neuro/Critical Life Threatening 

13 11/19-11/23 No Classes Thanksgiving Break 

14 11/26- 

A- Neuro 

11/30 

B-Critical Life Threatening 

15 12/3-12/7 Test 4 (LP 2 & 6) Critical Life 

16 12/10- 

12/14 

Threatening/Neuro 

Test 5 Cumulative Final 

1



543-113 

Course Description 

This three credit course prepares the learner to expand knowledge and skills 

from previous courses in caring for clients with alterations in the immune, 

neuro-sensory, musculoskeletal, gastrointestinal, hepatobiliary, renal/urinary 

and the reproductive systems. This course also is focused on management 

of care for clients with high-risk perinatal conditions, high-risk newborns 

and the ill child. Synthesis and application of previously learned concepts 

will be evident in the management of clients with critical/life threatening 

situations. There will be five hours of theory/discussion per week. 

This course was initially developed as a statewide curriculum course by 

nursing faculty of the sixteen technical colleges. Learning Plan 10 Care of 

the Sick Child has been integrated into the entire course as a life span 

consideration with specific pediatric readings included. The course was 

modified by the nursing faculty of WCTC to provide for classroom 

instruction. 

2

Program Outcomes 

ADN NURSE: 

ADN: Adhere to professional standards of practice within legal, ethical, and 

regulatory frameworks of the registered nurse 

ADN: Use effective communication skills 

ADN: Assess health of individuals, families, and groups within the context 

of the community 

ADN: Make clinical decisions to assure safe and accurate nursing care 

ADN: Provide safe caring interventions with diverse populations 

ADN: Use teaching and learning processes to promote and restore health 

ADN: Collaborate with others to respond to the needs of individuals, 

families, and groups across the health-illness continuum 

ADN: Manage care to facilitate continuity within and across health care 

settings 

3



543-113 

Bibliography 

Carpenito-Moyet, L. (2004). Nursing Diagnosis: Application to Clinical Practice 

(10 th ed.).Philadelphia: J.B. Lippincott. ISBN 0-7817-4354-0. 

Morris, D. (2002). Calculate with Confidence. (3 rd ed.). St. Louis, MO: Mosby, 

ISBN 0-323-01349-X. 

Elkin, M., Perry, A. & Potter, P. (2004). Nursing Interventions and Clinical Skills 

(3 rd ed.). St Louis, MO: Mosby. ISBN 0-323-02201-4. 

Delaune & Ladner (2002). Fundamentals of Nursing (2 nd edition). Albany, NY: Delmar Thomson 

Learning. ISBN 0-7668-5012-9. 

Ignatavicius, D. and Workman, M. (2006).Medical-Surgical Nursing: Critical Thinking for 

Collaborative Care. (5t h ed.) Philadelphia, PA. Saunders. ISBN 0-7216-8762-8. 

Lilley,L. Harrington, S. et al. (2005) Pharmacology and the Nursing Process, (4 th ed.) St. Louis: 

Mosby. ISBN 0-323-02408-4. 

London, M., Ladewig, P., Ball. J. and Bindler, R. Maternal-Newborn and Child Nursing. (2003). 

Upper Saddle River, NJ. Prentice Hall. ISBN 0-13-099406-5. 

Pagana, K. (2002) Manual of Diagnostic & Laboratory Tests. (2 nd edition) St Louis, MO: Mosby. 

ISBN 0-323-01609-X. 

Varcarolis, E. (2002). Foundations of Psychiatric Mental Health Nursing (4 th ed.). 

Philadelphia: Saunders. ISBN 0-7216-8896-9. 

WCTC (2006) Fourth Semester ADN Course Modules. 

WCTC (2005-2006) Calender/Handbook. 

WCTC (2005-2006) ADN Student Handbook. 

Williams, S. (2001). Basic Nutrition & Diet Therapy (11 th edition). St. Louis, MO: Mosby. ISBN 

0-323-00569-1. 

(Students may use a medical & nursing dictionary and drug handbook of their choice). 

4


Nursing Programs 

Nursing Complex Health Alterations 

543-113 

Student Role, Responsibilities and Assessment Process 

Nursing Complex Health Alterations is a three credit course. This course 

has been developed according to the WIDS format. This approach clearly 

defines the competencies that students need to develop and the criteria that 

indicate that the competency has been met. Student learning activities are 

clearly defined in course materials. These activities will assist the student in 

understanding the course concepts. . 

This course will be conducted as a discussion. Application of course 

concepts to simulated client situations may be utilized to enhance student 

learning. It is expected that students will have completed reading 

assignments and learning activities prior to the assigned discussions. Failure 

to do so may jeopardize success in the course. 

Assessment is a process that occurs between the student, faculty, and others 

who work with the student during their learning experience. This process 

begins at the time the student enters the course and continues throughout the 

course. 

The grade for this course will be determined by assessment of student 

competence through written tests (70%) and a project (30%). Students must 

achieve a 79% in testing in order to be successful in the course. The project 

score will be factored into the theory grade after a 79% has been achieved. 

5

WAUKESHA COUNTY TECHNICAL COLLEGE 

ASSOCIATE DEGEEE NURSING 

Nursing Complex Health Alterations II - 543-113 

Course Assessment Evidence 

Grade Evidence 

Grade Evidence Points Percentage 

Theory Tests & Quizzes 

Students must achieve 474 points of 

the 600 points to achieve 79% test 

average to pass this course 

70% of total course grade 

Care Plan / Case Study 100 points 30% of total course grade 

Total 700 points Total 100% 

Student Learning Assessments Worksheet 

Criteria Possible Points Percent Achieved 

Written Exams & Quizzes 

70% 

600 Points 

(474) points is the 

minimum required 

test / quiz points to 

pass theory at 79%) 

T1 _____ T4 _____ Q1 ___ Q4 ___ Q7 ___ 

T2 _____ T5 _____ Q2 ___ Q5 ___ Q8 ___ 

T3 _____ 

Q3 ___ Q6 ___ Q9 ___ 

Sum of T1-T6 + Sum of Q1-Q9 = _______/ 6 

=_______% x 0.7 

= ______ % from written exams & quizzes 

Care Plan / Case Study 

30% 

100 Total points from project ______ x 0.3 

= _____ % from projects 

Total 

100% 

Total from written exams & quizzes = _______ 

+ 

Total from project = ______ 

= Course grade _____ 

= Final Course Grade ________% 

7

Complex Health Alterations Testing Policy 

• Electronic devices will be turned off and placed in backpack and places at the 

entrance to testing rooms. 

• Student seating arrangements may be assigned by instructors. Students will be 

placed in every other seat if possible. 

• No food or drink allowed during tests. 

• Wearing caps will not be allowed. 

• A blank piece of paper will be provided by the instructor and handed in with the 

test. 

• If a calculator is required it will be provided by the instructor. 

• Bathroom breaks are not allowed unless there are extenuating circumstances. 

Students are expected to use the restroom prior to the start of testing. 

• Tissues will be provided by the instructor. 

• Students may only have 2 pencils with and eraser on their desk. 

Student Progression in Course 

• Any student who achieves a 72% or less on test 1 will receive a progress report. 

• Any student who has an average of less than 79% following test 2 or 3 will 

receive a progress report. 

Test Review 

• Students will have the opportunity to receive their initial test grade and review all 

questions after submitting the online test. 

• Class time will not be used for test review. 

• Students who wish to go over their test again or who have questions that need 

clarification are to make appointments to review the content with the instructor 

who taught the content. 

8

Tips for Successful Online Test Taking 

Taking online tests successfully means transferring test taking skills you already 

have. So the first thing is to relax because it is just like taking a test- something all 

of you have done before. 

1. After you have logged on to take the test but before you start, briefly close 

your eyes and take slow deep breaths to help you relax. If you are feeling 

stressed during the test and need to “take a moment” turn the screen off 

and repeat your breathing techniques. 

2. Focus on taking the test and not the clock. Tests are designed to be 

completed well within the allotted time frame. 

3. Read the stem and understand what it is asking you before you even begin 

to look at the distracters. 

o You can use scratch paper to jot down key words. 

o Some people find it helpful to rewrite the stem in their own words. 

4. Read all the distracters before choosing one to see if they answer the 

question- don’t jump to a conclusion because a word “jumps” out at you. 

o Before you mark your answer make sure that the other distracters are 

not correct or do not possibly answer the question better. 

5. If you are stumped and down to two answers, start the process in #2 all 

over- it may help you see with increased clarity. 

6. If you are till stumped don’t just pick one of the two, write the question # 

down on your scratch paper and go back later and try again. This way you 

will not have to worry about changing an answer (which usually does not 

work to your advantage). As you continue taking the test something in the 

remaining questions may also jog your memory and the answer could 

become more apparent. 

7. If you need clarification on a question try rephrasing it in your own words 

and asking faculty if your thinking is on the right track. If we can give you 

guidance we will. 

8. When you think you are done go back over and make sure that you 

answered all the questions. 

9. After you submit your test as complete and receive your grade review the 

test to see where you had areas of difficulty. 

10. When done reviewing, turn off the monitor. DO NOT PRINT an DO NOT 

LOGOFF. Your instructor will print and shut down at the end of the 

testing time. 

9


Critical Life Skills Assessment Rubrics 

Critical Life Skill 

Grammar - 

Use the basic mechanics of 

standard written English, 

such as spelling, 

punctuation, grammar. 

Writing - 

Use written 

communication 

appropriate to the situation 

to express ideas, needs and 

concerns clearly, concisely 

and accurately. 

Interpersonal 

Communication - 

Communicate in 

interpersonal or small 

group settings, such as 

classes, meetings, etc. 

Public Communication - 

Communicate in a formal 

public setting. 

Reading - 

Read critically and 

analytically. 

Problem Solving - 

Demonstrate effective 

problem-solving skills. 

Critical Thinking - 

Indicators 

Level 1 - Recalls the rules of acceptable English. 

Level 2 - Identifies examples of standard English rules. 

Level 3 - Is able to use standard English grammar. 

Level 4 - Makes appropriate corrections in standard English usage. 

Level 5 - Explains correct use of standard English grammar in complex constructions. 

Level 6 - Uses knowledge of standard English grammar to create a variety of sentence types with 

varying tones and emphases. 

Level 1 - Lists the steps in the writing process. 

Level 2 - Explains how the writing process helps create good writing. 

Level 3 - Produces accurate written material. 

Level 4 - Produces accurate written material with adequate evidence to support the ideas expressed. 

Level 5 - Compiles information into a meaningful written document appropriate to audience and 

situation. 

Level 6 - Produces a written document that uses appropriate tone and emphasis to respond to 

anticipated audience reaction. 

Level 1 - Knows that effective communication involves listening, interpreting and responding. 

Level 2 - Can explain good techniques for making communication effective. Recognizes the need for 

appropriate communication in the problem-solving process. 

Level 3 - Can choose from a menu of appropriate techniques to modify and improve interpersonal 

communications. Practices positive communication strategies for solving problems. 

Level 4 - Methodically analyzes his/her personal communication habits in order to prevent 

misunderstandings within the communication process. 

Level 5 - Manages situations in which appropriate communications techniques are encouraged and 

used to solve interpersonal problems. 

Level 6 - Evaluates the unique demands of each situation and chooses appropriate styles and 

techniques of interpersonal communication to address them successfully. 

Level 1 - Defines the general principles of effective public speaking. 

Level 2 - Provides examples of the general principles of effective public speaking. 

Level 3 - Explains material to an audience in an organized way. 

Level 4 - Uses research materials appropriate to his/her presentation. 

Level 5 - Delivers an organized, well-supported speech. 

Level 6 - Makes an effective presentation that uses audience feedback and interaction appropriately. 

Level 1 - Reads to find specific information. 

Level 2 - Explains the meaning of written material. 

Level 3 - Applies information to real life situations. 

Level 4 - Reads a variety of written formats critically and analytically. 

Level 5 - Draws logical conclusions after reading diverse sources. 

Level 6 - Judges worth and value of reading materials as it applies to his/her personal and 

professional circumstances. 

Level 1 - Correctly defines a problem along with its possible causal factors and identifies the steps in 

the problem-solving process. 

Level 2 - Identifies situations in which a systematic problem -solving process would be valuable. 

Level 3 - Selects from alternatives to address a problem and defines the process for each step. 

Level 4 - Investigates possible alternatives to determine the most workable solution for a problem. 

Level 5 - Devises a personal process for consistent and effective solving of problems. 

Level 6 - Evaluates the effectiveness of solutions and open-mindedly suggests strategies for arriving 

at a more satisfying solution. 

Level 1 - Defines common thinking strategies. 

11

Apply the techniques of 

analytical thinking and 

effective decision-making. 

Science and Technology - 

Apply principles of 

science and use technology 

appropriate to occupations. 

Professional and Personal 

Ethics - 

Apply a collection of 

generally accepted ethical 

standards for “right 

conduct” in both personal 

and professional areas. 

Mathematics - 

Demonstrate numerical 

and logical reasoning and 

apply mathematical 

concepts in occupational 

and personal settings. 

Information Seeking - 

Identify and fulfill 

information needs. 

Conflict Resolution - 

Apply effective techniques 

to resolve interpersonal 

conflict. 

Level 2 - Identifies common thinking strategies within a personal or occupational setting. 

Level 3 - Draws logical conclusions from adequate evidence. 

Level 4 - Examines reasons and evidence from different viewpoints. 

Level 5 - Constructs a case in support of a claim. 

Level 6 - Assesses the validity of decisions and cases. 

Level 1- Defines basic scientific concepts and lists current technologies. 

Level 2 - Identifies technologies used in specific scientific areas/contexts. 

Level 3 - Uses scientific knowledge and technological skill appropriate to the situation. 

Level 4 - Uses appropriate technology to analyze the scientific aspects of a situation. 

Level 5 - Designs an activity using appropriate technology and consideration of applicable scientific 

principles. 

Level 6 - Evaluates scientific concepts and adapts the associated technologies to maintain their 

relevance to personal and occupational situations. 

Level 1 - Defines core values and can identify instances of “right conduct” in personal and 

professional situations. 

Level 2 - Can explain the place of core values in personal and professional ethical decisions. 

Level 3 - Demonstrate the appropriate use of core values by choosing an appropriate ethical decision 

from a list of possible actions. 

Level 4 - Examines personal and professional situations for possible ethical consequences and 

implications of decisions. 

Level 5 - Consciously formulates thoughtful decisions based on sound ethical principles. 

Level 6 - Lives a life of integrity, actively practicing behavior which demonstrates appropriate 

ethical standards. 

