Nurse.org

How to Write a Nursing Care Plan

Nursing care plan components, nursing care plan fundamentals.

How to Write a Nursing Care Plan

Knowing how to write a nursing care plan is essential for nursing students and nurses. Why? Because it gives you guidance on what the patient’s main nursing problem is, why the problem exists, and how to make it better or work towards a positive end goal. In this article, we'll dig into each component to show you exactly how to write a nursing care plan. 

A nursing care plan has several key components including, 

  • Nursing diagnosis
  • Expected outcome
  • Nursing interventions and rationales

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections otherwise, it won’t make sense!

  • Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for their patients
  • Expected outcome - The measurable action for a patient to be achieved in a specific time frame. 
  • Nursing interventions and rationales - Actions to be taken to achieve expected outcomes and reasoning behind them.
  • Evaluation - Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

>> Related: What is the Nursing Process?

Get 10% OFF Nursing School Study Guides From nurseinthemaking.com ! Fill out the form to get your exclusive discount.

Before writing a nursing care plan, determine the most significant problems affecting the patient. Think about medical problems but also psychosocial problems. At times, a patient's psychosocial concerns might be more pressing or even holding up discharge instead of the actual medical issues. 

After making a list of problems affecting the patient and corresponding nursing diagnosis, determine which are the most important. Generally, this is done by considering the ABCs (Airway, Breathing, Circulation). However, these will not ALWAYS be the most significant or even relevant for your patient. 

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective nursing data . Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable.

This information can come from, 

Verbal statements from the patient and family

Vital signs

Blood pressure

Respirations

Temperature

Oxygen Saturation

Physical complaints

Body conditions

Head-to-toe assessment findings

Medical history

Height and weight

Intake and output

Patient feelings, concerns, perceptions

Laboratory data

Diagnostic testing

Echocardiogram

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and the objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA), defines a nursing diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step. 

Get 5 FREE study guides from Simplenursing.com - fill out the form for instant access! 1. Fluid & Electrolytes study guide 2. EKG Rhythms study guide 3. Congestive Heart Failure study guide 4. Lab Values study guide 5. Metabolic Acidosis & Alkalosis study guide

case study with nursing care plan

By clicking download, you agree to receive email newsletters and special offers from Nurse.org & Simplenursing.com. You may unsubscribe at any time by using the unsubscribe link, found at the bottom of every email.

Your request has been received. Thanks!

There are 4 types of nursing diagnoses.  

Problem-focused - Patient problem present during a nursing assessment is known as a problem-focused diagnosis

Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem developing

Health promotion - Improve the overall well-being of an individual, family, or community

Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions

After determining which type of the four diagnoses you will use, start building out the nursing diagnosis statement. 

The three main components of a nursing diagnosis are:

Problem and its definition - Patient’s current health problem and the nursing interventions needed to care for the patient.

Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed

Defining characteristics or risk factors - Signs and symptoms that allow for applying a specific diagnostic label/used in the place of defining characteristics for risk nursing diagnosis

PROBLEM-FOCUSED DIAGNOSIS

Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

RISK DIAGNOSIS

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART is an acronym that stands for,

It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. A medical diagnosis is made by a physician or advanced healthcare practitioner.  It’s important to remember that a medical diagnosis does not change if the condition is resolved, and it remains part of the patient’s health history forever. 

Examples of medical diagnosis include, 

Chronic Lung Disease (CLD)

Alzheimer’s Disease

Endocarditis

Plagiocephaly 

Congenital Torticollis 

Chronic Kidney Disease (CKD)

It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal. 

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization. 

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories: 

Physiological

Complex physiological

Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

Pain assessment

Position changes

Fall prevention

Providing cluster care

Infection control

Step 5: Evaluation 

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes, 

Based on the evaluation, it can determine if the goals and interventions need to be altered. Ideally, by the time of discharge, all nursing care plans, including goals should be met. Unfortunately, this is not always the case - especially if a patient is being discharged to hospice, home care, or a long-term care facility. Initially, you will find that most care plans will have ongoing goals that might be met within a few days or may take weeks. It depends on the status of the patient as well as the desired goals. 

Consider picking goals that are achievable and can be met by the patient. This will help the patient feel like they are making progress but also provide relief to the nurse because they can track the patient’s overall progress. 

Show Me RN-to-BSN Programs

Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan. The nursing plan is constantly updated with changes and new subjective and objective data. 

Key aspects of the care plan include,

Outcome and Planning

Implementation

Through subjective and objective data, constantly assessing your patient’s physical and mental well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a helpful and powerful tool.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Kathleen Gaines

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

Registered Nurse RN

Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. Join the nursing revolution.

Next Generation NCLEX Study Tips for Case Studies

In April of 2023, the NCSBN released the new version of the NCLEX exam, which is called the Next Generation NCLEX (or NGN, for short). One of the big changes with the Next Generation NCLEX was the introduction of case studies .

These new changes have caused some students and new graduates to become nervous, and some are wondering how they should be preparing for this new format.

Study Tips for Next Generation NCLEX Case Studies

What should your study plan be for the Next Generation NCLEX case studies?

First, let’s think about what’s different about a case study. A case study is going to give you a scenario of how a patient may present with a particular disease(s), and it’s going to walk you through a scenario of what may happen as the patient progresses.

These case studies are going to test your nursing knowledge on how to identify important symptoms, lab reports, what to watch for, how to deliver care, and provide patient education.

In other words, case studies are very similar to how things really work in the real world of nursing!

So the big question is how do you prepare for these case studies on the NGN?

Familiarize Yourself with NGN Case Studies

First, you’ll want to familiarize yourself with this new case study format so that you’ll understand how they work.

I developed a mock Next Generation NCLEX case study , and in that case study, I walk you through the sample questions step-by-step. I highly recommend you watch that video because it’s going to show you how to think critically as you answer these new NGN questions.

next generation nclex, ngn case study, next generation nclex case study, next generation nclex questions and answers, ngn practice

The Secret to Case Studies

As you prepare for case studies, you have to understand that merely memorizing a few facts about a disease will not work well to prepare you for these questions. Instead, you truly have to understand the material in a deeper way so that you are able to connect the dots and answer the different scenarios that might pop up.

To do this, I like to compare a disease to an onion. And just as onions have many different layers, there are many layers of what’s going on with a disease process, too. As you begin pulling back the layers of a disease, you can get to the core of what’s happening to your patient and see the domino effect that occurs.

But you have to go through those layers to get to that core. But if you skip those layers, you’re going to be missing things, and it is going to make these case studies much more difficult.

And the “layers” I’m referring to can be things like the pathophysiology, signs and symptoms, labs and diagnostics, treatment, medications, and your role as the nurse.

And you’ll want to be familiar with all of those different layers, because that will allow you to easily connect the dots and breeze through these case study questions.

Study Example for Case Study of Heart Failure

To illustrate my point, consider a case study over a h eart failure patient . The first “layer” you’d want to peel back as you study is the PATHO!

