Clinical Judgment Case Study Template for Prelicensure

Clinical Judgment Case Study Template for Prelicensure Programs Version 2.0 Phase I: Case Planning Case Study Topic: Diabetes Case Summary The school RN sees an 8-year-old male coming into the nursing office by his Phys Ed teaching with complaints of profuse sweating and confusion. The patient is currently afebrile. Objectives. (More or less are possible) Recognizing signs of hypoglycemia Differentiate between hypo- and hyperglycemia Initiates treatment plan for abnormal blood sugars Evaluating effectiveness of treatment plan Description of Client Age: 8 years Gender male Medical diagnosis or chief concern Abnormal blood sugars Care Setting (More than one are possible) Emergency Department Medical-Surgical Unit Pediatric Unit Maternity Unit Behavioral Health Unit Intensive care unit Post-anesthesia Care Unit Skilled-care Facility Home Outpatient Clinic Other setting: school Others present: History of chief concern/current condition/problem Symptom: sweating and confusion Onset: 30 minutes ago Treatments tried (if applicable): drank water and sat down Other history as indicated Allergies: NKA Weight/BMI (If applicable): 23 kg Medical diagnosis/surgeries/psychosocial: Type I DM diagnosed 1 year ago, no further past medical history, no surgical history Medications: Novolog Diagnostic tests: blood glucose POC, vital signs Assessments Important, abnormal, or relevant assessments Normal or irrelevant assessments Confusion Sweating Recent illness with “up and down” sugars PMHx DM Type I Afebrile Solutions Priority to address Desired outcome Confusion Sweating DM I history Alert and oriented x3 Normal blood sugars Actions/order indicated Actions/order not indicated/contraindicated Obtain blood sugar Obtain full set of vital signs Send back to gym class immediately Increase insulin dose Information Sources Phase Sheet Nurses’ Notes History and Physical Admission Notes Vital Signs Medications Orders Intake and Output Laboratory Report Flowsheet Progress Notes Diagnostic Report Other: What is most concerning finding? (10 points) What factors best explain client’s symptoms? Use specific pathophysiology. (15 points) What condition would most likely be expected? (10 points) What will happen if this condition is not treated? (10 points) What actions should the nurse take? (15 points) Which actions are contraindicated? (10 points) How should the nurse provide the glucose and why? (10 points) When should the RN re-check the blood glucose? (10 points) Under which circumstances would EMS be activated? (5 points) Who should the nurse notify? (5 points)

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