Level 1 - Recognizes the relevance and value of mathematics concepts to everyday personal and 

work life. 

Level 2 - Performs basic mathematical functions. 

Level 3 - Interprets a situation and applies the appropriate mathematical concept. 

Level 4 - Examines all aspects of a situation for possible mathematical applications. 

Level 5 - Applies appropriate mathematical concepts to address the needs of a specific solution. 

Level 6 - Evaluates the clarity and effectiveness of the mathematical concepts used to solve a 

problem and adjusts them as needed. 

Level 1 - Recognizes the need for information. 

Level 2 - Identifies a wide variety of sources for information. 

Level 3 - Describes and locates the specific type of information demanded by the situation. 

Level 4 - Carefully examines the validity and reliability of multiple sources of information. 

Level 5 - Collects and organizes a wide range of information sufficient to meet current needs. 

Level 6 - Frequently evaluates the accuracy of information sources and modifies his/her perspective 

to stay current and solve problems. 

Level 1 - Can name a variety of methods available for resolving conflict. 

Level 2 - Identifies that a conflict exists and can explain the basic nature of that conflict. 

Level 3 - Practices some reasonable methods for resolving minor conflicts. 

Level 4 - Examines a situation, taking into account opposing views/interests before choosing a 

resolution strategy. 

Level 5 - Proposes suitable methods for resolving conflicts with an understanding of the potential 

effectiveness of each method. 

Level 6 - Can evaluate the outcome of a resolution strategy and make adjustments to maximize the 

benefits for all parties. 

Social Responsibility and 

Effective Citizenship - 

Demonstrate awareness of 

the social and global 

environment by making 

Level 1 - Articulates the importance of active citizenship. 

Level 2 - Recognizes examples of appropriate community participation. 

Level 3 - Actively participates in an organized community improvement project. 

Level 4 - Critically analyzes possible responses to community issues. 

Level 5 - Thoughtfully organizes a campaign to encourage citizens to be involved in community 

12

informed decisions for 

effective participation in 

the community. 

Teamwork - 

Work effectively and 

cooperatively in a group 

setting. 

Valuing Diversity - 

Value differences among 

people. 

Effective Relationships - 

Develop positive 

relationships with family 

members, co-workers, 

friends and others. 

Career Development - 

Make career choices 

appropriate to current 

personal needs and to the 

changing nature of the 

labor market. 

Career Securing - 

Demonstrate effective job 

search skills. 

Study Skills - 

Use effective study skills 

in order to master course 

content. 

Stress Management - 

Manage stress in 

appropriate ways. 

improvement efforts. 

Level 6 - Chooses personal community involvement efforts with the overall needs of the greater 

community in mind. 

Level 1 - Lists techniques which encourage cooperative group (team) efforts. 

Level 2 - Recognizes/identifies effective techniques experienced in group (team) settings. 

Level 3 - Behaves in ways which will facilitate the cohesiveness of a group (team) effort. 

Level 4 - Examines the feasibility of tasks and techniques for cooperative team efforts. 

Level 5 - Organizes constructive team activity through the use of appropriate skills and techniques. 

Level 6 - Evaluates the effectiveness of teamwork and adjusts techniques to accomplish desired 

goals. 

Level 1 - Defines basic universal human needs. 

Level 2 - Describes situations in which individual differences are acknowledged or ignored. 

Level 3 - Works effectively with others of differing backgrounds. 

Level 4 - Differentiates behaviors which contribute positively to the valuing of others. 

Level 5 - Formulates an approach to life which incorporates a positive belief in others and an 

openness to differences. 

Level 6 - Modifies personal behavior to acknowledge differing needs of others and makes full use of 

human resources. 

Level 1 - Lists factors which are influential in effective personal relationships. 

Level 2 - Gives examples of relationships which demonstrate effective relationship techniques. 

Level 3 - Incorporates newly learned skills to improve a personal relationship. 

Level 4 - Thoughtfully examines the variety of factors which may influence the effectiveness of a 

relationship. 

Level 5 - Implements the use of appropriate skills/techniques to build an effective relationship. 

Level 6 - Maintains satisfying personal relationships through the implementation of effective 

attitudes and relationship skills. 

Level 1 - Defines the factors which may influence career choice and development. 

Level 2 - Recognizes specific factors which are influencing decision making in hypothetical career 

situations. 

Level 3 - Applies the understanding of influential career factors to their own personal career 

decisions. 

Level 4 - Carefully examines all appropriate career choice influences. 

Level 5 - Creates a plan for integrating appropriate career choice information into personal decision 

making. 

Level 6 - Adjusts career choices appropriately to meet current personal needs and to reflect the 

changing nature of the workplace. 

Level 1 - Names prospective employers/job opportunities. 

Level 2 - Prepares examples of appropriate job search tools. 

Level 3 - Uses job search skills appropriate to specific employment demands. 

Level 4 - Critically analyzes and develops appropriate job search tools. 

Level 5 - Pursues appropriate employment using all necessary job search tools. 

Level 6 - Secures appropriate employment through the use of effective job search skills and with 

consideration of future career potential. 

Level 1 - Names a variety of effective study skill strategies. 

Level 2 - Explains the important aspects of each study skill. 

Level 3 - Applies workable study skills to individual study needs. 

Level 4 - Critically analyzes personal study habits, strategies, and course/project requirements. 

Level 5 - Develops a study plan using a variety of strategies to facilitate the successful completion of 

course work. 

Level 6 - Anticipates demands of course work in order to implement effective study skills and 

maximize learning potential. 

Level 1 - Can define stress, identify its possible sources, and can list a number of stress management 

techniques. 

Level 2 - Can recognize and give examples of stressful occurrences in his/her life and can describe 

how stress management techniques work. 

13

Coping with Change - 

Understand and manage 

change appropriately. 

Time Management - 

Organize activities to 

accomplish desired tasks 

in the time available. 

Self-Concept - 

Evaluate one’s 

self-concept in regard to 

self-esteem, values, 

attitudes, interests, goals, 

strengths and weaknesses. 

Level 3 - Can choose a stress management technique to appropriately deal with a common stressful 

situation. 

Level 4 - Thoughtfully analyzes the stresses in his/her life and chooses appropriate coping or 

management techniques. 

Level 5 - Incorporates stress management techniques into a comprehensive life plan. 

Level 6 - Anticipates possible future stresses and adjusts existing plan to compensate for them. 

Level 1 - Defines change as inherent variations in life and work. 

Level 2 - Identifies a variety of positive coping strategies. 

Level 3 - Uses coping strategies appropriate to the situation. 

Level 4 - Examines personal change and the effectiveness of his/her current coping strategies. 

Level 5 - Constructs a plan to positively manage the transitions in his/her life. 

Level 6 - Reflects on the effectiveness of his/her plan in implementing personal values while 

adequately managing continual change. 

Level 1 - Lists behaviors which facilitate good time management. 

Level 2 - Explains effective and ineffective time management strategies. 

Level 3 - Periodically practices some of the strategies in effective time management. 

Level 4 - Compares personal use of time with effective time management strategies. 

Level 5 - Creates a unique personal plan for life activities which reflects use of appropriate time 

management techniques. 

Level 6 - Critically assesses a personal time management plan for possible modifications and 

improvements. 

Level 1 - Can name the qualities and characteristics which contribute to a person’s self-concept. 

Level 2 - Describes those specific personal qualities which make his/her self-concept unique. 

Level 3 - Applies new experience and feedback to positively modify understanding of self. 

Level 4 - Critically analyzes the many factors which influence perceptions of self. 

Level 5 - Can reasonably interpret the influences on self-concept and can focus perceptions in a 

positive manner in order to develop a healthy appreciation of self. 

Level 6 - Appropriately channels personal life experiences into a growing acceptance of his/her 

unique self-concept. 

Copyright 2002 

This item may not be reproduced 

without written permission from WCTC. 

14

Reading List 

WAUKESHA COUNTY TECHNICAL COLLEGE 

NURSING COMPLEX HEALTH ALTERATIONS II 543-113 

LP LP Topic Authors, chapters, and/or page numbers 

1 Alterations in the Immune 

System 

Required: 

Ignatavicius & Workmen, Chapters 23, 24 pp. 409-412 and Chapter 25, pp 423- 

448. 

Lilly, et.al. Chapter 39, 45 and 47 

London, et al, Chapter 40, pp 970-987 

Williams, Chapter 23, 99 454 -463. 

Kenny, P. (2004) “The changing face of AIDS.” Nursing. August p. 56-63. 

Kirton, C, (2005) “The HIV/AIDS epidemic: A case of good news, bad news. 

Nursing made Incredibly Easy. p. 29-41. 

Nowlin, A. (2004) “Highlight on hospice.” Advance for Nurses. November 8, p. 

2 Alterations in Neurological- 

Sensory Systems 

3 Alterations in the Musculoskeletal 

system 

4 Alterations with 

Gastrointestinal/Hepatic 

Systems 

5 Alterations in the Renal/Urinary 

System 

28-36. available online at www.advanceweb.com 

Required: 

Ignatavicius & Workmen, Chapter 45, pp. 950-955, Chapter 46, pp. 977-1003, and 

Chapter 48 pp. 1044-1055. (Review chapter 44 as needed) 

Lilly, et al, Chapter 12,13,17, and 25. 

London, et al, Chapter 49, pp. 1300-1313. 

Brettler, S. (2004) “Trauma nursing: traumatic brain injury.” RN. April. P. 32-37. 

Holland, N., Madonna, M. (2005). “Nursing grand rounds: Multiple sclerosis.” 

Journal of Neuroscience Nursing. February. p. 15-19. 

Jones, T. (2005). “A bolt out of the blue – Dealing with the aftermath of spinal cord 

injury.” Nursing Made Incredibly Easy. November/December. p. 15-28. 

Required: 

Ignatavicius & Workmen, Chapter 54, pp. 1172-1181. (Review Chapter 53 as 

necessary) 

Lilly, et al, Chapter 10 and 12 

London, et al, Chapter 50 pp. 1319, 1335-1341. 

Williams, Chapter 5, 11, 16, 23. (as it supports the disease topics) 

Metules, T. (2002). “Duchenne muscular dystrophy.” RN. October 2002. pp. 39-47. 

Required: 

Ignatavicius & Workman, Chapter 59, pp11306-1311. Chapter 62, pp 1368 – 1390, 

Chapter 63, pp. 1402-1418. 

London, et al, Chapter 46, pp 1194 – 1201 

Recommended: 

Lilly, et al, Chapter 38, pp 655-658; Chapter 46, pp 780-783; Chapter 47, p 819 

Williams, Chapter 9, pp162 -175; Chapter 18, pp 344 – 354; Chapter 23, pp- 442 – 

454. 

Durston, S. (2005). “What you need to know about viral hepatitis.” Nursing 2005, 

35(8), 36-41. 

Whiteman, K. & McCormick, C. (2005). “When your patient is in liver failure.” 

Nursing 2005, 35 (4), p. 58-63. 

Required: 

Ignatavicius & Workman, Chapter 74 pp. 1716- 1719 and Chapter 75 (Review 

Chapter 72 as necessary) 

Burrows-Hudson, S. (2005). “Chronic kidney disease: An overview.” AJN. 

February. Pp.40-48 

Ward, K. (2005). “Kidneys don’t fail me know.” Nursing Made Incredibly Easy. 

March/April. 18-26. 

Recommended: 

Lilly, et al, Chapters: 25, 26(pp. 444 - 452) and 44. (Review content as it relates to 

topic) 

London, et al, Chapter 47, pp 1218 – 1233, 1234-1238. 

Williams, Chapter 21 pp. 400 - 411. (as it supports content) 

6 Critical/Life Threatening 

Situations 

Required: 

Ignatavicius & Workman, Chapter 29 (biological agents) pp519-520. Chapter 40 

15

7 Alterations in the Reproductive 

System. 

8 Care of the High-Risk Prenatal 

Client 

(shock). Chapter 42 pp. 871-879. Chapter 71 (Burns) pp. 1618-1650. 

Lilly, et al, Chapter 26 and 27 

London, et al. Chapter 43 (shock) pp 1094–1098. Chapter 52 (burns) pp.1403- 

1412. 

“Bioterrorism Readiness Plan: A Template for Healthcare Facilities” on 

Blackboard as a PDF file. 

Recommended: 

Cheek, D., McGehee-Smith, H., Cunneen, J. and Cartwright,M. (2005). Sepsis: 

taking a deeper look. Nursing January. 35(1). 38-43 

DeSanti, L. (2005). “Pathophysiology and Current Management of Burn Injury.” 

Advances in Skin and Wound Care. July/August. 323-332. 

www.woundcarejournal.com 

Diehl-Oplinger, L. and Kaminski, M. (2004). “Choosing the right fluid to counter 

hypovolemic shock.” Nursing. March. 50-54. 

Dressler, D. (2004). “DIC: Coping with a coagulation crisis.” Nursing. May. P.58 - 

62. 

Ecklund, M. and Ecklund, C. (2007). “How to Recognize and Respond to 

Hypovolemic Shock.” American Nurse Today. April. 2(4). 28-31. 

Kelley, D. (2005). “Hypovolemic Shock-An Overview.” Critical Care Nursing 

Quarterly. 28(1). 2-19. 

Miller, J. (2005). “To Clot or not to clot.” Nursing Made Incredibly Easy. 

November/December. 4-9. 

Rzucindlo, S. & Shirk, B. (2004) “Trauma Nursing: Pediatric Patients.” RN. June. 

36-41. (note section on shock) 

Walsh, C. (2005). “Multiple Organ Dysfunction Syndrome after Multiple Trauma.” 

Orthopedic Nursing. September/October. 24 (5). 324 -333. 

Wood, S., Lavieri, M. and Durkin, T. (2007). “What you need to know about 

sepsis.” Nursing. March. 37 (3). 46-51. 

Required: 

Ignatavicius & Workman, Chapter 76, 77. Chapter 78 pp 1843-1854. Chapter 79 

pp. 1856-1876. 

Lilly, et al., Chapter 33 and 34 

Held-Warmness, J. (2002) “What your patient needs to know about Prostate C 

Duval, S. (2004) “Inflammatory breast cancer.” RN. February pp. 43 -44. 

Greifzu, S. (2004). “Breast Cancer.” RN. February p. 36 -42. 

Lynch, M. and Rosalina’s, E. (2004). “Cervical cancer screening.” Advance for 

Nurses. September 13. p. 29-30. (Available online at ancer.” Nursing. December. 

pp. 36-42. 

Recommended: 

London et al. Chapter 4 pp. 82 -93. 

Williams, Chapter 23, pp 443 – 454. 