Layer 1: Understand the Pathophysiology

I cannot emphasize enough that taking time to really dig into the pathophysiology of a disease will really help you understand what’s happening and why, which will be crucial in helping you understand how the different body systems are affected.

As you study, you want to ask yourself, “What’s occurring in the body? Which systems are affected? What causes this, and why?”

This step will take a lot of energy and time on your part, but in my opinion, it’s one of the best uses of your study time. Once you truly grasp this part, it will have a “domino effect” of helping you connect the dots.

Layer 2: Allow the Signs and Symptoms to Flow from the Patho

When you truly understand the patho of a disease, the signs and symptoms will easily fall into place. In many cases, you won’t even need to spend time memorizing a list of signs and symptoms for a disease! Understanding the patho will help you easily piece that together in your mind.

For example, in heart failure, you know we have a fluid volume overload . If the heart failure is on the right side, it’s going to cause a backup of fluid that can lead to things like JVD (jugular venous distention), ascites, edema, and enlarged liver.

If the heart failure is on the left side, it’s going to be affecting the lungs, leading to things like shortness of breath, crackles , orthopnea, difficulty breathing at night, and even pulmonary edema.

Layer 3: Determine Relevant Labs and Diagnostics

Next, I’d recommend focusing on the relevant labs and diagnostic reports. Even though we don’t order these as the nurse, they are very important to us because we need to know what we need to monitor for and what should be expected for that patient.

And the abnormal signs and symptoms you just learned about will go along with those labs and diagnostic reports. It’s all going to click and make sense.

Layer 4: The Patient’s Plan of Care

Those layers will then feed right into the patient’s plan of care. As you study, be asking yourself, “What do I expect the doctor to order? What are the common medications and procedures?”

One you peel back this layer, it will make your job as the nurse very easy to understand because what we do a nurses goes right along with the treatments ordered.

Layer 5: Focus on What We Do (and Don’t Do) for the Patient

In this final layer, you’ll want to be thinking about what you would and wouldn’t do for the patient. For example, think of questions such as, “What’s going to help this patient get better? What should I monitor? What should I report? What important patient education should I provide?”

With medications, for what side effects are you going to be monitoring? If a patient with heart failure is on loop diuretics , what side effects could occur? You’re going to look at urinary output, electrolytes (particularly the potassium level).

You’ll also want to consider information you’ll provide to the patient throughout their stay, along with discharge education points and care.

Conclusion of Study Tips for NGN Case Studies

In summary, the best way to prepare for the case studies on the Next Generation NCLEX is to actually understand the disease holistically, which means digging into the pathophysiology first, and then allowing that to flow to the signs and symptoms, medications, patient education, and so forth.

By taking the time to absorb the material, and digging deep in to the disease process, it’s going to pay off big when it comes time to answer these questions that evolve and require a deeper level of critical thinking.

That’s why I always try to take the time to cover these important concepts in my NCLEX review lectures on YouTube . I really try to help students connect the dots and understand these diseases in a way that will click and make it easier to remember, both on exams and in the real world of nursing.

Nurse Sarah’s Notes and Merch

fluid electrolytes nursing nclex, notes, mnemonics, quizzes, nurse sarah, registerednursern

Just released is “ Fluid and Electrolytes Notes, Mnemonics, and Quizzes by Nurse Sarah “. These notes contain 84 pages of Nurse Sarah’s illustrated, fun notes with mnemonics, worksheets, and 130 test questions with rationales.

You can get an eBook version here or a physical copy of the book here.

Please Share:

  • Click to print (Opens in new window)
  • Click to share on Facebook (Opens in new window)
  • Click to share on Twitter (Opens in new window)
  • Click to share on Pinterest (Opens in new window)
  • Click to share on Reddit (Opens in new window)
  • Click to share on LinkedIn (Opens in new window)
  • Click to share on WhatsApp (Opens in new window)
  • Click to share on Pocket (Opens in new window)
  • Click to share on Telegram (Opens in new window)

Disclosure and Privacy Policy

Important links, follow us on social media.

  • Facebook Nursing
  • Instagram Nursing
  • TikTok Nurse
  • Twitter Nursing
  • YouTube Nursing

Copyright Notice

8 Myocardial Infarction (Heart Attack) Nursing Care Plans

case study with nursing care plan

Nurses play a critical role in assessing, monitoring, and caring for patients who are experiencing a heart attack. This comprehensive care plan guide focuses on the essential nursing assessment , interventions, nursing care plans and nursing diagnoses for effectively managing patients with myocardial infarction .

Table of Contents

What is myocardial infarction, nursing problem priorities, nursing assessment, nursing diagnosis, nursing goals, 1. initiating pain relief and ischemia & improving respiratory function, 2. monitor laboratory and diagnostic tests, 3. administering medication and pharmacologic support, 4. improving cardiac output & monitoring potential complications, 5. improving tissue perfusion & initiating cardiac rehabilitation, 6. reducing anxiety and fear, 7. improving tolerance to activity, 8. initiating health education & teaching, recommended resources, references and sources.

Myocardial infarction (MI) or acute myocardial infarction (AMI) commonly known as heart attack , is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance in oxygen supply and demand, which is most often caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium (Zafari, 2015).

Myocardial infarction is a part of a broader category of a disease known as acute coronary syndrome (ACS) , resulting from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. The ACS continuum representing ongoing myocardial ischemia or injury consists of unstable angina , non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).

Cardiovascular diseases, the leading cause of death in the United States and Western Europe usually result from cardiac damage or complications of MI. Mortality is high when treatment is delayed and almost one-half of sudden deaths due to an MI occur before hospitalization, within one hour of the onset of symptoms. The prognosis improves if vigorous treatment begins immediately.

MI may be classified into various types based on pathological, clinical, and prognostic differences, along with different treatment strategies. MI caused by atherothrombotic coronary artery disease and usually precipitated by atherosclerotic plaque disruption is designated as a type 1 MI . The pathophysiological mechanism leading to ischemic myocardial injury in the context of a mismatch between oxygen supply and demand has been classified as type 2 MI . Type 3 MI is suspected when an acute myocardial ischemic event is high, even when cardiac biomarker evidence of MI is lacking. This includes clients who manifest a typical presentation of MI and die before it is possible to obtain blood for cardiac biomarker determination. (Thygesen et al., 2018)

Nursing Care Plans and Management

The primary goals of managing acute myocardial infarction (MI) are to limit myocardial damage, preserve cardiac function, and prevent complications. This is achieved by interventions that restore blood flow in the coronary arteries. To minimize damage, strategies focus on reducing oxygen demand and increasing oxygen supply through medications, oxygen therapy, and rest. Relief of pain and improvement in ECG findings indicate a balanced oxygen demand and supply, as well as potential reperfusion. Confirmation of blood flow through an open vessel in the catheterization laboratory provides evidence of successful reperfusion.

The following are the nursing priorities for patients with myocardial infarction:

  • Managing pain and ischemia.
  • Monitoring for potential complications.
  • Promoting adequate tissue perfusion .
  • Reducing anxiety .