Carlson, S. (2004). “Prostate Disease”. RN. September 9. 54 -59. 

www.advanceweb.com.) 

Dell, D., (2005). “Battling Breast Cancer.” Nursing Made incredibly Easy.” 

September/October. pp 4-20. 

Required: 

Lilly, et al., Review chapter 31 and 33. 

London, et al. Chapter 12 and Chapter 13. 

Recommended: 

Williams, Chapter 10. 

9 Care of the High-Risk Newborn Required: 

London, et al. Chapter 28. pp. 606 – 640, Chapter 29. Pp.642-681. 

Munro Cohen, S (2006) “Jaundice and the Full term Newborn” Pediatric Nursing. 

May/June. pp202-209 

Recommended: 

Williams: pp199-204 

10 Care of the Ill Child This learning plan will be integrated as a lifespan consideration in all other learning 

plans. 

16

Learning Plans 


Learning Plan 1 - Alterations in the Immune System 

Overview 

This learning plan will continue to focus on the nursing care of clients with alterations in the 

immune system. The learning plan will build on theory and content that was presented in 

previous nursing courses, while expanding your knowledge of HIV, AIDS and lupus 

erythematosus. 

Target Learning Outcomes 

Competency 

1. Evaluate nursing care for clients with alterations in the immune systems 

Performance Standards 

You will demonstrate your competence: 

O by responding to a case study or scenario of patients with alterations in the 

immune system 

Your performance will be successful when: 

O response utilizes the nursing process for clients with alterations in the immune 

system 

O response describes the pathophysiology, etiology, and clinical manifestations of 

alterations in the immune system 

O response identifies available agency and community resources to promote care 

for clients with alterations in the immune system 

O response explains procedures used to screen, diagnose, and treat clients with 


O response plans nutritional interventions for clients to promote/maintain health 

with alterations in the immune system 

O response integrates pharmacological therapy in the care of clients with 


O response selects teaching/learning topics to promote self care for the client with 


17

Learning Objectives 

This learning plan addresses the following learning objectives to help you master the 

competency: 

a. Describe the pathophysiology, etiology, and clinical manifestations of the 

following immune system alterations: HIV, AIDS, and lupus erythematosus. 

b. Discuss how post organ transplant management may affect the immune system. 

c. Explain diagnostic tests and procedures used to screen, diagnose, and treat 

clients with the above alterations in the immune system. 

d. Utilizing the nursing process identify nursing interventions that would be 

implemented for clients with the above immune system alterations. 

e. Plan nutritional interventions to promote/maintain health for clients with the above 

alterations in the immune system. 

f. Integrate pharmacological/non-pharmacological therapies into the care of clients 

with the above alterations in the immune system. 

g. Select teaching/learning topics to promote self care for the client with the above 

alterations in the immune system including health and preventive education. 

h. Identify available agency and community resources to promote care for clients 

with the above alterations in the immune system including hospice care. 

i. Discuss the long term emotional, psychological and economical effects of the 

above immune system alterations. 

j. Identify collaborative problems that the nurse may need to manage/monitor for 

clients with the above immune system alterations. 

k. Develop and evaluate nursing diagnoses appropriate to this learning plan. 

Learning Activities 

_____1. 

_____2. 

_____3. 

_____4. 

_____5. 

_____1. 

_____2. 

Reference: Carpenito, Nursing Diagnosis text, as appropriate to this learning 

plan. 

Review cell-mediated immunity (T cells) versus antibody-mediated immunity 

(Bcells). 

Access: www.cdcnpin.org for the latest up to date information on HIV and AIDS. 

Access www.lupus.org: Bring to class the laboratory tests that are most specific 

for SLE. Is the LE cell prep test specific for SLE? 

Research any reputable article on HIV/AIDS and investigate a new 

treatment/drug/test. 

Assessment Activities 

Complete the written test. 

Complete the required written Case Study/Care Plan 

18




543-113 

Case Study - Altered Immunity 

K.D. is a 36 year old gay professional man who has been HIV positive for 6 years. Until recently, he 

demonstrated no signs or symptoms of AIDS. The appearance of purplish spots on his neck and arms 

persuaded him to make an appointment with his physician. Upon arrival at the doctor’s office, the nurse 

performs a brief assessment. His vital signs are: BP: 138/86, Pulse 100, Respirations 30, Temp. 100.8 

K.D gives history of feeling fatigued for several months and is experiencing occasional night sweats but he 

has been working long hours, has skipped meals, and has been particularly stressed over a project at work. 

Physical Exam is a normal exam except for a rapid heart rate and respirations and low grade fever, and skin 

lesions. The Doctor orders lab work: CBC, lymphocyte studies, and orders a tuberculin skin test. K.D. is 

instructed to return in 5 days to discuss the results of his tests. 

Over the next two weeks, K.D. develops a fever of 101 degrees F, nonproductive cough, and increasing 

shortness of breath. Late one night he becomes acutely SOB, so his roommate, J.F. takes him to the ED 

where he is subsequently admitted to the hospital with probable PCP (pneumocystis carinii). K.D. has a 

bronchoalveolar lavage examination which confirms the diagnosis. K.D.’s admission white blood cell 

(WBC) and lymphocyte studies demonstrate an increased pattern of immunodeficiency from earlier studies. 

K.D. is placed on nasal oxygen, IV fluids, and IV trimethoprim/sulfamethoxazole. 

K.D asks the nurse to describe what is PCP? Define 

What is the significance of the purplish spots over K.D’s neck and arms? 

Identify four problems for K.D. 

What precautions will you need to use when caring for K.D.? 

What will be the focus of your ongoing assessment? (List 3) 

What major side effects of his antibiotic should you monitor K.D. for? 

Differentiate between HIV – positive status and AIDS. 

19

Why is K.D’s development of PCP of particular importance in light of his HIV status? 

K.D. is responding well to treatment and plans are being made for discharge. He will be started on 

standard therapy, with follow-up on an outpatient basis. What is the current standard therapy for K.D? 

K.D> was taught about disease transmission and safe sex, and encouraged to maintain moderate exercise, 

rest, and dietary habits when he was first diagnosed as HIV positive. Give at least four additional topics 

that should be discussed with KD. Before he goes home. 

What laboratory data will most likely be monitored on KD in the future? 

List at least five other opportunistic infections that K.D. is at risk for developing. 

20


Learning Plan 2 - Alterations in Neurological-Sensory Systems 

Overview 


neurological-sensory system. The learning plan will build on theory and content that was 

presented in previous nursing courses, while expanding your knowledge of traumatic brain and 

spinal cord injuries, multiple sclerosis, and cerebral palsy. 


Competency 

2. Evaluate nursing care for clients with alterations in the neuro-sensory system 



o by responding to a case study or scenario of patients with neuro-sensory system 

alterations 


o response utilizes the nursing process for clients with alterations in the neurosensory 

system 

o response describes the pathophysiology, etiology, and clinical manifestations of 

alterations in the neuro-sensory system 

o response explains procedures used to screen, diagnose, and treat clients with 


o response identifies available agency and community resources to promote care 

for clients with alterations in the neuro-sensory system 

o response plans nutritional interventions for clients to promote/maintain health 

with alterations in the neuro-sensory system 

o response integrates pharmacological therapy in the care of clients with 


o response selects teaching/learning topics to promote self care for the client with 

an neuro-sensory system alteration 

21



competency: 

a. Review the anatomy and physiology of the brain and spinal cord. 

b. Describe the pathophysiology, etiology, and clinical manifestations of the 

following neuro-sensory system alterations: traumatic brain/spinal cord injuries, 

multiple sclerosis, and cerebral palsy. 

c. Explain diagnostic tests and procedures used to screen and diagnose clients with 

the above alterations in the neuro-sensory system. 

d. Utilizing the nursing process, identify nursing interventions that would be 

implemented for clients with the above neuro-sensory system alterations. 


neuro-sensory alterations. 

f. Integrate pharmacological and nonpharmacological therapy in the care of clients 

with the above alterations in the neuro-sensory system. 

g. Select teaching/learning topics to promote self care for the client with the above 

neuro-sensory system alteration, including wellness and preventive care. 

h. Identify available agency and community resources that could provide long term 

care/assistance for clients with the above alterations in the neuro-sensory 

system. 

i. Discuss ethical issues for children and adults with the above neuro-sensory 

system alterations. 


clients with the above neuro-sensory system alterations. 



1. Review the anatomy and physiology of the central and peripheral nervous system. 

2. Reference: Carpenito, Nursing Diagnosis text, as appropriate to this learning plan. 

3. Identify at least 4 community resources which provide support for neurologically 

impaired clients and/or their families/care givers within your community. 

4. Complete assigned in-class case studies. 

5. Access: www.msfacts.org (multiple sclerosis foundation) and view the treatment 

options for MS. Identify one drug that is used (compare it with your med-surg 

text/drug book) and then share this information with your class. 

6. Access: www.spinalinjury.net for an excellent review of spinal cord injury, (Spinal 

Cord 101). Also, using this site, identify the 2 closest spinal cord injury centers for 

southeast Wisconsin. 


_____1. 

_____2. 


Complete the required written Case Study/Care Plan project. 

22

WCTC – Complex Health Alterations II 

Neuro 

Case Study - Acute Head Injury 

Scenario: J.R. is a 28-year-old man who is doing home repairs. He falls from the top of a 6-foot stepladder, 

striking his head on a large rock. He experiences momentary loss of consciousness. By the time his 

neighbor gets to him, he is conscious but bleeding profusely from a laceration over the right temporal area. 

The neighbor drives him to the ED of your hospital. As the nurse, you immediately apply a cervical collar, 

and immobilize him on a long board stretcher, and take J.R. to a treatment room. 

1. What steps should you take to assess J.R.? 

2. List at least five components of a neurologic examination. 

You complete your neurologic examination and find the following: GCS 15, pupils equal, round, react to 

light (PERRL), and full sensation. J.R. c/o a headache and is becoming increasingly drowsy. 

3. As the radiology technician performs a portable cross-table lateral C-spine x-ray, J.R. begins to speak 

incoherently and appears to drift off to sleep. What is the next action you would take? 

You find J.R. has become unresponsive to verbal stimuli and responds to painful stimuli by abnormally 

flexing his extremities (decorticate posturing). He has no verbal response. The right pupil is larger than the 

left, and does not respond to light. 

4. What is J.R.’s GCS score at this time? Also indicate what this score means. 

5. Based on his GCS score, what are the next steps you should take? 

6. What is the significance of the dilated pupil and fixed pupil on the right? 

The physician orders 500 mL of 25% mannitol solution IV. 

23

What is mannitol, and why is it being used on J.R.? 

J.R. is transported to x-ray for helical or spinal CT scan, where he is found to have a large epidural 

hematoma on the right with hemispheric shift to the left. He will be taken straight to the OR for evacuation 

of a right epidural hematoma. 

While en route from the CT scan to the OR, the physician instructs the respiratory therapist to initiate 

hyperventilation of the patient to “blow off more CO2.” 

7. What is the rationale for this action? 

8. Explain at least six interventions you would use to prevent increased ICP in the first 48 hours 

postoperative. 

While he is in surgery, J.R.’s family arrives at the ED. They ask that their faith healer anoint J.R. and pray 

over him. 

10. What should the nurse say? 

24


Neuro 

Case Study - Basilar Skull Fracture 

Scenario: S.B. is a 17-year-old male who lost control of his SUV and struck a tree. Witnesses reported he 

was not restrained and his face hit the windshield on impact. When paramedics arrived S.B. was responsive 

but confused, had significant facial swelling, and c/o pain in his right wrist and left forearm. The 

paramedics initiated C-spine precautions, strapped him to a backboard, started O2 at 15L/min via a 

nonrebreather mask, and started a 16-gauge IV with 0.9%Ns. VS: 120/75, 125, 36, Sao2 94%. On arrival to 

the local ED 5 minutes later his VS were 110/62, 110, R28-32 and shallow, 99%. An additional 16-gauge 

IV was inserted and the following labs were drawn: CBC, type and screen, CMP, PT/PTT, INR, and ETOH 

levels. The trauma physician completed a head to toe assessment and found the following: Obeys 

commands, responds to voice but not oriented to time or place. Generalized facial edema with fullthickness 

2-cm cheek laceration and bilateral mandibular depressed fractures. Blood behind L TM 

(tympanic membrane), edema with slight discoloration over L mastoid process. Mid to upper chest 

contusions w/o crepitus, breath sounds clear. Abdomen slightly firm, nontender. Catheritized for 500 mL 

clear yellow urine, Neg for blood, glucose, ketones. Positive deformity of R wrist and diffuse tenderness L 

lower forearm. 

1. S.B.’s skull x-ray was negative for basilar skull fracture. How significant is this finding? 

2. On arrival, S.B. had slight discoloration over L mastoid process, and blood behind the L tympanic 

membrane. What is the significance of this finding? 

3. Why did S.B. have edema with slight discoloration and not ecchymosis over the mastoid process? 

4. Identify two complications associated with basilar skull fracture? 

5. Why is a dural tear likely to produce CSF leak? 

6. The term “raccoon eyes” is frequently used when describing someone who has a BSF. Explain the 

term “raccoon eyes.” 

7. What is the most reliable diagnostic indicator for basilar skull fracture? 

8. How would you test S.B. for evidence of CSF leakage? 

25

9. Identify the most serious complication of basilar skull fracture? 

10. What are the symptoms of an anterior fossa fracture (fracture of the paranasal sinuses)? 

11. What are the symptoms of a posterior fossa fracture (fracture of temporal petrous bone)? 

12. S. B. is suspected of having a BSF. Why don’t you want to place an NG tube in S. B.? 

13. What is the treatment strategy for a BSF with a limited CSF leak? 

14. Acetazolamide (Diamox) is a medication often prescribed with those requiring continued observation 

after BSF. Why is this medication prescribed? 

15. Which cranial nerves are most likely to be affected by a BSF? 

26


Neuro 

Case Study - Spinal Cord Compression 

Scenario: B.J. is a 34-year-old woman who has been thrown from a galloping horse in a remote area. She 

was flown to the trauma center by helicopter from a rural hospital with spinal cord compression due to 

spinal fracture and disk fragments in her lumbar spine. Her cervical spine is free from injury. She arrives 

strapped to rigid backboard and begins to vomit. 

1. What would you do to keep B.J. from aspirating? 

2. What would you do to assess B.J.? 

You find B.J. is hypotensive and bradycardic. She has an IV of 1000 mL LR with a large-bore catheter at 

75 mL /hr. 