Patients with MI commonly present with acute and continuous chest pain , often accompanied by symptoms like shortness of breath, indigestion, nausea , and anxiety. They may exhibit cool, pale, and moist skin, along with an increased heart and respiratory rate. These signs and symptoms, caused by sympathetic nervous system activation, can be brief or persistent. Distinguishing between MI and unstable angina based on symptoms alone can be challenging, leading to the broader term acute coronary syndrome.

Assess for the following subjective and objective data:

  • Reports of chest pain with/without radiation
  • Facial grimacing
  • Restlessness, changes in the level of consciousness
  • Changes in pulse, BP
  • Alterations in heart rate and BP with activity
  • Development of dysrhythmias
  • Changes in skin color/moisture
  • Exertional angina
  • Generalized weakness

Assess for factors related to the cause of myocardial infarction:

  • Tissue ischemia (coronary artery occlusion)
  • An imbalance between myocardial oxygen supply and demand
  • Presence of ischemic/necrotic myocardial tissues
  • Cardiac depressant effects of certain drugs (beta-blockers, antiarrhythmics )

Following a thorough assessment, it is essential to formulate a nursing diagnosis that specifically addresses the problems associated with myocardial infarction (heart attack). This diagnosis reflects your clinical judgment regarding the patient’s health conditions and needs.

The main goals for patients with acute coronary syndrome (ACS) include pain relief, prevention of myocardial damage, respiratory function maintenance, adequate tissue perfusion, anxiety reduction, adherence to self-care , and early recognition of complications. Goals and expected outcomes may include:

  • The client will verbalize relief/control of chest pain within the appropriate time frame for administered medications, display reduced tension, a relaxed manner, and ease of movement, and demonstrate the use of relaxation techniques.
  • The client will recognize and verbalize feelings, identify causes and contributing factors, verbalize the reduction of anxiety, demonstrate positive problem-solving skills, and identify and use resources appropriately.
  • The client will maintain stable hemodynamics (e.g., normal blood pressure, cardiac output) and report reduced dyspnea and angina, while demonstrating improved activity tolerance.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with myocardial infarction may include:

The classic symptom a client experience during a cardiac event is pain. It is important for the nurse to differentiate the pain of an MI or angina attack from a multitude of other pain syndromes that can mimic a coronary event. Non-cardiac chest pain may be caused by other cardiovascular issues including pericarditis, aortic aneurysm , or dissection. 

Monitor and document characteristics of pain, noting verbal reports, and nonverbal cues (moaning, crying, grimacing, restlessness, diaphoresis, and clutching of the chest). Variations in the appearance and behavior of clients in pain may present a challenge in assessment. Most clients with an acute MI appear ill, distracted, and focused on pain. Verbal history and deeper investigation of precipitating factors should be postponed until the pain is relieved. Respirations may be increased as a result of pain and associated anxiety; the release of stress-induced catecholamines increases heart rate and BP. The client may present with abdominal discomfort or jaw pain as their anginal equivalent. Women tend to present more commonly with atypical symptoms than men (Zafari, 2015).

Obtain a full description of pain from the client including location, intensity (using a scale of 0–10), duration, characteristics (dull, crushing, described as “like an elephant in my chest”), and radiation. Assist the client to quantify pain by comparing it to other experiences. Pain is a subjective experience and must be described by the client. This also provides a baseline for comparison to aid in determining the effectiveness of therapy, resolution, and progression of the problem. Clients commonly describe the discomfort as crushing, oppressive, or constricting or as a pressure that may radiate to the left arm, neck, jaw, infrascapular area, or epigastric region. Transient symptoms that last less than 15 minutes and disappear at rest are classified as angina. The discomfort associated with MI typically lasts more than 30 minutes, is not relieved by rest or nitroglycerin, and may or may not be severe.

Review the history of previous angina, anginal equivalent, or MI pain. Discuss family history if pertinent. A delay in reporting pain hinders pain relief and may require an increased dosage of medication to achieve relief. In addition, severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnostics and relief of pain. A positive family history includes any first-degree male relative aged 45 years or younger or any first-degree female relative aged 55 years or younger who experienced MI (Zafari, 2015).

Check vital signs before and after narcotic medication. Morphine sulfate is the analgesic of choice for anginal pain relief in STEMI and for unstable angina and NSTEMI barring contraindications (Zafari, 2015). Hypotension and respiratory depression can occur as a result of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency.

Monitor the client’s vital signs closely. Hypertension may precipitate myocardial infarction, or it may reflect elevated catecholamine levels due to anxiety, pain, or exogenous sympathomimetics. Hypotension may indicate ventricular dysfunction due to ischemia. Impaired left ventricular diastolic function leads to pulmonary vascular congestion with shortness of breath and tachypnea and, eventually, pulmonary edema with orthopnea. Shortness of breath may be the client’s anginal equivalent or a symptom of heart failure (Zafari, 2015).

Monitor respirations and note the work of breathing. Cardiac pump failure and/or ischemic pain may precipitate respiratory distress; however, sudden or continued dyspnea may indicate thromboembolic pulmonary complications. Impaired left ventricular diastolic function leads to pulmonary vascular congestion with shortness of breath and tachypnea and, eventually, pulmonary edema with orthopnea (Zafari, 2015). Regular and careful assessment of respiratory functions detects early signs of pulmonary complications.

Administer supplemental oxygen by means of a nasal cannula or face mask, as indicated. Oxygen is administered via nasal prongs at a flow rate of 2 to 5 L/minute to improve myocardial and tissue oxygenation. It can alleviate discomfort associated with tissue ischemia by increasing the available oxygen for myocardial uptake. However, the use of oxygen therapy should be limited to hypoxic patients, as it may increase coronary vascular resistance and potentially lead to higher mortality rates in non-hypoxic patients (Shah et al., 2019). Alongside medication therapy, oxygen supplementation is recommended to relieve symptoms and reduce pain related to inadequate myocardial oxygen. The administration route, typically using nasal cannula, and flow rate should be documented, with a range of 2 to 4 L/min often sufficient to maintain oxygen saturation levels above 95%, unless there is underlying chronic pulmonary disease. It’s important to note that supplemental oxygen may have adverse effects on non-hypoxic patients with ST-elevation myocardial infarction (STEMI), increasing the risk of myocardial injury, recurrent myocardial infarction, and major cardiac arrhythmias (Zafari, 2015).

Instruct the client to report pain immediately. Atypical presentations are common and frequently lead to misdiagnosis. Moreover, any client may present with atypical symptoms, which are considered the anginal equivalent for that client. Atypical chest pain is common, especially in older clients and clients diagnosed with diabetes . Morbidity and mortality from MI are significantly reduced if clients and bystanders recognize symptoms early, activate the emergency medical service system, and thereby shorten the time to definitive treatment (Zafari, 2015).