3. What is causing the hypotension and bradycardia? 

The neurosurgeon arrives in the ED and examines B.J. He finds her areflexic below the lumbar region of 

the spinal cord. There is absence of sweating in the region and no sensation below the level of the lesion. 

He writes the following orders: CT scan of the spine; myelogram; prepare for surgery; admit to ICU; 10 mg 

dexamethasone (Decadron) IV now. 

4. Why did the physician order both a CT scan and a myelogram? Differentiate between the diagnostic 

value of each? 

5. What is dexamethasone, and why is it being used on B.J.? 

6. List four problems relevant to B.J.’s care. 

7. What are complications and problems associated with spinal cord shock? (List at least six.) 

27

8. List six ways you would detect complications from spinal cord shock. 

9. What are seven interventions that could be initiated to prevent or treat complications from spinal cord 

shock? 

B.J. went to surgery directly from x-ray for decompression of her spinal cord, and was admitted to ICU on 

absolute bed rest. From ICU she was transferred to the surgical unit and fitted for a back brace; she began 

physiotherapy. After undergoing surgery for a bone graft and spinal fusion, she was transferred to 

rehabilitation. After months of intense physiotherapy, B.J. regained the use of her legs and basic 

functioning and was discharged to home. 

28


Neuro 

Case Study - Spinal Cord Injury 

Scenario: T.W. is a 22-year-old man who fell 50 ft. from a chairlift while skiing and landed on hardpacked 

snow. He is found to have a T10-T11 fracture and paraplegia. He was initially admitted to the 

SICU and placed on high-dose steroids for 24 hours. He was taken to surgery 48 hours post accident for 

spinal stabilization. He spent 2 additional days in the SICU, 5 days on the neurologic unit, and now is ready 

to be transferred to your rehab unit. He continues to have no movement of his lower extremities. 

1. The goal of treatment in the acute phase of spinal cord injury (SCI) is to help T.W. survive the injury 

and maintain physiologic stability through the period of spinal shock. Once the acute phase is over, 

T.W. moves into the postacute and early rehabilitation phases. What are the treatment goals for T.W. 

in these phases? 

2. Considering a hierarchy of rehabilitative needs for patients like T.W., number the following from 

highest (1) to lowest (5) priority. 

______Community integration and employment. 

______Accomplishment of self-care and ADL’s. 

______Self-actualization. 

______Stabilization of the physiologic systems. 

______Adjustment to living at home. 

3. T.W. receives high-dose steroid therapy every 24 hours; then he is placed on a smaller maintenance 

dose. What effect will steroids have on T.W.? 

4. List three critical potential infections that T.W. should be monitored for throughout his hospitalization. 

A person with an SCI at the T10-12 level should be independent in a wheelchair and able to manage 

ADL’s. Including bowel and bladder care. 

5. T.W. is taking vitamin C 250mg PO bid. What is the purpose of this? 

You request a consultation with a RD because you realize that T.W. needs proteins for healing; however, 

too much protein can stress the kidneys. The RD will adjust his diet to ensure adequate amount of protein, 

carbohydrates, calcium, magnesium, and zinc. 

29

6. Rehabilitation teaching includes teaching T.W. how to manage his urinary drainage system. What 

would this teaching include? 

Some patients are able to catheterize themselves three to four times a day and not wear a continuous 

drainage. These patients need to know how to perform the following: (3 items) 

For those who must maintain a closed UDS (urinary drainage system) teaching should include: (14 items). 

7. What is the usual amount of time for the return of reflex function of the bladder? 

8. The large bowel musculature has its own neural center that can directly respond to distention caused by 

fecal material. This is what allows most SCI patients to regain bowel control. What dietary instructions 

are important for T.W.? 

9. T.W. should also be taught bowel training techniques. What would this teaching include? (8items). 

10. What medications can assist with a bowel program? 

11. Describe digital stimulation. 

12. T.W. asks you whether he’ll ever be able to have sex again. What do you tell him, and what are some 

possible referrals? 

30

For patients with lesions at T6 or above, there is the potential for AD (autonomic dysreflexia). Noxious 

stimuli below the level of injury triggers the sympathetic nervous system, causing massive release of 

catecholamines producing vasoconstriction. The patient develops severe hypertension (as high as 240- 

300/150 mm Hg), pounding headache, bradycardia, blurred vision, nausea, nasal congestion, and flushing 

and sweating above the level of the injury and goose bumps or pallor below the level of the injury. 

Potential causes include bladder distention, obstruction, infection, spasms, catheterization, and bladder 

irrigations done too fast or with cold fluid; bowel constipation, impaction, or rectal stimulation; and 

alterations in skin integrity including pressure, infection, injury, and cold or hot. AD can cause retinal 

hemorrhage, CVA, and seizure activity. 

13. What are the interventions r/t AD? 

31


Learning Plan 3 - Alterations in the Musculo-skeletal system 

Overview 


musculo-skeletal system. The learning plan will build on theory and content that was presented 

in previous nursing courses, while expanding your knowledge of muscular dystrophy, 

osteomyelitis, and bone cancer, 


Competency 

3. Evaluate nursing care for clients with alterations in the musculo-skeletal system 



o by responding to a case study or scenario of patients with musculo-skeletal 

system alterations (format may be oral, written, or graphic) 


o response utilizes the nursing process for clients with alterations in the 

musculoskeletal system 


alterations in the musculoskeletal system 




with alterations in the musculoskeletal system 



o response selects teaching/ learning topics to promote self-care for the client with 

a musculoskeletal system alteration 


for clients with alterations in the musculoskeletal system 



33

competency: 


following musculoskeletal system alterations: muscular dystrophy, osteomyelitis 

and bone cancer. 

b. Explain diangnostic tests and procedures used to screen, diagnose, and treat 

clients with the above alterations in the musculoskeletal system. 

c. Utilizing the nursing process, identify nursing interventions that would be 

implemented for clients with the above musculoskeletal system alterations. 

d. Plan nutritional interventions to promote/maintain health for clients with the above 

alterations in the musculoskeletal system. 

e. Integrate pharmacological and non-pharmacological therapies in the care of 

clients with alterations in the musculoskeletal system. 

f. Select teaching/ learning topics to promote self-care for the client with a 

musculoskeletal system alteration including health and preventive education. 

g. Identify available agency and community resources to promote care for clients 

with the above musculoskeletal system alterations. 

h. Identify collaborative problems that the nurse may need to manage/monitor for 

clients with the above musculoskeletal system alterations. 

i. Develop and evaluate nursing diagnoses appropriate to this learning plan. 

_____1. 

_____2. 



plan. 

Access www.cancerindex.org to help you answer the following questions. What 

are the 2 most common types of bone cancer? Is Ewing's sarcoma a childhood or 

adult disease? 

_____1. 

_____2. 



Complete the required written Case Study/Care Plan project 

34


Musculoskeletal 

Case Study - Fractured Tib/Fib w/ Osteomyelitis 

Scenario: H.K. is a 26-year-old man who tried to light a cigarette while driving and lost control of his Jeep. 

The Jeep flipped and landed on the passenger side. H.K. was transported to the ED with a deformed, 

edematous right lower leg and a deep puncture wound approximately 5 cm long over the deformity. Blood 

continues to ooze from the wound. 

1. What further assessment should the nurse make of the leg injury and what precautions should she take 

in making this assessment? 

2. What would be the most appropriate method for controlling bleeding at this site? 

3. From the above information, it is clear that H.K. is a smoker. List at least three issues r/t his smoking 

that can complicate his care and recovery. What interventions could be instituted to counter these 

complications? Would using a nicotine patch eliminate these problems? 

4. What is the best way to immobilize the leg injury prior to surgery? 

H.K. is taken to surgery for ORIF of the tibia and fibula fractures. He returns with a full-leg fiberglass cast 

with windows over the areas of surgery. 

5. Describe the assessment of a patient with a long leg cast involving trauma and surgery. 

35

6. In assessing H.K.’s cast on the third day postop, you notice a strong foul odor. Drainage on the cast is 

extending, and H.K. is c/o pain more often and seems considerable more uncomfortable. VS are 

123/78, 102, 18, T 101. What is the analysis of these findings? 

H.K. returns to surgery. The wound over H.K.’s fracture site has become necrotic with purulent drainage. 

The wound is debrided and cultured; then a posterior splint is applied. H.K. returns to his room with orders 

for wet-to-moist dressing changes. The physician suspects osteomyelitis and orders nafcillin, and 

gentamicin. 

7. As you continue to assess H.K. over the following days, what evidence will you look for that 

antibiotics are effectively treating the infection? 

8. What should H.K. be taught concerning the care of his cast? 

9. What nutritional needs will H.K. have, and why? 

10. To ensure pain management, H.K. is given a 75 mcg transdermal fentanyl patch. What therapeutic 

category does this drug belong to? What s/s would you see if her were to have a toxic or overdose 

reaction? 

11. What is the antidote to toxic narcotic reactions? And how is it to be administered? 

36


Learning Plan 4 - Alterations with Gastrointestinal/Hepatic Systems 

Overview 


gastrointestinal and hepatobiliary systems. The learning plan will build on theory and content 

that was presented in previous nursing courses, while expanding your knowledge of 

malabsorption disorders in infant/child, cancer of the stomach, liver and pancreas, cirrhosis, 

hepatitis,and pancreatitis. 


Competency 

4. Evaluate nursing care for clients with alterations in the gastrointestinal and 

hepatobiliary systems 



o by responding to a case study or scenario of patients with gastrointestinal and 

hepatobiliary system alterations 



gastrointestinal and hepatobiliary system 


alterations in the gastrointestinal and hepatobiliary system 




for clients with alterations in the gastrointestinal and hepatobiliary system 


with alterations in the gastrointestinal and hepatobiliary system 




an gastrointestinal and hepatobiliary system alteration 

37



competency: 

a. Review the anatomy and physiology of the stomach, liver, and pancreas. 

b. Describe the pathophysiology, etiology, and clinical manifestations of the 

following alterations in the gastrointestinal and hepatobiliary systems: 

malabsorption disorders in infant/child, cancer of the stomach, liver, and 

pancreas, cirrhosis, hepatitis,and pancreatitis, 

c. Explain diagnostic tests and procedures used to screen, diagnose, and treat 

clients with the above alterations in the gastrointestinal and hepatobiliary 

systems. 


implemented for clients with the above gastrointestinal and hepatobiliary system 

alterations. 

e. Integrate pharmacological and nonpharmacological therapy in the care of clients 

with alterations in the gastrointestinal and hepatobiliary systems. 

f. Plan nutritional interventions to promote/maintain health for clients with 

alterations in the gastrointestinal and hepatobiliary systems. 

g. Select teaching/learning topics to promote self care for the client with 

gastrointestinal/hepatobiliary system alterations including health and preventive 

education. 

h. Identify available agency and community resources to promote care for clients 

with alterations in the gastrointestinal and hepatobiliary systems. 

i. Identify collaborative problems that the nurse may need to manage/monitor for 

clients with the above gastrointestinal/hepatobiliary system alterations. 

j. Develop and evaluate nursing diagnoses appropriate to this learning plan. 


_____1. Review the anatomy and physiology of the gastrointestinal and hepatobiliary 

systems. 

_____2. Reference: Carpenito, Nursing Diagnosis text, as appropriate to this learning 

plan. 

_____3. Access: www.liverfoundation.org and www.hepfi.org for information on hepatitis 

and cirrhosis. 

_____4. View CD-ROM: Thumb's Up disc 3, College of DuPage 2002, as appropriate to 

learning plan. 

_____5. In small group discussion compare and contrast Hepatitis A, B, and C. 

_____6. 

_____1. 

_____2. 

Class discussion: Should the client with alcoholic cirrhosis be on the liver 

transplant list? 




38

Complex Health Alterations 

543-113 

Case Study - Gastrointestinal Disorders 

JD is approximately 50 years old, is admitted to your floor from the ED. He is lethargic, has a cachectic 

appearance, does not follow commands consistently, and is mildly combative when aroused. He smells 

strongly of alcohol and has a notably swollen abdomen and lower extremities. This man was sent to the 

ED by local police who found him lying unresponsive along a rural road. He was aroused somewhat in the 

ED. Examination and x-rays are negative for any injury, and he is admitted to your unit for observation. 

He is not awake or coherent enough to give any history or to answer questions. Admitting orders are: 

Admit to medicine with R/O hepatic encephalopathy with ETOH intoxication; IV D5 .45NACL with 

20meq KCL at 75mL/hr; add 1 amp MVI (multivitamins) to 1 liter of fluid per day. Nasogastric tube to 

low wall suction; Foley catether; Head of Bed at 30 to 45 degrees at all times; Lactulose 45mL PO qid until 

three soft stools; abdominal ultrasound in AM; CBC with differential, Basic chem. Panel; LFT, PT/PTT, 

Amonia level now and in AM; soft restraints prn; vitamin K 10mg IV QD for three doses; thiamine 100mg 

IM QD; Folic Acid 5mg IM QD; pyridoxine 100mg PO qd; once patient is able to take PO give low-protein 

diet, eat with assistance only; call MD for any sign of GI bleed, DT’s or SBP >140 or

4. How would you further assess the distended abdomen, and what is the clinical name for your 

findings? 

5. What is your concern about the client’s nutritional status? What are your objective findings? 

6. Why is the patient not on a high-protein diet? 

7. What are the signs and symptoms of DTs? 

40


Learning Plan 5 - Alterations in the Renal/Urinary System 

Overview 


renal/urinary system. The learning plan will build on theory and content that was presented in 

previous nursing courses while expanding your knowledge of acute/chronic renal failure, 

peritoneal and hemodialysis, renal transplant, nephrotic syndrome, and glomerulonephritis. 


Competency 

5. Evaluate nursing care for clients with alterations in the renal/urinary system 



o by responding to a case study or scenario of patients with renal/urinary system 

alterations 



renal/urinary system 


alterations in the renal/urinary system 




for clients with alterations in the renal/urinary system 


with alterations in the renal/urinary system 




an renal/urinary system alteration 

41



competency: 


following renal/urinary system alterations: acute and chronic renal failure, 

peritoneal dialysis and hemodialysis, renal transplant, nephrotic syndrome, and 

glomerulonephritis. 

b. Explain diagnostic tests and procedures used to screen, diagnose, and treat 

clients with the above alterations in the renal/urinary system. 


implemented for clients with the above renal/urinary system alterations. 

d. Integrate pharmacological and non-pharmacological therapies in the care of 

clients with the above alterations in the renal/urinary system. 



f. Select teaching/learning topics to promote self care for the client with a 

renal/urinary system alteration including health and preventive education. 

g. Discuss ethical issues associated with kidney transplant. 

h. Identify available agency and community resources that provide/promote long 

term care/assistance for clients with alterations in the renal/urinary system. 

i. Identify collaborative problems that the nurse may need to manage/monitor for 

clients with the above renal/urinary system alterations. 

j. Develop and evaluate nursing diagnoses appropriate to this learning plan. 


_____1. REVIEW the anatomy and physiology of the renal/urinary system 

_____2. Read: Pharmacology text, Reiss as appropriate to the learning plan. 


plan. 

_____4. Submit a diet plan for a child with nephrosis or an adult with ESRD. 

_____5. Classroom discussion: Compare continuous renal replacement therapy with 

traditional hemodialysis. 

_____6. View video: Peritoneal dialysis in the nursing skills lab. Concept Media, 1999. 

_____1. 

_____2. 




42


Renal 

Case Study – Acute Renal Failure 

Scenario: You are working in the ICU of an acute care hospital and assume the care of E.B.; a 78-year-old 

woman who is 3 days post inferior wall MI. E.B. had been healthy before admission except for a 

longstanding history of osteoarthritis treated with rofecoxib (Vioxx) 50 mg daily and longstanding 

hypertension treated with atenolol (Tenormin) 50 mg daily. On presentation to the ED, E.B. had severe 

hypertension 210/122; therefore, thrombolytics were contraindicated. An IV was started with D5W at KVO 

rate and she was taken directly to the cath. Lab for PTCA. Her angioplasty was successful, and she has 

been pain-free since the PTCA. You are reviewing E.B.’s lab work and note the following values: Na 142, 

K 4.6, Cl 100, BUN 60, creatinine 3.8, and glucose 158. 

1. What abnormalities are there in E.B.’s lab work? 

2. What are the possible causes for these abnormalities? 

3. Describe prerenal, intrarenal, and postrenal causes of ARF. Given the potential causes of E.B.’s 

elevated BUN and creatinine, how would they be categorized? 

You are given the results of E.B.’s lab work from today. The results are Na 140, K 5.0, Cl 104, CO2 24, 

BUN 68, creatinine 4.0, and glucose 104. You also noted her urine output for the past 8 hours is 160 mL. 

4. Based on these values, what is your next action going to be? 

5. Define oliguria and anuria. Which term best describes E.B.’s renal function? 

6. In reviewing E.B.’s VS, you cannot identify any episodes of hypotension since her admission. What 

might be a possible explanation for her increase in BUN and creatinine? 

7. What are your interventions and priorities for a patient in ARF? 

43

8. E.B. has been very quiet. Suddenly she asks you, “Am I going to die?” How will you respond? 

9. You talk to her about the possibility of dialysis, which may be a treatment option for her. She 

responds, “You, know, I’m 78 years old. I’ve had a pretty good life, and I don’t want to be hooked to a 

machine.” What will you say? 

44


Renal 

Case Study – End-State Renal Disease 

Scenario: K.B. is a 32-year-old woman being admitted to the medical floor for c/o fatigue and 

dehydration. While taking your history you discover that she has diabetes and has been insulin-dependent 

since the age of 8. She has undergone hemodialysis for the past 3 years. Your initial assessment of K.B. 

reveals a pale, thin, lethargic woman in NAD (no acute distress). Her admitting chemistries are Na 145, K 

6.0, Cl 93, HCO3 27, BUN 48, creatinine 5.0, and glucose 238. Her skin is warm and dry to touch with 

poor skin turgor and her mucous membranes are dry. Her VS are 140/88, 116, 18, 99.9 F. She tells you she 

has been nauseated for 2 days so she has not been eating or drinking. She reports severe diarrhea. Serum 

calcium, phosphate, and magnesium have been drawn but are not yet available. 

1. What aspects of your assessment support her admitting diagnosis of dehydration? 

2. Identify two possibilities for K.B.’s low-grade fever. 

The rest of K.B.’s physical assessment is within normal limits. She tells you she has an AV fistula in her 

left arm. 

3. What is a fistula? Why does K.B. have one? 

4. In assessment of an AV fistula, what physical findings would you expect during auscultation and 

palpation? 

Over the next 24 hours, K.B.’s nausea subsides, and she is able to eat normally. Her physician believes her 

nausea to be r/t her elevated Cr/BUN. While you are helping her with her AM care, she confides in you that 

she has never really understood what “diet I’m supposed to be on anyway.” 

5. What information would you seek from K.B. now? 

6. Because K. B. is on hemodialysis, what are her special nutritional needs? 

45

K.B.’s CBC yields the following results: WBC 7600, RBC 3.2, Hgb 8.1, Hct 24.3, and platelets 333,000. 

7. Are these values normal? If not what are the abnormalities? 

8. K.B.’s physician notes that she is anemic, which is most likely the cause of her increasing fatigue. 

Why is K.B. anemic? 

The following day K.B. is discharged feeling much better and with a good understanding of her dietary 

restrictions. Her iron stores have been evaluated and found to be adequate. Her physician has instructed her 

to resume her preadmission medications, except for the addition of recombinant human erythropoietin 50 

units/kg three times a week with dialysis. 

9. What information would you give K.B. about her new medication? 

46


Renal 

Case Study – Pediatric Renal Disease and Transplantation 

Scenario: Sandra is a 14-year-old adolescent who live at home with her mother, stepfather, and two 

younger siblings. When Sandra was 9 years old, she was involved in a motor vehicle accident and severely 

injured. As a result, she developed acute renal failure that eventually progressed to chronic renal failure. 

She has been receiving peritoneal dialysis for the past 4 years. She is registered with the organ procurement 

agency in the city 30 miles from her home because her parents have been ruled out as potential donors. 

Sandra is doing satisfactorily at home, receiving her peritoneal dialysis at night. This allows her to attend 

school and interact with her friends. She is anxious to receive a kidney transplant to she will not have to 

continue with her dialysis Sandra’s parents receive a phone call from the hospital at 0200 telling then that 

the hospital has procured a kidney for Sandra as a result of a motor vehicle crash that killed a 10-year-old 

boy. Her mother calls Sandra’s grandmother to baby-sit for the younger siblings, and then Sandra’s parents 

take her to the hospital, where they are met by the transplant team. 

1. What is chronic renal failure and End-Stage-Renal-Disease? 

2. Discuss the possible connection between Sandra’s motor vehicle accident and her development of 

ESRD. 

3. Discuss the incidence and etiology of chronic renal failure in children. 

4. Discuss the complications associated with Sandra’s diagnosis. 

47

5. What are the priorities of care for Sandra’s ESRD? 

6. Why is Sandra receiving peritoneal dialysis? 

7. Compare the advantages and disadvantages of peritoneal dialysis and hemodialysis in children. 

8. Discuss the impact Sandra’s diagnosis may have on her growth and development. 

9. What other assessment data would be helpful for the nurse to have to prepare Sandra’s care plan? 

48

10. Discuss the impact of the phone call Sandra’s parents received informing them of a kidney donor for 

Sandra. 

11. What is the incidence of renal transplants in a child Sandra’s age? 

12. Two days following her surgery, Sandra is admitted to the pediatric transplant unit where she received 

her kidney transplant. What are the priority nursing interventions for Sandra? 

13. Sandra weighs 110 lb. and is prescribed prednisone 30 mg by mouth qid, cyclosporine 100 mg by 

mouth qid, and azathioprine 50 mg by mouth qid. Discuss these medications and if they are safe for 

Sandra in the doses prescribed. 

14. One month following Sandra’s discharge from the hospital, she develops a fever, has decreased urine 

output, and has gained 3.2 kg (7lb). Her mother calls Sandra’s transplant physician and is advised to 

bring Sandra to the hospital clinic. On arrival her VS are: 140/86, 90, 30, T100.4 F. Her BUN 24, 

creatinine 4.0. Discuss your impressions of Sandra’s condition. 

49

15. Sandra is admitted to the hospital and prescribed prednisone 40 mg by mouth qid, cyclosporine 125 mg 

by mouth qid, and azathioprine 62.5 mg by mouth qid. Discuss the relationship between Sandra’s 

condition and the increase in her medications. 

16. Sandra’s acute rejection is successfully treated and she returns home. Three years later Sandra is doing 

well and her transplanted kidney is functioning well. Does Sandra need to continue her 

immunosuppressant therapy? If so for how long? 

50


Learning Plan 6 - Critical/Life-Threatening Situations 

Overview 

This learning plan will focus on the nursing care of clients with Critical/Life-Threatening 

Situations. The learning plan will build on theory and content that was presented in previous 

nursing courses and expand your knowledge of all types of shock, DIC, burns, biological 

agents/warfare and Sepsis. 


Competency 

6. Evaluate nursing care for clients with critical/life threatening situations (burns, 

shock, etc.) 



o by responding to a case study or scenario of patients with critical/life threatening 

situations 


o response utilizes the nursing process for clients experiencing critical/life 

threatening situations 


clients experiencing critical/life threatening situations 

o response explains procedures used to screen, diagnose, and treat clients 

experiencing critical/life threatening situations 

o response plans nutritional interventions for clients experiencing critical/life 


o response integrates pharmacological therapy in the care of clients experiencing 

critical/life threatening situations 

o response implements the teaching/learning process to promote informed 

decisions for the client and significant others 

o response proposes caring interventions to provide for psychosocial needs of the 

client experiencing critical/life threatening situations and their significant others 

o response explores collaborative aspects of caring for clients with critical/life 



51


competency: 

a. Describe the pathophysiology, etiology, and clinical manifestations of clients 

experiencing the following critical/life threatening situations: shock (4 types), 

DIC, Sepsis, burns, and biological agents/warfare. 

b. Explain diagnostic tests and procedures used to screen, diagnose, and treat 

clients with the above critical/life threatening situations. 


implemented for clients with critical/life threatening situations. 

d. Identify pharmacological and nonpharmacological therapy in the care of clients 

experiencing critical/life threatening situations. 

e. Plan nutritional interventions, including appropriate IV fluids, for clients 

experiencing critical/life threatening situations. 

f. Discuss caring interventions to provide for psychosocial needs of the client and 

family experiencing critical/life threatening situations. 

g. Describe the nurse's advocacy role to promote informed decisions for the client 

and family (including end of life issues). 

h. Select teaching/learning topics to implement for the client with the above 

situations/conditions, including wellness and prevention. 

i. Identify available agency and community resources to promote self care for 

clients with extensive recovery periods (burns). 


clients with critical/life threatening situations. 




plan. 

_____2. Read: Cheek, D et al. "Sepsis: Taking a deeper look." Nursing 2005, January. p. 

38-43. 

_____3. Classroom discussion: compare and contrast the clinical manifestations and 

treatment of the various types of shock. 

_____4. Visit the following website: 

htpp://www.nlm.nih.gov/medlineplus/tutorials/burns.html. Locate and view the 

Interactive Tutorial for Burns, posted on that page. 

_____5. 

_____1. 

_____2. 

Access: www.cdc.gov and click on Emergency Preparedness and Response and 

then Bioterrorism agents for additional information on this topic. 




52


Associate Degree Nursing 


543-113 

Case Study – Burns 

Tom is a forty-four year-old who has sustained partial (2 nd degree) and full thickness (third degree) burns 

on his face, neck, chest, back, and arms. He’d been drinking and smoking in bed, then fell asleep with his 

cigarette smoldering. By the time neighbors called the fire department, his apartment was engulfed in 

flames. En route to the hospital, emergency medical technicians had administered 100% oxygen. They’d 

also inserted a large-bore cannula and had begun infusing lactated Ringer’s solution. 

1. What are the priorities of treatment in the emergent phase? 

On arrival, Tom’s vital signs are: blood pressure, 110/60; pulse, 124; respirations, 36 and labored, shallow, 

and rapid; and temperature, 96.6F (35.9 C) He’s responsive but confused, and he can’t give an accurate 

medical history. His face is burned and his nasal hair is singed; he’s coughing us thick, gray-black sputum. 

His voice is hoarse; he has bilateral breath sounds. 

Cutting away his clothes, you quickly check his burns and look for other injuries. Nearly all of his burns 

are full-thickness involving his anterior and posterior neck, chest, and both arms (including the hands). His 

radial pulses are palpable. 

2. What are the risk factors for this patient? Clinical manifestations and physical assessment 

findings on this client in emergent phase. 

3. Identify the stage of shock. 

4. Use the rule of nines to calculate extent of injury. 

53

5. What diagnostic tests are useful in the emergent phase to evaluate patient? 

6. Identify Nursing Diagnoses for this client in emergent state. 

7. Identify drug therapy for use in emergent phase. (Shock, Burns) 

54


Associate Degree Nursing 


543-113 

Case Study – MODS 

Mary is a 25 year old, married, and mother of 2 children (boy - 3 1/2 years; girl- 6 months). Mary has 

asthma. Mary's allergies include: smoke, rag weed, dust and PCN. On a brisk autumn day, Mary is raking 

leaves when suddenly, she is overcome by the smoke from a neighbor's burning leaves and another 

neighbor hears her wheezing. The neighbor asks if she is OK and Mary advises him that it's just her asthma 

acting up. Mary decides to quit raking and return inside as the smoke is making it difficult for her to 

breathe. As Mary enters her home, her breathing is becoming more labored. As Mary is reaching for her 

inhaler for rescue breathing, she passes out and hits the bathroom floor. Mary's son, upon awakening from a 

nap, notices his mother's body on the floor and tries to awaken her. When Mary's son is unable to awaken 

her, he goes outside and tells the neighbor "My mommy is sleeping on the floor. I can't wake her up! The 

baby is crying." The neighbor follows the boy into the house and realizes the gravity of the situation and 

calls 911. 

Upon their arrival, the paramedics assesses that Mary is a pulseless non-breather. CPR is initiated and the 

paramedics are able to restore Mary's pulse but she requires assisted breathing. Mary is taken to the local 

Hospital's ED where she is assessed and her diagnosis is Comatose: secondary to STATUS Asthmaticus. 

Mary is intubated and placed on a ventilator and taken to ICU. 

Mary's initial assessment is: 

• Neuro: no spontaneous eye opening; no following commands; decorticate posturing on the right 

and decerebrate posturing on the left to nail bed pen roll; pupils are 4.0 mm and non-reactive. 

• Cardiac: regular rate and rhythm of 60, heart sounds S1, S2, no S3/S4, no rubs; no JVD; peripheral 

pulses are +3/4 uppers and lowers. BP 100/60. IV of D5.45 NaCl with 20 meq KCl/liter at 80 ccs 

per hour. 

• Pulmonary: chest symmetrical, no assist of the ventilator (is on an Assist Control rate of 14 and 

her rate is 14) lung sounds with coarse breath sounds throughout lung fields. 