Provide a quiet environment, and calm activities, and place the client in a position of comfort. Approach the client calmly and confidently. This decreases external stimuli, which may aggravate anxiety and cardiac strain, limiting coping abilities and adjustment to the current situation. Physical rest in bed with the backrest elevated or in a cardiac chair helps to decrease chest discomfort and dyspnea.

Instruct the client to do relaxation techniques such as deep and slow breathing, distraction behaviors, visualization, and guided imagery. Assist as needed. This is helpful in decreasing perception and response to pain, provides a sense of having some control over the situation, and increases a positive attitude. Alternative therapies such as pet therapy can also help certain clients relax and reduce anxiety, therefore reducing chest pain.

Administer medications for pain relief as indicated.  See pharmacological interventions

Cardiac enzymes and biomarkers, including troponin, creatine kinase (CK), and myoglobin, are essential diagnostic tools for identifying acute myocardial infarction (MI). These tests detect the release of cellular components into the bloodstream when heart muscle cells are damaged. Analyzing the time courses of these biomarkers allows for a prompt and accurate diagnosis.

Monitor laboratory data such as cardiac enzymes, ABGs , and electrolytes . Enzymes monitor the resolution or extension of infarction. Remeasuring cardiac enzyme levels at regular intervals for the first 24 hours is a reasonable approach to improving the sensitivity of detection of myocardial necrosis, and the degree of positivity can be important for prognostication. The presence of hypoxemia indicates the need for supplemental oxygen. Hypoxemia may result from pulmonary congestion, atelectasis , or ventilatory impairment secondary to complications of MI or excessive sedation or analgesia (Zafari, 2015). Electrolyte imbalances such as hypokalemia or hyperkalemia adversely affect cardiac rhythm and contractility.

Troponin Troponin, a protein that regulates myocardial contraction, is a critical biomarker for detecting myocardial injury. Troponin I and troponin T, which are specific to cardiac muscle, are reliable indicators of myocardial damage. The level of troponin in the blood increases within a few hours of an acute myocardial infarction (MI) and remains elevated for up to 2 weeks. However, it’s important to note that troponin levels can also rise in conditions such as inflammation, sepsis , heart failure, and respiratory failure.

Creatine Kinase CK (creatine kinase) has three isoenzymes: CK-MM (skeletal muscle), CK-MB (heart muscle), and CK-BB (brain tissue). CK-MB is specific to the heart and rises when there is cardiac damage. Increased levels of CK-MB indicate an acute myocardial infarction (MI), with levels starting to rise within hours and peaking within 24 hours of the infarct.

Myoglobin Myoglobin, present in cardiac and skeletal muscle, plays a role in oxygen transport. Its levels begin to rise within 1 to 3 hours and peak within 12 hours after symptom onset. While an increase in myoglobin is not highly specific to indicate an acute cardiac event, negative results can help rule out an acute myocardial infarction (MI).

The patient with suspected MI should promptly receive supplemental oxygen, aspirin , nitroglycerin, and morphine to alleviate pain and anxiety. Careful monitoring for adverse effects, such as hypotension or respiratory depression, is essential during morphine administration. Beta-blockers may be utilized to manage dysrhythmias, and unfractionated heparin or LMWH can be prescribed, along with platelet-inhibiting agents, to prevent additional clot formation.

Antianginals such as nitroglycerin, isosorbide dinitrate, and mononitrate Nitrates are useful for pain control by coronary vasodilating effects, which increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial workload and oxygen demand. Systolic BP <90 mm Hg, HR <60 or >100, and right ventricular infarction are contraindications to nitrate use (Zafari, 2015).

Beta-blockers such as atenolol, pindolol, propranolol, nadolol , and metoprolol Beta-blockers are important second-line agents for pain control through the effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand. These may be given alone or with nitrates. Metoprolol is the standard of care and is a selective beta1-adrenergic receptor blocker that decreases the automaticity of contractions. Specific contraindications to the usage of this therapy include signs of heart failure, low output state, increased risk for cardiogenic shock , pulse rate interval greater than 0.24 seconds, and active asthma (Zafari, 2015).

Analgesics such as morphine and meperidine Although intravenous (IV) morphine is the usual drug of choice, other injectable narcotics may be used in acute-phase and/or recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation, and decrease myocardial workload. IM injections should be avoided, if possible because they can alter the CPK diagnostic indicator and are not well absorbed in under-perfused tissue.

Antiplatelet agents: aspirin , abciximab (ReoPro), clopidogrel (Plavix). These agents reduce mortality in MI clients and are taken daily. Aspirin also reduces coronary occlusion after percutaneous transluminal coronary angioplasty (PTCA). ReoPro is an IV drug used as an adjunct to PTCA for the prevention of acute ischemic complications. Antiplatelet agents have a strong mortality benefit. There is an increased risk of bleeding in cases of emergency coronary artery bypass graft (CABG) (Zafari, 2015).

Anticoagulants : heparin or enoxaparin (Lovenox). Low-dose heparin is given during PTCA and may be given prophylactically in high-risk clients (e.g., atrial fibrillation, obesity, a ventricular aneurysm, or history of thrombophlebitis ) to reduce the risk of thrombophlebitis or mural thrombus formation. LMWH is commonly used because of convenient dosing, reliable therapeutic levels, and decreased incidence of HIT, especially if anticipated use is greater than 2 to 3 days (Zafari, 2015).

Thrombolytic therapy such as streptokinase, urokinase, and reteplase. Thrombolytic therapy has been shown to improve survival rates in ST-segment elevation MI but is not indicated in the treatment for non-ST-segment elevation MI. Door-to-door drug time should be no more than 30 minutes. The main objective of thrombolysis is to restore circulation through a previously occluded vessel by the rapid and complete removal of a pathologic intraluminal thrombus or embolus that has not been dissolved by the endogenous fibrinolytic system.

Administer antidysrhythmic drugs as indicated. Dysrhythmias are usually treated symptomatically, except for PVCs, which are often treated prophylactically. Early inclusion of ACE inhibitor therapy (especially in presence of large anterior MI, ventricular aneurysm, or HF) enhances ventricular output, increases survival, and may slow the progression of HF. Administer ACE inhibitors as soon as possible as long as the client has no contraindications and remains in stable condition. ACE inhibitors have the greatest benefit in clients with ventricular dysfunction (Zafari, 2015).

Administer beta-blockers as indicated. In the setting of myocardial ischemia, beta-blockers have antiarrhythmic properties and reduce myocardial oxygen demand secondary to elevations in heart rate and inotropy. Beta-blockers also reduce the inotropic state of the left ventricle, decrease diastolic dysfunction, and increase LV compliance (Zafari, 2015).

Administer diuretics :  furosemide (Lasix), spironolactone with hydrochlorothiazide (Aldactazide), hydralazine (Apresoline). Diuretics may be necessary to correct fluid overload. Drug choice is usually dependent on the acute or chronic nature of symptoms. Diuretics are used to decrease plasma volume and peripheral edema. The reduction in extracellular fluid and plasma volume associated with diuresis may initially decrease cardiac output, and, consequently, blood pressure. With continuing diuretic therapy, the plasma volume and peripheral vascular resistance usually return to pretreatment values (Ren, 2019).