• Abdomen: flat, soft, non-tender, with hypoactive bowel sounds all 4 quadrants; no masses or 

organomegaly. OG tube drains bilious drainage, small amounts. 

• GU: Foley patent, draining clear straw colored urine. 

What do you think is going on with Mary? What is Mary's Glascow coma score? 

Mary's husband, mother, father and mother-in-law enter the room with the family physician; they are 

obviously shaken. 

An hour later, Mary is taken down for a CT Scan of her head and the result is: No significant acute/active 

bleeding but significant cerebral edema and a basal skull Fracture. 

Upon returning from the CT Scan, Mary has a grand mal seizure. Why do you think this happens? The 

physician orders Valium 10 mg IV PUSH. How fast will you administer this medication? Is Valium 

compatible with your IV fluids? If no, what will you do now? 

The physician also orders Dilantin 1 gm IV STAT and 100 mg IV q 8 hours. How fast will you administer 

the Dilantin? The physician also orders the Cortiocosteroid Decadron 4mg IV q6 hours. How fast will you 

administer this med and what are possible side effects and nursing implications? 

DAY 2 

Mary has not had any further seizure activity nor has her assessment changed, except her lung sounds are 

very diminished in the bases and you are suctioning undigested food like substances and tenacious, yellow 

55

green secretions from her ET tube. What do you think happened yesterday? 

Later that afternoon, Mary's rectal temp is found to be 102.0 The physician orders STAT blood cultures, 

sputum specimen and urine culture. Would you administer the Tylenol suppository (ordered q 4 hr prn 

temp) before or after the blood cultures (which are drawn by lab)? 

The physician places Mary on the anti-infective Ancef (Cefazolin) 500 mg. IVPB q8 hours. What condition 

if present, would stop you from administering this medication? What are possible side effects and nursing 

implications? 

Late that day, the physician decides to change the antibiotic to the Fluoroquinolone Ciprofloxacin (Cipro) 

400 mg IVPB q 12. Why did he change the antibiotic? What are possible side effects and nursing 

implications? 

DAY 3 

Mary's temp is under control, her lungs sound better, but her OG tube now drains a dark tea colored 

substance with dark flecks. What should the nurse do? What could be the cause of the dark drainage and 

flecks? Mary is started on Zantac (Ranitidine) 50 mg IV q 6 hours. Why? How will you administer this 

drug? What are possible side effects and nursing implications? 

The nurse also notices that Mary has small amounts of serosanguinous drainage coming out of her nose and 

thinks that it is from unsuccessful attempts to place an NG tube; hence an OG tube was placed. What else 

should you consider as a cause of the drainage? How would you check it? 

DAY 4 

Mary is flaccid bilaterally, her pupils are 9.0 mm and non-reactive; all reflexes are gone What is going on? 

The nurse notices on Mary's pillow and bed sheets, drops of blood with yellow rings around them. What do 

you make of this? Mary's temp has climbed to 104.5 rectally. Mary's blood pressure is 80/50 and her pulse 

is 110. Mary's urine output has dropped to 5 ccs per hour. The physician comes in, evaluates Mary and 

places her on the anti-infective Cephalosporin, Rocephin (Ceftriaxone) 2 gm IVPB q 12 hours. Why? What 

are the possible side effects and nursing implications? The physician also orders an IV fluid challenge of 

0.9 NaCl 500 cc’s as fast as it will go. Why? What are nursing implications? Despite 2 fluid challenges 

Mary's BP is now 70/50 and the physician orders Plasmanate (a volume expander). Why? What are the 

possible side effects and nursing implications? Despite all the fluids, Mary's blood pressure does not 

respond, nor do her kidneys, the physician orders a Dobutamine (Dobutrex) drip to start at 5 micrograms 

per kilogram per minute and to titrate to maintain a systolic blood pressure between 100-120. 

If Mary weighs 55kg and the standard drip is 500 mg of Dobutramine in 500 ccs of D5W, how fast will you 

set your IV to run at 5 micrograms per kilogram per minute? What are the possible side effects of this 

medication? What are the nursing implications? 

Day 5 

Mary's Dobutamine drip is at 9 micrograms per kilogram per minute. How fast is her IV running? 

Day 6 

Mary's condition continues to deteriorate and her heart is now in a third degree heart block. The physician 

calls in a Cardiologist who places a temporary pacemaker. 

Day 7 

Mary's kidneys have not put out any urine in 24 hours so the attending physician calls in the Nephrologist 

who starts Mary on Ultrafiltration. 

Day 8 & 9 

The hospital's ethics board is called upon the family's request. Mary has 2 EEGs 24 hours apart which 

demonstrate cerebrosilence and a cerebro flow study which demonstrates no cerebral blood flow (no viable 

brain tissue). All life support is discontinued and Mary is pronounced dead. 

56

Questions to Investigate 

What is the function of the lungs? 

What are symptoms of Hypoxia? 

What are normal ABG’s? 

What are the functions of the kidneys? 

What is Oliguria? 

What does Serum Creatinine tell you? 

What is the function of the stomach and intestines? 

What are symptoms/signs of a paralytic ileus? 

What arc symptoms/signs of GI bleeding? 

What are the functions of the Liver? 

What is serum bilirubin? What Is the ALT(SGPT) and the AST(SCOT)? What is the significance of their 

rise in the blood? 

What is the significance of jaundice with respect to the liver? 

What is the function of the heart? 

What are the symptoms of heart dysfunction? 

What is the purpose of platelets? 

What are the purposes of the brain stem? 

What is the best indicator of neurological functioning? 

What is the significance of a Glascow scale score of 3? 

57


Learning Plan 7 - Alterations in the Reproductive System 

Overview 

This learning plan will focus on the nursing care of clients with alterations in the reproductive 

system. The learning plan will build on theory and content that was presented in previous 

nursing courses, while expanding your knowledge of breast, ovarian, cervical, testicular and 

prostate cancers; infertility and the care of the client needing a hysterectomy. 

Competency 

7. Evaluate nursing care for clients with alterations in the reproductive system 



o by responding to a case study or scenario of patients with reproductive system 

alterations 



reproductive system 


alterations in the reproductive system 




for clients with alterations in the reproductive system 


with alterations in the reproductive system 




an reproductive system alteration 



competency: 

a. Review the anatomy and physiology of the female and male reproductive 

systems. 

b. Discuss risk factors for cancers of the male and female reproductive systems 

59

including breast, ovarian, cervical, testicular, and prostate. 

c. Describe the pathophysiology, etiology, and clinical manifestations of the 

following reproductive system alterations: cancer of the breast, ovary, cervix, 

testicle, and prostate; and infertility. 

d. Discuss the reproductive system alterations that may indicate the need for a 

hysterectomy. 

e. Explain diagnostic tests and procedures used to screen, diagnose, and treat 

clients with the above alterations in the reproductive system. 

f. Utilizing the nursing process, identify nursing interventions that would be 

implemented for clients with the above reproductive system alterations. 

g. Integrate pharmacological and non-pharmacological therapies in the care of 

clients with alterations in the reproductive system. 

h. Plan nutritional interventions to promote/maintain health for clients with 

alterations in the reproductive system. 

i. Select teaching/learning topics to promote self care for clients with alterations in 

the reproductive system, including wellness and preventive care. 

j. Examine emotional, legal, and ethical considerations of infertility. 

k. Identify available agency and community resources to promote care for clients 

with the above alterations in the reproductive system. 

l. Identify collaborative problems that the nurse may need to manage/monitor for 

clients with the above reproductive system alterations. 

m. Develop and evaluate nursing diagnoses appropriate to this learning plan. 

_____1. 

_____2. 

_____3. 

_____4. 

_____5. 

_____6. 


Review anatomy and physiology of the reproductive systems 


plan. 

In class discussion: Discuss the chemotherapy treatments for ovarian and 

testicular cancer. 

Access the following web sites for additional information on reproductive 

alterations. www.y-me.org, www.nationalbreastcancer.org and www.obgyn.net. 

Teach your classmates some of the exercises that would be part of a postmastectomy 

client's plan of care. 

Develop a plan of care for the client undergoing a hysterectomy. 

_____1. 

_____2. 


Complete the witten test. 

Complete the required Case Study/Care Plan Project. 

60


Associate Degree Nursing Program 


543-113 

Case Study - Alterations in the Reproductive System 

D.M. is a married 36 – year-old woman with four children who works part-time as a clerk. She is 5’8” tall 

and weighs 135 pounds. She has insurance through her husband’s employer. She has never smoked and 

has an occasional social drink. She has PMH of plastic surgery for breast implants in August of last year. 

When she returned for her breast implant check-up 10 months later, a 2.2 cm lump was discovered in her 

right breast. When a biopsy indicated the lump was malignant, she elected to have a lumpectomy and 

axillary lymph node dissection. The pathology report indicated that 3 of 14 lymph nodes were positive. 

Her CT scan and bone scans were negative. You are a staff nurse at the group oncology clinic where she 

was referred to receive chemotherapy. After she completes chemotherapy she is scheduled to receive 

radiation therapy. Admitting diagnosis: infiltrating ductal carcinoma, stage T2 Ni MO, premenopausal, 

estrogen receptor (ER) 3+, progesterone receptor (PR) negative, and Her2-new 3+ (Note: Her2 – neu is also 

known as C-ErbB – 2) 

1. D. M. wants you to explain exactly what state T2 N1 MO means. What will you tell her? 

2. Next, D.M. wants to know what the ER, PR, and Her2-neu values mean. 

3. She asks you to explain what her chances of survival are. How will you explain this to her? 

4. D.M. will be receiving six cycles of combination chemotherapy, consisting of doxorubicin 

(Adriamycin), and cyclophosphamide (Cytoxan). What are the major side effects you want to 

prepare her for? 

5. Elaborate on issues R/T head/care. 

61

6. What is a major complication in patients receiving a high amount of doxorubicin? 

7. Explain to D.M. in lay terms what she needs to know about immunosuppression. 

D.M. completes her chemotherapy. She lost most of her hair and has been wearing a scarf but now her 

hair is beginning to grow back. She is being transferred to the radiation therapy department for treatment 

and is scheduled to begin radiation therapy. 

You perform an admission assessment. Findings are as follows: weight 148 pounds: VS 104/70. 80, 

20, 98.0F (oral). Cardiovascular: S1 S2 without murmurs or rubs. Respiratory: clear to auscultation 

throughout. Neuromuscular/ skeletal: negative, patient C/O bone pain. GI: without hepatosplenomegaly or 

masses. GU: negative. Integumentary/oral: hair growth ⅓ inch over entire head, oral mucosa reddened, 

and patient C/O soreness. Lymph node: no palpable adadenopathy in the cervical, supraclavicular, axillary, 

or inguinal nodes. Extremities: no peripheral edema, all peripheral pulses palpable. 

8. What area of the above assessment concerns you? Explain. 

D.M. receives 6 weeks of daily (weekdays) radiation therapy treatments with a total dose of 6400 cGy. 

She has a terrible time with fatigue, and at one point tells you, “When I led down, I can’t become enough of 

the bed.” You helped her develop an activity-rest plan and support her in obtaining outside help with 

housework. At her last visit, she tells you, “Now I hope I can see my kids grow up.” She is scheduled to 

return to the oncologist every 3 months for follow-up care and monitoring. 

9. D.M. comes to her scheduled follow-up appointment. She appears very anxious. When 

questioned, she tells you, “I’ve been worried about my daughters. Why do they get breast cancer? 

What can I do to help them?” What is your response? 

62

10. You ask her whether she has other questions. She tells you she is worried about the breast cancer 

coming back and wants to know whether she would have to go through the chemotherapy and radiation 

therapy all over again. What can you do, and what will you tell her? 

63


Learning Plan 8 - Care of the High-Risk Perinatal Client 

Overview 

In this learning plan you will focus on care of the high-risk perinatal client. The learning plan will 

build on theory and content that was presented in previous nursing courses, while expanding 

your knowledge of Rh incompatibility, PIH, pre-term labor, spontaneous abortion and 

gestastional diabetes 


Competency 

8. Evaluate nursing care for the high-risk perinatal client 



o by responding to a case study or scenario of high risk perinatal clients 


o response utilizes the nursing process for high risk perinatal clients 

o response demonstrates provision of psychosocial support for high risk perinatal 

client and family 


high risk perinatal conditions 

o response explains procedures used to screen, diagnose, and treat high risk 

perinatal conditions 


for clients with high risk perinatal conditions 

o response plans nutritional interventions for clients to promote/maintain health for 

clients with high risk perinatal conditions 

o response integrates pharmacological therapy in the care of clients with high risk 

perinatal conditions 


high risk perinatal conditions 



competency: 

a. Review the physiologic changes that occur during a normal pregnancy. 

b. Describe maternal and fetal pathophysiology, etiology and clinical manifestations 

65

of the following high-risk pregnancy conditions: Rh incompatibility, pregnancy 

induced hypertension, pre-term labor, spontaneous abortion and 

diabetes/gestational diabetes 

c. Describe the various maternal and/or fetal diagnostic tests/procedures performed 

to evaluate the health of the mother and fetal development. 


implemented for clients experiencing high-risk pregnancy. 

e. Integrate pharmacological and non-pharmacological therapies in the care of 

clients experiencing high-risk pregnancy. 

f. Plan nutritional interventions to promote/maintain health for clients experiencing 

high-risk pregnancy alterations, especially diabetes and PIH. 

g. Discuss strategies to use that will help the family experiencing perinatal loss; 

adequate bereavement time and coping skills. 

h. Design an individualized client educational plan based on the perinatal risk and 

data obtained from the nursing assessment. 

i. Identify agency and community resources for a client experiencing high-risk 

pregnancy. 


clients experiencing high-risk pregnancy. 


_____1. 

_____2. 

_____3. 

_____4. 

_____1. 

_____2. 


Review anatomy and physiology of the pregnant woman. 


plan. 

Complete the case study on PIH for chapter 13 at www.prenticehall.com 

/london. The website www.preeclampsia.org may provide insight as you complete 

this assignment. 

In class discussion on comparing and contrasting gestational diabetes Type I and 

Type II. 




66


Learning Plan 9 - Care of the High-Risk Newborn 

Overview 

This learning plan will focus on the nursing care of the high risk newborn. The learning plan will 

build on theory and content that was presented in previous nursing courses, while expanding 

your knowledge of hyperbilirubinemia, hypoglycemia, FAS, drug dependency, respiratory 

distress syndrome, and pre/post term birth, and how these conditions place the newborn at 

high-risk. 