Administer vasodilators such as dopamine and fenoldopam. Given in small doses, dopamine causes selective dilation of the renal vasculature, therefore enhancing renal perfusion. Fenoldopam maintains or increases renal perfusion while it lowers BP, however, this may be particularly beneficial only to clients with renal insufficiency who present in hypertensive crisis.

Administer anti-anxiety and hypnotics as indicated:  alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), and flurazepam (Dalmane). This promotes relaxation and rest and reduces feelings of anxiety, which may act as barriers to health restoration. However, in a study, only 15 subjects (15%) had documented that the efficacy of this therapy had been evaluated, although evaluation of the efficacy of an administered drug is standard nursing care. The effectiveness of anxiolytic therapy must always be evaluated because pain medication such as morphine may create serious consequences when taken with anxiolytics at the same time (Frazier et al., 2002).

Myocardial infarction occurs when there is a loss of blood supply to part of the heart muscle, causing damage or death to the heart cells. This damage reduces the heart’s ability to pump effectively, leading to decreased cardiac output . The decrease in cardiac output can also cause further complications such as heart failure, arrhythmia , and even shock. MI at the left coronary artery system is most likely to produce extensive injury because it covers more territory than the right system; with impairment of function, pulmonary congestion, and low output (Zafari, 2015).

Auscultate BP. Compare both arms and obtain lying, sitting, and standing pressures when able. Hypotension may occur related to ventricular dysfunction, hypoperfusion of the myocardium, and vagal stimulation. However, hypertension is also a common phenomenon , possibly related to pain, anxiety, catecholamine release, and/or preexisting vascular problems. Orthostatic (postural) hypotension may be associated with complications of infarction ( heart failure ) (Zafari, 2015)

Evaluate the quality of pulses on both pulse points. Decreased cardiac output results in diminished weak or thready pulses. Irregularities suggest dysrhythmias, which may require further evaluation and monitoring. A decrease in the cardiac output causes a reduction in the strength and amplitude of peripheral pulses, such as the radial pulse in the wrist or the femoral pulse in the groin. It can also result in decreased pulse rate and variability, reflecting a slowing or instability in the heart rate.

Auscultate heart sounds. Note the development of S3, S4, and the presence of murmurs or friction rubs. S3 is usually associated with HF, but it may also be noted with mitral insufficiency (regurgitation) and left ventricular overload that can accompany severe infarction. S4 may be associated with myocardial ischemia, ventricular stiffening, and pulmonary or systemic hypertension. The presence of murmurs or friction rubs Indicates disturbances of normal blood flow within the heart: incompetent valve, septal defect, or vibration of papillary muscle and/or chordae tendineae (a complication of MI). The presence of rub with infarction is also associated with inflammation, pericardial effusion, and pericarditis.

Auscultate breath sounds. Crackles reflecting pulmonary congestion may develop because of depressed myocardial function. Rales or wheezes may be auscultated; these occur secondary to pulmonary venous hypertension, which is associated with extensive acute ventricular myocardial infarction. Unilateral or bilateral pleural effusions may produce egophony at the lung bases (Zafari, 2015).

Monitor heart rate and rhythm. Document dysrhythmias via telemetry. Heart rate and rhythm respond to medication, activity, and developing complications. Dysrhythmias (especially premature ventricular contractions or progressive heart blocks) can compromise cardiac function or increase ischemic damage. Acute or chronic atrial flutter may be seen with coronary artery or valvular involvement and may or may not be pathological.

Note the response to the activity and promote rest appropriately. Overexertion increases oxygen consumption and demand and can compromise myocardial function. The heart muscle is damaged in MI, therefore it needs time to heal. Additionally, stress from overexertion can also have a negative impact on the heart. Resting helps improve blood flow to the heart muscles and promotes the healing process. 

Monitor vital signs. Although not all dysrhythmias are life-threatening, immediate treatment may be required to terminate dysrhythmia in the presence of alterations in cardiac output and tissue perfusion. The client’s heart rate is often increased secondary to sympathoadrenal discharge. With right ventricular myocardial infarction or severe left ventricular dysfunction, hypotension is seen. The respiratory rate may be increased in response to pulmonary congestion (Zafari, 2015).

Review serial ECGs. ECG provides information regarding the progression or resolution of infarction, the status of ventricular function, electrolyte balance, and the effects of drug therapies. The ECG is the most important tool in the initial evaluation and triage of clients for whom an ACS is suspected. It is confirmatory of the diagnosis in approximately 80% of cases. Obtain daily serial ECGs for the first 2 to 3 days and additionally as needed (Zafari, 2015).

Review chest x-ray and echocardiography . This may reflect pulmonary edema related to ventricular dysfunction. On chest radiographs, pleural effusion is evidenced by blunted costophrenic angles; on echocardiography, they are evidenced by echo lucent zones adjacent to the heart (Zafari, 2015).

Measure cardiac output and other functional parameters as appropriate. Cardiac index, preload, afterload, contractility, and cardiac work can be measured noninvasively with the thoracic electrical bioimpedance (TEB) technique. An important parameter obtained by the TEB technique is thoracic fluid conductivity (TFC), which represents the whole fluid component in the thorax and is related to the blood circulation state and myocardial contractility (Meng et al., 2021). This is useful in evaluating responses to therapeutic interventions and identifying the need for more aggressive and emergency care.

Provide small and easily digested meals. Limit caffeine intake and caffeine-containing products. Large meals may increase myocardial workload and cause vagal stimulation, resulting in bradycardia or ectopic beats. Caffeine is a direct cardiac stimulant that can increase heart rate. Note: New guidelines suggest no need to restrict caffeine in regular coffee drinkers. However, studies have reported a rapid increase in the risk of stroke and MI right after coffee ingestion was observed. The main components of caffeine can increase the risk of hypertension, serum concentrations of cholesterol and homocysteine, and the incidence of type 2 diabetes mellitus . Therefore, caution still should be applied with regard to the amount of coffee consumed daily (Mo et al., 2018).

Provide a calm and quiet environment. Review reasons for the limitation of activities during the acute phase. This reduces stimulation and release of stress-related catecholamines, which can cause or aggravate dysrhythmia, and vasoconstriction, increasing myocardial workload. Limiting the client to bed or chair rest during the initial phase of treatment is particularly helpful in reducing myocardial oxygen consumption. This limitation should remain until the client is pain-free and hemodynamically stable.

Encourage the use of stress management behaviors such as relaxation techniques, guided imagery, and slow, deep breathing. This promotes client participation in exerting some sense of control in a stressful situation. Gentle physical activity, such as walking or yoga, can help reduce stress and improve cardiovascular circulation. Techniques such as deep breathing, progressive muscle relaxation, and meditation, can help calm the mind and reduce stress levels.

Have emergency equipment and/or medications available. Sudden coronary occlusion, lethal dysrhythmias, an extension of infarct, and unrelenting pain are situations that may precipitate cardiac arrest, requiring immediate life-saving therapies and/or transfer to CCU. All clients with suspected MI should be given chewable aspirin unless they have a documented allergy to aspirin. When severe pain is present, the client may be given IV morphine. Should toxicity occur, naloxone should be given to reverse it (Zafari, 2015).

Maintain IV or Hep-Lock access as indicated. A patent intravenous line is important for the administration of emergency drugs in presence of persistent lethal dysrhythmias or chest pain. Refractory or severe pain should be treated symptomatically with IV morphine, meperidine, or pentazocine. Relative hypotension may be treated by giving fluids. Atropine , in doses similar to those given in the prehospital phase, may increase blood pressure (Zafari, 2015).

Assist with insertion and maintenance of pacemaker , when used. Pacing may be a temporary support measure during the acute phase or may be needed permanently if infarction severely damages the conduction system, impairing systolic function. Evaluation is based on echocardiography or radionuclide ventriculography. However, implantable cardioverter defibrillators (ICD) may be unnecessary in select post-MI clients with severe LV dysfunction and negative electrophysiology study (EPS). Clients with severe LV dysfunction and negative EPS show no inducible ventricular tachycardia and have low long-term rates of arrhythmia or death without receiving an ICD (Zafari, 2015).

Decreased systolic ventricular performance may lead to impaired perfusion of vital organs and reflex-mediated compensatory responses, such as restlessness, impaired mentation, pallor, peripheral vasoconstriction and sweating , tachycardia, and prerenal failure. In clients with extensive myocardial injury, coronary blood flow diminishes as cardiac output declines and heart rate accelerates. Because coronary artery disease is usually generalized or diffuse, ischemia occurs at a distance from the infarcted segment and may result in a vicious cycle in which stuttering and expanding myocardial infarction ultimately leads to profound LV failure, hypotension, and cardiogenic shock (Zafari, 2015).

Investigate sudden or continued alterations in mentation (changes in LOC, mentation, stupor). Cerebral perfusion is directly related to cardiac output and is influenced by electrolyte and/or acid-base variations, hypoxia, and systemic emboli. Ineffective peripheral tissue perfusion can cause a lack of oxygen and nutrients in the brain, which can affect cognitive function and lead to changes in mental status.

Inspect for pallor, cyanosis, mottling, and cool and clammy skin. Note the strength of peripheral pulses. Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses. Peripheral cyanosis, edema, pallor, diminished pulse volume, delayed rise, and delayed capillary refill may indicate vasoconstriction, diminished cardiac output, and right ventricular dysfunction or failure (Zafari, 2015). 

Monitor intake, and note changes in urine output. Record urine specific gravity as indicated. Decreased intake or persistent nausea may result in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function. The kidneys receive a significant portion of their blood supply from the renal arteries. When peripheral tissue perfusion is ineffective, it can reduce the blood flow to the kidneys, impairing their ability to filter waste products and produce urine.

Assess GI function, noting anorexia , decreased or absent bowel sounds, nausea, and vomiting , abdominal distension, and constipation . Reduced blood flow to mesentery can produce GI dysfunction, e.g., loss of peristalsis . Problems may be aggravated by the use of analgesics, decreased activity, and dietary changes. Clients frequently develop tricuspid incompetence; hepatojugular reflux may be elicited even when hepatomegaly is not marked (Zafari, 2015).

Assess for Homans’ sign (pain in calf on dorsiflexion), erythema, and edema. Indicators of deep vein thrombosis (DVT), although DVT can be present without a positive Homans’ sign. Dependent edema may be graded 0 to 4 by assessing the depth of persistent pitting after thumb pressure is applied to the client’s inner shin for more than 10 seconds or by evaluating the lower back if the client has had their legs elevated (Zafari, 2015).

Monitor laboratory data: CBC, ABGs, BUN, creatinine , electrolytes, and coagulation studies (PT, aPTT, clotting times). These are indicators of organ perfusion and function. Abnormalities in coagulation may occur as a result of therapeutic measures. Obtain a CBC if MI is suspected in order to rule out anemia as a cause of decreased oxygen supply and prior to giving thrombolytic agents. The platelet count may become dangerously low after the use of heparin because of heparin-induced thrombocytopenia (HIT) (Zafari, 2015).

Elevate the client’s head of the bed as appropriate. Elevation of the head of the bed is beneficial because it improves tidal volume due to reduced pressure from abdominal contents on the diaphragm and better lung expansion and gas exchange. This position also improves the drainage of the upper lung lobes and increases venous return to the heart, resulting in a decrease in the workload of the heart (Zafari, 2015).

Encourage active or passive leg exercises and avoidance of isometric exercises. This enhances venous return, reduces venous stasis, and decreases the risk of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and oxygen consumption. Flex, extend, or rotate the feet periodically Assist the client with ambulation as tolerated gradually to promote organ function and enhance general well-being.

Instruct the client in the application or periodic removal of the anti-embolic hose, elastic support hose, or graduated compression stockings, when used. Apply and regulate intermittent pneumatic compression as indicated This limits venous stasis improves venous return and reduces the risk of thrombophlebitis in the client who is limited in activity. Sequential compression devices may be used to improve blood flow velocity and empty vessels by providing artificial muscle-pumping action.

Apply warm, moist compresses or heat cradle to the affected extremity if indicated. This may be prescribed to promote vasodilation and venous return for resolution of local edema and to enhance comfort. However, caution must be given in applying warm compresses because this may be contraindicated in arterial insufficiency, in which heat can increase cellular oxygen consumption and nutritional needs, aggravating the imbalance between supply and demand.

Assist with reperfusion therapy. Percutaneous transluminal coronary intervention (PTCI) is a recommended method of reperfusion when it can be performed in a timely manner. PTCI is the placement of a small mesh tube called a stent into an infarcted or narrowed coronary artery. The procedure consists of cardiac catheterization and the insertion of a catheter with a balloon tip that is inflated to open the artery.

Prepare for PTCA (balloon angioplasty), with or without intracoronary stents. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery and improve the odds of long-term patency. Several randomized trials have demonstrated that rapidly available primary PTCA, performed by skilled operators, for acute MI is associated with long-term outcomes similar to those achieved with IV thrombolysis (Zafari, 2015).

Transfer to critical care or a specialty center. More intensive monitoring and aggressive interventions are necessary to promote optimum outcomes. A study showed that the transfer of clients to an invasive-treatment center for primary PCI is superior to on-site fibrinolysis provided that the transfer can be accomplished within two hours. The transfer should be considered for those clients who are likely to benefit from PCI or cardiac surgery but who are in an institution where access to such interventions is not immediate (Zafari, 2015).

Auscultate breath sounds for the presence of crackles. This may indicate pulmonary edema secondary to cardiac decompensation. Poor prognosis is associated with evidence of congestive heart failure or frank pulmonary edema by Killip classification of >II or >III (Zafari, 2015). 