Competency 

9. Evaluate nursing care for a high-risk newborn 



o by responding to a case study or scenario of high risk newborn clients 


o response utilizes the nursing process for high risk newborn clients 

o response demonstrates provision of psychosocial support for the family of the high risk 

newborn 

o response describes the pathophysiology, etiology, and clinical manifestations of high risk 

newborn conditions 

o response explains procedures used to screen, diagnose, and treat high risk newborn 

conditions 

o response identifies available agency and community resources to promote care for 

clients with high risk newborn conditions 

o response plans nutritional interventions for clients to promote/maintain health for clients 

with high risk newborn conditions 

o response integrates pharmacological therapy in the care of clients with high risk 


o response selects teaching/learning topics to promote care for the family with high risk 




competency: 

a. Review the normal physiologic responses and physical assessment of the newborn. 

b. Describe pathophysiology, etiology and clinical manifestations of the following conditions 

67

that place newborns at risk: hyperbilirubinemia, hypoglycemia, fetal alcohol syndrome, 

drug dependency, respiratory distress syndrome, SIDS, and pre/post term birth. 

c. Explain diagnostic tests and procedures used to screen, diagnose, and treat high-risk 

newborns. 

d. Integrate pharmacological and non-pharmacological therapies in the care of high-risk 

newborns. 

e. Utilizing the nursing process, identify nursing interventions that would be implemented 

for high-risk newborns. 

f. Plan nutritional interventions for high-risk newborns to promote/maintain health. 

g. Discuss the educational and psychological support needed by families with newborns 

who have congenital anomalies. 

h. Select teaching/learning topics to promote self care for the family/caregivers with highrisk 

newborns, including wellness and preventive care. 

i. Examine legal and ethical considerations of hospitalized and/or long term care of the 

high-risk newborn. 

j. Identify agency and community resources for families with high-risk newborns. 

k. Identify collaborative problems that the nurse may need to manage/monitor for high-risk 

newborns. 

l. Develop and evaluate nursing diagnoses appropriate to this learning plan. 

_____1. 

_____2. 

_____3. 

_____4. 

_____5. 

_____6. 


Review the normal anatomy and physiology of the neonate. 


plan. 

In class discussion on the differences between physiologic and pathologic 

jaundice and the care of the newborn. 

Access www.sids.org and contrast respiratory distress syndrome and sudden 

infant death syndrome. 

In class discussion on specific measures the nurse can initiate to encourage 

bonding between the parents and the high risk hospitalized newborn. 

Develop a plan of care for a high risk hospitalized newborn that may need either 

reduced or increased stimulation while in the nursery. 

_____1. 

_____2. 



Complete the required written Case Study/Care Plan project. 

68


Learning Plan 10 - Care of the Ill Child 

Overview 

In this learning plan you will focus on nursing care strategies for the child and family 

experiencing acute or chronic illness. The learning plan will build on theory and content that 

was presented in previous nursing courses, while expanding your knowledge on the effects of 

hospitalization of the ill child and strategies to promote coping and normal development during 

hospitalization. There will also be discussion on preparation for procedures/surgery, available 

community resources, and long term and/or home care of the ill child. 


Competency 

10. Evaluate nursing care for the ill child 



o by responding to a case study or scenario of an acute or chronically ill child 


o response shows developmentally appropriate modification of nursing measures of the 

acutely or chronically ill child 

o response identifies interventions that minimize stress of illness and hospitalization for 

children and families 

o response incorporates effects of illness and hospitalization on the child and family 



competency: 

a. Identify the nurse's role in various settings where care is given to ill children. 

b. Discuss factors and stressors that affect a child's response to hospitalization and 

treatment. 

c. Develop strategies to promote coping and normal development of the ill child during 

hospitalization and/or long term home care. 

d. Indicate how nursing interventions need to be modified according to the developmental 

stage of the child. 

e. Evaluate the nursing plan of care for a child preparing for surgery or a procedure. 

f. Discuss the psychological responses of families to the illness of a child in the family. 

69

g. Compare and contrast the effects on the family and child when dealing with an acute 

versus a chronic illness. 

h. Identify agency and community resources for families with acute and/or chronically ill 

children. 

i. Develop and evaluate nursing diagnoses appropriate to this learning plan. 


_____1. Read: OB/Pads text, London, et.al, Chapter 34, 37, and review Chapter 38 as 

appropriate to the learning plan. 

_____2. Read: Nutrition text, Williams, Chapter 11 as appropriate to the learning plan. 

_____3. Read: Pharmacology text, Reiss, et al, Chapters 5 as appropriate to the learning 

plan. 

_____4. Read: Salati, D. "Caring for a sick child in a nonpediatric setting." Nursing 2004, 

April. p.54-60. 


plan. 

_____6. Participate in an online search activity on www.kidshealth.org. CLICK kids and 

then type in hospital. Select a topic and compare that information to your text and 

discuss any new information or discrepancies in class. 

_____7. Submit a general list of nursing interventions that will decrease a child's anxiety 

prior to a treatment/procedure. 

_____8. Develop a plan of care that includes a list of agencies and community resources 

for parents with an ill child. 

_____9. In classroom discussion: Identify the pros and cons of always having a parent 

present when providing care to a child in the health care setting. 

_____1. 

_____2. 




70

Written Projects 

Writing a Formal Paper 

Introduction to the paper 

The body of a paper opens with an introduction that presents the specific problem or thesis under 

study. A good introduction answers the question, "What is the point of the study/article/project?", 

summarizes the relevant arguments and data presented, and gives the reader a firm sense of why 

the project, research, and article was done and why. 

Body of the paper 

You can achieve clear communication by presenting ideas in an orderly manner and by 

expressing yourself smoothly and precisely. By developing ideas clearly and logically and 

leading your reader smoothly from thought to thought, you make the task of reading your paper 

an agreeable one. 

Continuity 

Words, sentences, and paragraphs must be orderly. So that readers will understand what you are 

presenting, you must aim for continuity in words, concepts, and thematic development from the 

opening statement to the conclusion of the paper. Continuity can be achieved in several ways. 

For instance, punctuation marks contribute to continuity by showing relationships between ideas. 

They cue the reader to the pauses, inflections, and pacing normally heard in speech. Neither 

overuse nor underuse one type of punctuation, such as commas. 

Transitioning 

Another way to achieve continuity is through the use of transitional words. These words help 

maintain the flow of thought, especially when the material is complex. A pronoun (he, she) that 

refers to a noun (Anderson) in the preceding sentence not only serves as a transition but also 

avoids repetition. Be careful not to overuse. 

Other transition devices are time links (then, next, after, while, since), cause-effect links 

(therefore, consequently, as a result), addition links (in addition, moreover, furthermore, 

similarly), and contrast links (but, conversely, nevertheless, however, although, whereas). 

If upon reading your paper you find that your writing is abrupt, more transition from one topic to 

another may be needed. Possibly you have abandoned an argument or theme prematurely; if so 

you need to revisit the discussion. 

71

Word Choice 

Make certain that every word means exactly what you intend it to mean. Avoid colloquial 

expressions such as, practically all, very few, and quite a large part. Simple pronouns such as 

this, that, these, and those are troublesome and confuse the reader. Use the noun form instead. 

Grammar 

Incorrect grammar and careless construction of sentences distract the reader. Spell 

check, if you have one in your software, should be used to correct any spelling errors. The ATL 

can be very helpful if you are having trouble with grammar and sentence structure. Reading your 

paper aloud or having someone else read the paper with a critical eye can also be helpful in 

determining if you are saying what you want to say. 

Summary of the paper 

The summary belongs at the end of the paper. It provides a closure to the paper by summarizing 

major points and conclusions made by the writer. 

An excellent on-line help for writing is the site offered by the University of Wisconsin- 

Madison Writing Center @ http://www.wisc.edu/writing/ 

Taken from A Publication Manual of the American Psychological Association@ 4 th ed. 

72

APA Sample Paper 

Running Head: CARE (abbreviated from title to match header.) Care 1 

APA Sample Paper: How the Nurse Cares for the Patient 

Your Name 


Month Day, Year 

NOTE: 

ALL ITEMS BOLDED ARE DONE SO TO BRING ATTENTION TO THE 

CONTENT – NOT BECAUSE APA WARRANTS IT. DO NOT BOLD IN 

APA. 

73

Care 2 

How the Nurse Cares for the Patient (title of paper) 

The paper should be written using the American Psychological Association 

(APA) format as much as possible. Obviously, there will be occasions in which the 

format is violated, but those are rare exceptions. The paper should be type written using 

acceptable fonts. The American typewriter fonts of pica and elite are acceptable. This 

means that your fonts should be 10 to 12 characters per inch when using a computer. 

In addition, it is important that you have a printer that produces clear and dark 

printouts. Dot matrix printers are very difficult to read and should be avoided. One 

strong suggestion is that each student should become familiar with the computers on 

campus if there is no other personal access. 

This paragraph is written with the margins justified to the right. When the margins 

are justified both on the left and the right sides, the paragraph looks like it was set 

for a newspaper. DO NOT DO THIS FOR YOUR PAPERS. PLEASE, LEAVE 

THE RIGHT MARGIN RAGGED AND UNEVEN. 

Not all of your writing problems will be related to the APA format (American 

Psychological Association, 2001). **Note here that I can use the abbreviation for 

American Psychological Association or APA. This is because the first time I cited this 

reference at the beginning of this page I spelled it out in its entirety. 

Writing is a skill that requires time and effort. If you have difficulty writing, it may be 

necessary for you to seek tutorial help through your instructor, The Learning Place, and 

through other resources. Be very careful that you read the directions given to you for any 

writing assignment. If you are given a point grid prior to writing a paper, note which 

areas have the heavier point weight. In addition, if there is not a point grid, ask the 

instructor about how the points are to be distributed. 

74

Care 3 

When citing research studies, please realize that the study or the article did not 

do 

anything. The researchers or authors are the ones being cited. For example, the study 

did not demonstrate caring behaviors. Instead, the researchers ( Eggan & Kauchall, 

2001) reported that caring behaviors were demonstrated. When using a quote make sure 

the source is cited at the end of the quotation. Remember that a quote should only be 

used when a writer is unable to paraphrase information without losing the contextual 

meaning. “For a direct quotation in the text, give the author, year, and page 

number in parentheses”(APA, 2001, p. 117-118). Quotations of fewer than 40 words 

should be incorporated in the text. 

Longer quotations greater than 40 words should be indented and without 

quotation marks. Indent five to seven spaces from the left margin without the 

usual 

paragraph opening indent and single space (APA, 2001, p. 117-118). 

Students often have difficulty distinguishing when to insert a reference for paraphrasing. 

If you paraphrase an author, it means you’ve taken the author’s ideas/information and 

put it into your own words. Nevertheless, you’ve used a reference, and the idea is the 

author’s. Here is an example: older adults may be at risk for impaired or decreased 

nutrition. Factors thought to contribute to this phenomenon include decreased sense of 

smell, decreased visual acuity, decreased energy and mobility for food preparation, 

decreased income, and decreased socialization (Lemone & Burke, 2000). While these 

ideas are known to many nurses, the cluster emerged from the reference you used, 

probably not your own head. YOU NEED TO REFERENCE AT THIS POINT. 

Failure to credit sources is considered plagiarism. It will get you a black eye with the 

75

Care 4 

professional community, or with your teacher. It can lead to your expulsion from this, or 

any, academic program. If you are unsure, be safe and reference. 

A variety of material is available on the web. Writers using internet sources 

should observe the following two guidelines: Reference specific documents rather than 

home or menu pages and provide addresses that work (APA, 2001). The fifth edition of 

the American Psychological Association (2001) relates that at a minimum a reference of 

an internet source should include a document title or description, a date, and an address. 

If none of these are available this site is not considered a reliable reference and should 

not be used. Whenever possible, identify the author or authors of a document. If an 

author is unavailable use the organization as the author not the website. If uncertain of 

how to reference a no author internet site, refer to the reference page of this document. 

An example of a no author citation within a document (including internet) 

would look like (GVU,2000). The GVU stands for the organization, as the author is 

unknown. This resource is cited on this document’s reference page. 

An example of an author citation within a document (including internet) 

would look like (Jamison, 2000). This resource is cited on this document’s reference 

page. Remember that when you cite an author within a document you use the 

author’s last name only. If there is more than one refer to this document’s 

reference page. 

If you need further information on how to reference on-line journals or articles see 

http://www.westwords.com/guffey/apa_z.html or 

http://oscar.ctc.edu/library/research.html that also has a citation section that includes 

APA format as well as sources on developing a topic, finding, and evaluating resources. 

76

Care 5 

An additional writing resource site you may find useful is http://www.wisc.edu/writing/ . 

For questions beyond this handout students are referred to the Publication Manual of the 

American Psychological Association, 5 th edition. 

Margins should be set at one inch and there should be five spaces between the 

header and the page number. Numbers below ten should be written out while numbers 

above should be listed as 22, unless the number is at the beginning of a sentence, in 

which case it is then written out. Double space between sentences. Remember that 

there are NO one sentence paragraphs in APA. One or two words should not dangle 

at the end of a page. To stop this initiate “widow and orphan” protection. This is usually 

found in the format section under page set up. Also, make sure you alphabetize the 

reference page. 

There are many nuances to good writing. Remember from high school that a 

paper begins with an introductory paragraph and ends with a summary. Paragraphs 

or topic areas should also flow into one another through use of a transition sentence or 

paragraph. Use this guide for a quick APA reference. It has been created to demonstrate 

all of the particulars such as spacing, placement, and how to reference. 

Good luck in your writing endeavors! 

77

Care 6 

References 

American Psychological Association. (2001). Publication manual of the American 

Psychological Association (5 t ' ed.). Washington DC: American Psychological 

Association. (book, one author). 

Author. (2001). Article title. Journal Title, volume number (issue number), 117-123. 

Retrieved October 13, 2001, from htpp://jbr.org/articles/html. (regular journal 

article, in print, but retrieved from Internet) 

Author. (2000, March 7). Underwater basket weaving in the setting of nursing 

education. Nursing Ridiculousness, 3, Article 0001 a. Retrieved November 20, 

2000, from http://journals.apa.org/prevention/volume3/preOO3001a.html. 

(Internet-only journal article, not in print). 

Eggan, P.D., & Kauchall, D. (2001). Educational psychology: classroom 

connection. New York: Merrill. (two authors of one book). 

Fox, R.W., & Lears, T.J.J. (1999). Title of chapter. In A. Editor, B. Editor, and C. 

Editor (Eds.), The power of culture: critical essays in American history (pp. 