Perform a risk stratification using the Killip classification. The Killip classification is widely used in clients presenting with acute MI for the purpose of risk stratification. Killip class I includes individuals with no clinical signs of heart failure; Killip class II includes individuals with rales or crackles in the lungs, an S3 gallop, and elevated jugular venous pressure; Killip class III describes individuals with frank acute pulmonary edema; and Killip class IV describes individuals in cardiogenic shock or hypotension, and evidence of low cardiac output (Zafari, 2015).

Note jugular vein distention (JVD) and development of dependent edema. This suggests developing congestive heart failure or fluid volume excess . In clients with acute inferior-wall myocardial infarction with right ventricular involvement, distention of neck veins is commonly described as a sign of failure of the right ventricle (Zafari, 2015).

Measure I&O, noting a decrease in output, and concentrated appearance. Calculate fluid balance . Decreased cardiac output results in impaired kidney perfusion, sodium and water retention, and reduced urine output. Heart failure with reduced ejection fraction is a risk factor for kidney disease. When the heart is unable to pump forcefully, the amount of blood it ejects with each contraction decreases. This reduces the amount of blood that reaches the kidneys, causing urine and waste output to drop (Cleveland Clinic, 2020).

Weigh daily. Sudden changes in weight reflect alterations in fluid balance. Edema that occurs in a client with MI can increase the body weight, which can result in the client being unable to move around freely and become active. This can further increase the workload of the heart and potentially worsen cardiovascular function.

Monitor potassium as indicated. Hypokalemia can limit the effectiveness of therapy and can occur with the use of potassium -depleting diuretics. Electrolyte abnormalities are commonly associated with all diuretic agents, and their mechanisms of such effect are well-established. Hypokalemia, for example, is caused by all diuretics except potassium-sparing diuretics, which cause hyperkalemia (Arumugham & Shahin, 2022).

Monitor urine-specific gravity. This measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate the urine.

Maintain total fluid intake at 2000 mL/24 hours within cardiovascular tolerance. This meets normal adult body fluid requirements but may require alteration or restriction in presence of cardiac decompensation. A study showed that frequently drinking small volumes exerted benefits for CHF rats, which may be partially mediated through the water diuresis mechanism. Cardiologists commonly use ice chips to relieve thirst in clients diagnosed with CHF (Zheng et al., 2017).

Encourage moderate consumption of sodium in the diet and beverages. A study showed that those who use salt more liberally while preparing meals are less likely to have a history of MI. Overall, the average amount of salt consumed per day by the general public in the US would be considered moderate, according to most studies. An emerging number of studies have found an association between increased mortality and low sodium intake. Moderate salt intake seems to have the best outcomes in terms of mortality and morbidity compared to high or low salt intakes (Mohan, 2021).

Refer to a cardiac rehabilitation program. This provides continued support and/or additional supervision and participation in the recovery and wellness process. Cardiac rehabilitation is a long-term program of medical evaluation, exercise, risk factor modification, education, and counseling designed to limit the physical and psychological effects of cardiac illness and improve the client’s quality of life.

Alleviating anxiety and fear is an important nursing function to reduce the sympathetic stress response. Decreased sympathetic stimulation decreases the workload of the heart, which may relieve pain and other signs and symptoms of ischemia. It is critical to optimize anxiety management in order to preserve myocardial muscle and minimize the risk of further deterioration.

Identify and acknowledge the client’s perception of the threat and situation. Encourage expressions of, and do not deny feelings of, anger, grief , sadness, and fear. Coping with the pain and emotional trauma of an MI is difficult. The client may fear death and/or be anxious about the immediate environment. Ongoing anxiety (related to concerns about the impact of a heart attack on future lifestyle, matters left unattended or unresolved, and effects of illness on family) may be present in varying degrees for some time and may be manifested by symptoms of depression.

Note the presence of hostility, withdrawal , and/or denial (inappropriate affect or refusal to comply with medical regimen). Research into survival rates between type A and type B individuals and the impact of denial has been ambiguous; however, studies show some correlation between the degree or expression of anger or hostility and an increased risk for MI. Some exploratory studies provided preliminary evidence that denial contributes to delayed adherence to effective cardiac treatment by disavowing the diagnosis and minimizing the perceived symptom burden and symptom severity (Fang et al., 2016).

Observe verbal and nonverbal signs of anxiety (restlessness, changes in vital signs), and stay with the client. Intervene if the client displays destructive behavior. The client may not express concern directly, but words and actions may convey a sense of agitation, aggression, and hostility. Intervention can help the client regain control of their own behavior.

Assess the client’s and caregiver ’s level of anxiety and coping mechanisms. These data provide information about psychological well-being. Causes of anxiety are variable and individual and may include acute illness, hospitalization, pain, disruption of activities of daily living at home and at work, changes in role and self-image due to illness, and financial concerns. Because anxious family members can transmit anxiety to the client, the nurse must also identify strategies to reduce the family’s fear and anxiety.

Maintain a confident manner but avoid giving false reassurances. The client and caregiver can be affected by the anxiety/uneasiness displayed by health team members. Honest explanations can alleviate anxiety. Providing information to the client and family in an honest and supportive manner encourages the client to be a partner in care and greatly assists in creating a positive relationship.

Accept but do not reinforce the use of denial. Avoid confrontations. Denial can be beneficial in decreasing anxiety but can postpone dealing with the reality of the current situation. Conflict can promote anger and increase the use of denial, reducing cooperation and possibly impeding recovery. An atmosphere of acceptance helps the client know that their concerns and fears are realistic and normal.

Orient the client and caregiver to routine procedures and expected activities. Promote participation when possible. Predictability and information can decrease anxiety for the client. Decreasing anxiety may also increase the client’s ability to process new information regarding their diagnoses, and to better understand instructions for tests or procedures that will be done.

Answer all questions factually. Provide consistent information; repeat as indicated. Accurate information about the situation reduces fear, strengthens the nurse-client relationship, and assists the client and caregiver to deal realistically with the situation. Attention span may be short, and repetition of information helps with retention.

Encourage the client and caregiver to communicate with one another, share questions and concerns, and provide privacy. Sharing information elicits support and comfort and can relieve the tension of unexpressed worries. Privacy provides an opportunity for the client and their partner to share their feelings and fear, offer support and encouragement to one another, relieve anxiety, and establish effective coping methods.

Provide rest periods and/or uninterrupted sleep time, and quiet surroundings, with the client controlling type and amount of external stimuli. This conserves energy and enhances coping abilities. Anxiety can also be decreased by offering the client opportunities for control in the acute setting. Examples include the timing of simple activities such as visitor presence, bathing, and eating.

Promote the use of relaxation and stress management techniques. A number of interventions may be done at the bedside to promote relaxation, including specific relaxation and imagery techniques, meditation, music therapy, and the use of relaxation tapes. Stress management techniques such as breathing exercises and massage can help reduce tension and anxiety, provide a sense of control, and enhance coping skills.