111-119. Chicago: University of. Chicago Press. (chapter from a book with 

editor or editors) 

GVus's WWW user survey. (n.d.). Retrieved August 8, 2000, from http://www. 

ec.gatech.edu/gvu/user surveys/survey-1997-10/ (stand-alone document, no 

author, no date, found on Web) 

Jamison, K.R. (2000). Manic-depressive illness and creativity. Scientific American, 

272 (6), 62-67. (Journal article, one author, volume number in italics, issue number 

follows in standard type, page numbers follow. 

Jamison, K.R., Burke, P.A., & Connell-Weiand, B. (2000). Manic-depressive 

illness and creativity. Scientific American, 272 (6), 62-67. (how a journal 

article should be cited with multiple authors. Don't alphabetize authors within 

the citation. Cite as given at head of article. Jamison will thus fall under the J's in 

your reference list). 

78

Care 7 

Sandler, I.N., Tein, J., Coatworth, D., Wolchik, S.A., Lengua, L., West, S.G., et.al. (2000). 

An experimental evaluation of theory-based mother and mother-child programs for 

children of divorce. Journal of Counseling and Clinical Psychology, 68, 843-856. 

(more than six authors in an article; a journal that is continuously paginated 

throughout the publishing year, thus an issue number can be omitted) 

Research and Training Center on Independent Living. (1993). Guidelines for reporting and 

writing about people with disabilities (4 th ed.) [Brochure]. Lawrence, KS: Author. 

(corporate brochure with no single author) 

Schaller, G.B. (2000). The last panda. Chicago: University of Chicago Press (one 

author of a book) 

The Times atlas of the world (9 th ed.). (1999). New York: Times Books. (book, no 

author or editor) 

U.S. Bureau of the Census. (1989). Statistical abstract of the United States (109 th ed.). 

Washington, DC: U.S. Government Printing Office. (government document) 

Citation of a work discussed in a secondary source: name the original work in text, 

and give a citation for the secondary source. It looks like this in text: Seidenberg and 

McClelland's study (as cited in Coltheart, Curtis, Atkins, & Haller, 1993) demonstrated 

that subjects who read aloud preoperatively taught reported less anxiety and pain 

postoperatively... 

Citation of the same work on your reference list only cites secondary authors: 

Coltheart, M., Curtis, B., Atkins, P., & Haller, M. (1993). Models of reading aloud: 

Dual-route and parallel-distributed-processing approaches. Psychological Review, 

100, 589-608. 

The criteria of many of your papers require correct APA citation. If the many examples 

given above do not help you determine how to cite your source, refer to the Publication 

Manual of the American Psychological Association, 5 th edition, and chapter four, Reference 

List. 

79


543-113 

Care Plan/Case Study Rubric 

Directions: Utilize the rubric and the nursing care plan schematic located in the module for the assigned case study to develop a plan of care for the client. The case study is due 

at the start of class on the assigned due date. 

Rating Scale: • 5 Discusses criterions in a thorough concise manner 

• 4.5 Discusses criterion but lacks some detail 

• 4 Discussion of criterion is incomplete or weak 

• 3 Discussion too brief 

• 0 Not discussed 

Program Outcomes Measured: 

Adhere to professional standards of practice within legal, ethical, and regulatory frameworks of the registered nurse. 

Assess health of individuals, families, and groups within the context of the community 

Make clinical decisions to assure safe and accurate nursing care 

Collaborate with others to respond to the needs of individuals, families, and groups across the health-illness continuum 

Criteria 

Pathophysiology 

Possible 

Points 

Score 

Comments 

1. In your own words describe how normal physiological function 

is affected by this pathology and link to the client’s 

signs/symptoms. 

5 

2. List and explain rationale for diagnostic studies that you would 

anticipate being ordered for this client. 

5 

Pharmacology 

1. Correlate all expected medications and treatments to treat client 

pathology. Include discussion of appropriate intravenous fluids. 

5 

Nutrition 

1. Identify and describe nutritional interventions related to the 

pathology for this client to promote/maintain health. 

5 

Nursing Plan of care 

1. Identify three priority nursing diagnoses for the client. Write 

each nursing diagnosis statement utilizing three part format. 

(Use one care plan template for each diagnosis) 

5 

81

2. List specific subjective and objective assessment data found in 

case study to support EACH individual diagnosis. 

15 

3. Develop expected client outcomes that are comprehensive, 

client specific, realistic and measurable. 

15 

4. Develop specific individualized & comprehensive 

interventions 

•Identify independent nursing actions as well as medical 

interventions 

• where applicable list interventions that promote self 

care. 

• include rationale for each nursing intervention. 

15 

5. Evaluate if each outcome was met or not met with supportive 

data. 

15 

Teaching Learning 

1. Identify two priority learning needs appropriate for this client 

to promote health and wellness. 

5 

2. Identify and describe appropriate local and national community 

resources that your client should be referred to upon discharge 

from an acute care setting 

Format, Mechanics & Clarity 

a. Type, double spaced, utilizing APA format 

b. Correct in-text citation, title / reference page 

c. Use minimum of 3 nursing references (2 must be 

articles from current North American Nursing Journals 

dated within the last 3 years). 

d. Use correct grammar, punctuation, spelling and 

sentence structure. 

e. Clear introduction, transitioning, conclusion and 

summary 

f. Submit your articles with paper. 

5 

5 

Total Points 100 

82

Care Plan 

Nursing Diagnosis Outcome Evaluation 

Assessment Interventions Rationale 

83

CLINICAL WORKSHEET: Nursing Care Plan 

2 

Nursing Diagnosis 

3 

Expected Outcomes 

6 

Evaluation 

• Three part nursing diagnostic 

statement that defines 

the problem, etiology, 

and defining characteristics (AEB). 

• Diagnostic label (client’s health 

condition or response to medical 

illness or therapy for which 

nursing may intervene) R/T etiology (causes 

most likely to be involved in development of 

problem) AEB (defining 

characteristics)clinical signs and symptoms 

which confirm the problem exists. 

• Directly related to the problem 

• Stated in terms of the client’s behavior – not 

the nurse 

• Stated positively rather than negatively 

• Be specific 

• Be individualized and personal 

• Be measurable 

• Have deadline 

• One evaluation for each outcome 

• Did the client meet each outcome? If not, 

what revisions are/were necessary? 

• Provide supporting evidence which indicates 

if each outcome was met or revised. 

1 

Assessment 

• Assessment data creates the foundation for the 

nursing diagnosis. 

• Assessment data must support the selection of 

the nursing diagnosis. 

4 

Nursing Interventions 

• Steps that r/t the ND and will lead to 

achievement of the outcome. 

• Detailed action plan of what the nurse will 

do: 

*How will it be done? 

*Who will do it? 

*How often will it be done? 

• Includes dependent and independent 

interventions. 

5 

Rationale 

• One scientific rationale for each intervention 

• Each rationale must be referenced. 

85




543-113 

Case Study - Care of the Patient with Esophageal Varices 

The following patient report was received by the nurse on the medical unit for a new admission for a complex 

health problem. 

. 

JP, due to his habitual drinking, has recently lost his job as a foreman at a local factory. He has sworn off alcohol and has 

not had a drop to drink in the last 2 months. Unfortunately, his cirrhotic liver has not recovered from 20 years of heavy 

drinking. During the past two days he has had a “bad” cough. This morning he coughed up bright red blood and come to 

the ED. His coughing and bleeding have subsided for now. An IV of D5 ½ NS with 20 mEq KCL at 100 ml/hour is started 

and baseline labs are drawn (Hct and Hbg Q 6 hours, basic chem. panel, now and in a.m.). He is sent to the floor for 

observation with the diagnosis of bleeding esophageal varices. 

Shortly after you admit J.P., you hear him coughing while passing his room. You enter and you observe a tissue on his bed 

side table with a bloody clot. His vital signs are: Temp 98.0, RR 20, HR 90, BP 116/70. The lab calls and reports his H & 

H is 8.0/26. You notify his physician and receive the following orders: Type and crossmatch, give 2 units PRBCs, 

Sandostatin (octreotide) IV drip at 25 ug/hour, repeat H &H after blood and Q 2 hours, gastroenterology consult now. 

The gastroenterologist orders the patient transferred to the ICU and performs and endoscopic exam for band ligation of 

esophageal varices. J.P. looks at you when you are transferring him to ICU and asks, “Am I going to die?” You ask if he 

has any family you should call, and he tells you that he is separated from his wife and he is estranged from his 2 grown 

children. 

86



Nursing Complex Alterations 

543-113 

Case Study - Care of the High Risk Obstetric Patient 

The following patient report was received by the nurse for the patient being admitted to high risk obstetrical unit 

for a complex obstetrical problem. 

A pregnant 19 year-old female patient presents to your OB unit with complains of headache, nausea and vomiting. She 

thinks she is at least six months pregnant, but reports she has had no prenatal care because of inability to pay. She 

complains of intermittent cramping, with low back pain but no vaginal leakage. She is a poor historian, but reports her 

obstetrical history as four pregnancies with two therapeutic abortions. Her 4 year old child is presently living with her 

mother in another state. The patient came in alone, and states she is staying with friends. 

She thinks she has the flu, and when questioned about anticubital bruising admitted to occasional cocaine and heroin use. 

She reports unusual fatigue, and can't get her rings off because of swelling. No known allergies, and denies any other 

illnesses or injuries. 

Initial physical assessment by the nurse documents a thin, pale, pregnant female complaining of mild discomfort. VS BP 

158/94, HR 88, temp 99.2 orally, Resp 24. Fetal heart Tones at 160, contraction monitor noting 30-60 second mild 

contractions every 5 minutes. Lungs clear, heart sounds WNL. Anticubital bruising bilaterally, + BS x 2 quads, + 3 

reflexes bilaterally with one beat of clonus. No vaginal drainage or bleeding noted on pad. Plus one pitting edema on feet, 

to the knees, bilaterally. 

Medical diagnosis include preterm labor, rule out pregnancy induced hypertension. Her initial admission orders include 

bedrest, Lactated ringers 1000cc at 100cc/hr, NPO with ice chips, no vaginal exams, continuous fetal and contraction 

monitoring. 

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Nursing Complex Alterations 

543-113 

Case Study - Care of the Patient with Neuro-Musculoskeletal Disorder 

J.T. is a 21 year male who is admitted to the Neuroscience ICU. J. T. is on Spring break and had been staying at a Hotel in 

Florida. While partying with other students, J.T. jumped off a balcony into the swimming pool (the balcony was 2 stories 

up). Admission Diagnosis: Acute Spinal Cord Injury and bilateral wrist fractures. Past Medical/Surgical History: 

Asthma 

Upon Admission, J.T. looks very frightened. J.T. is on a trauma bed with crutchfield tongs in place and 45# of traction 

applied. J.T. has an endotracheal tube in place and is on a ventilator. J.T. has bilateral dressings on his wrists which are 

heavily soiled with diarrhea stool; an NG tube in place that drains tea colored drainage with bloody flecks; a foley catheter 

that drains clear amber urine; an IV of Lactated Ringers per left juggular vein. 

Physical Exam: BP: 78/50, Pulse: 50; Respirations: on the ventilator with a respiratory rate set at 16, and a temp of 101. 

Pt is AAOX3; no movement or sensation from the neck down; lungs clear upper/mid fields, very decreased bibasilar; Heart 

sounds S1S2 crisp/clear, no murmurs, rubs; brady rate, regular rhythm; no peripheral edema; peripheral pulses +1/4, CRT 

3 seconds; skin cool/dry peripherally; warm/dry centrally; abdomen: flat, soft, non-tender with hypoactive bowel sounds 

all 4 quads. 

Admission Orders: NPO; IV of Lactated Ringers at 100 cc’s per hour; Dopamine drip titrated to keep SBP > 90; 

Atropine 0.5 mg IV q 3-5 minutes prn; Methylprednisolone 2700 mg IV over 15 minutes then in 45 minutes, followed by 

a drip of 486 mg/hr X 24 hours; Ranitidine 50 mg IV q 8 hours. Bedrest with Cervical traction to be maintained at 45 #. 

Ventilator: Assist/Control mode; tidal volume of 900; FiO2 at 40; Pulmonary to see and write orders; Ortho to see and 

write orders for wrist fractures. 

X-rays: C-Spine X-rays demonstrate a C3 crush fracture of the spine and bilateral radial/ulna compound fractures. MRI 

of the spine demonstrates a C2 complete spinal cord injury. 

Labs: WBCs: 9.5 X 10 3 ; RBC: 4.5 X 10 6 Hgb/Hct 14/42; Blood alcohol 0.8 

J.T. is single, attends college in New York where he is a senior. J.T. will be graduating with honors in one month and has 

already been accepted to medical school in the fall. J.T.’s family live in Wisconsin, his father is a doctor and his mother is 

an attorney. J.T. has a 16 year old sister. 

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543-113 

Case Study - Care of Patient with Multiple Organ Dysfunction/Shock 

The following patient report was received by the nurse in the intensive care unit for the patient being admitted for 

complex health problems. 

You are the trauma nurse working in a busy tertiary care facility. You receive a call from the paramedics that they are en 

route to your facility with the victim of multiple gunshot wounds to the chest and abdomen. The paramedics have started 

two large-bore IV lines with Lactated Ringers, Oxygen by mask at 15 L/min. The patient has chest wounds on the left and 

a wound in the upper right quadrant of the abdomen. Vital signs are as follows: Blood Pressure: 80/36, Pulse 140, 

Respirations: 42. The patient is diaphoretic, very pale, and confused. The paramedics have an estimated time of arrival as 

4 minutes. 

On arrival to the Emergency Room, your patient, B.W. is cyanotic and in severe respiratory distress. When he is 

transferred to the trauma stretcher, you notice that there is an occlusive dressing over the sucking chest wound. It is taped 

down on all sides. 

Upon initial exam of the patient the following tests are ordered. Complete Blood Count, (CBC) Type and Cross for 8 units 

of Whole Blood, and ready patient for the operating room. You are concerned that the patient has become unconscious, 

no obtainable vital signs and EKG is showing sinus bradycardia with a rate of 30. 

After surgery the patient is placed in the intensive care unit. The surgical report is as follows: Left lower lobe resection 

with chest tubes in place, spleenectomy and large liver laceration with resection? 

Twoo hours post surgery the patient is found with copious blood return in chest drainage, no urine output, vital signs are as 

follows: Bp 50/20, Pulse rate of 120, and shallow respirations. The patient’s skin is cool and pale. The cardiac monitor is 

showing dysrythmias. The patient is arousable to painful stimuli. 

89

Associate Degree Nursing Program - Workforce 3 One

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