Encourage independence, self-care, and decision-making within the accepted treatment plan. Increased independence from staff promotes self-confidence and reduces feelings of abandonment that can accompany transfer from the coronary unit or discharge from the hospital. The most effective way to increase the probability the client will implement a self-care regimen after discharge is to identify the priorities as perceived by the client, provide adequate education about heart-healthy living, and facilitate the client’s involvement in a cardiac rehabilitation program. Client’s participation in developing plans to meet their specific needs further enhances the potential for an effective treatment plan.

Encourage discussion about post-discharge expectations. This helps the client and/or caregiver identify realistic goals, thereby reducing the risk of discouragement in the face of the reality of the limitations of the condition and/or pace of recovery.

Administer anti-anxiety and hypnotics as indicated . See pharmacological interventions.

Administer timely and effective pain relief. Relief of pain is most effective in reducing client anxiety. In the event that pain is not relieved with nitroglycerin, or fibrinolytic in the initial treatment of ischemia, pain relievers such as morphine sulfate are usually effective.

Provide referrals for spiritual counseling or social services. If the client finds support in religion, spiritual counseling may assist in reducing anxiety and fear. Social services can also assist with posthospital care and financial concerns, somehow relieving the sense of anxiety about hospital bills if the financial situation is tight.

Acute coronary syndrome (ACS) occurs due to inadequate oxygen flow to the heart muscle due to occlusion of the coronary arteries. The decrease in oxygen supply will have an impact on daily activities from light to heavy activities. Additionally, it also causes ventricular contraction failure and continues to decrease cardiac output which is characterized by hemodynamic instability (Andriani et al., 2022).

Assess and document heart rate and rhythm and changes in BP before, during, and after activity. Correlate with reports of chest pain or shortness of breath. Trends determine the client’s response to activity and may indicate myocardial oxygen deprivation that may require a decrease in activity level and/or return to bedrest, changes in medication regimen, or use of supplemental oxygen. Older adult clients and those diagnosed with diabetes may have particularly subtle presentations and may complain of weakness, fatigue , or syncope (Zafari, 2015).

Review signs and symptoms reflecting intolerance of present activity level or requiring notification of a nurse or healthcare provider. Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate a need for changes in an exercise regimen or medications. The client may also appear weak and have disturbances in carrying out activities from mild to severe levels (Andriani et al., 2022).

Encourage rest initially. Thereafter, limit activity on the basis of pain and/or adverse cardiac response. Provide non-stress diversional activities. This reduces myocardial workload and oxygen consumption, reducing the risk of complications. Confine the client to bed rest to minimize oxygen consumption until reperfusion and initial therapy are complete. This usually lasts about 24 to 48 hours; after that, the client’s activity may be accelerated slowly as tolerated (Zafari, 2015).

Instruct the client to avoid increasing abdominal pressure (straining during defecation). Activities that require holding the breath and bearing down (Valsalva maneuver) can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardia with elevated BP. Due to cardiovascular effects produced during the Valsalva maneuver, it may be contraindicated in certain medical conditions such as myocardial infarction and could be a trigger of sudden cardiac death (O Fisher-Hubbard et al., 2016).

Provide a quiet environment and limit visitors. Encourage stress management and diversional activities as appropriate. This reduces stress and excess stimulation, therefore promoting rest. Stress management techniques can help reduce tension and anxiety, providing the client with a sense of control and enhancing their coping skills.

Explain the pattern of graded increase of activity level: getting up to commode or sitting in a chair, progressive ambulation, and resting after meals. The progressive activity provides a controlled demand on the heart, increasing strength, and preventing overexertion. The bedside commode generally is allowed; studies have shown this to be less stressful than using a bedpan. If the client’s condition is stable, sitting in a chair at the bedside is permitted after 12 hours. Activities are increased gradually as tolerated.

Promote tolerable, light physical exercise as indicated. Physical exercises have an impact on changes in cardiac output and redistribution of blood supply from inactive organs to active organs. Physical exercise provides the client the ability to inspire longer and it is also able to remove more metabolic waste through expiration. During physical activity, muscles need adequate oxygen as fuel so that energy distribution is smooth and stable (Andriani et al., 2022).

Assist in procedures for inserting ventricular assist devices. The use of ventricular assist devices (VAD) to aid the failing heart is becoming more common with advances in technology. These devices temporarily take partial or complete control of cardiac function, depending on the type of device used. VADs may be used as a temporary or complete assist in AMI and cardiogenic shock when there is a chance for recovery of normal heart function after a period of cardiac rest.

To enhance patient adherence to a self-care regimen post-discharge, it is crucial to identify their priorities, provide comprehensive education on heart-healthy living, and support their engagement in a cardiac rehabilitation program. Involving the patient in the development of an individualized program promotes the effectiveness of the treatment plan.

Assess the client or family member’s level of knowledge and ability and desire to learn. This is necessary for the creation of individual instruction plans. The client requires intensive education, support from family members, and frequent direction from left-ventricular assistive device (LVAD) nurses or coordinators to self-management of the LVAD home care regimen (Casida et al., 2016).

Be alert to signs of avoidance (changing the subject away from information being presented or extremes of behavior). This reinforces the expectation that this will be a “ learning experience.” Verbalization identifies misunderstandings and allows for clarification. Clients and caregivers are generally prepared for the self-management of LVAD home care regimen before discharge during the first implant hospitalization. However, during the first few weeks to several months after hospital discharge, clients are completely or highly dependent on their caregivers in regard to implementing and adhering to the LVAD home care regimen (Casida et al., 2016).

Encourage the client to enroll in smoking cessation classes. This provides the opportunity for the client to retain information and assume control and participate in the rehabilitation program. Following MI, educate all clients regarding the critical role of smoking in the development of coronary artery disease. Smoking cessation classes should be offered to help clients avoid smoking after their MI (Zafari, 2015).

Promote a moderate consumption of alcoholic beverages. Mild alcohol consumption has been associated with a decreased risk of stroke and myocardial infarction. Cautiously consider recommending and discussing alcohol use on a case-by-case basis (Zafari, 2015).

Warn against the isometric activity, Valsalva maneuver, and activities requiring arms positioned above the head. These behaviors and chemicals have direct adverse effects on cardiovascular function and may impede recovery, and increase complications. When compared with a single bout of aerobic exercise, one session of isometric exercise apparently does not have vascular and hemodynamic benefits in clients undergoing primary PCI after MI (Kollet et al., 2021).

Present information in varied learning formats: programmed books, audiovisual tapes, question and answer sessions, and group activities. Natural defense mechanisms , such as anger or denial of the significance of the situation, can block learning, affecting the client’s response and ability to assimilate information. Changing to a less formal or structured style may be more effective until the client and caregiver are ready to accept or deal with the current situation.

Reinforce explanations of risk factors, dietary and/or activity restrictions, medications, and symptoms requiring immediate medical attention. Using multiple learning methods enhances the retention of material. A high index of suspicion should be maintained for MI, especially when evaluating women, clients with diabetes, older adult clients, clients with dementia , clients with a history of heart failure, cocaine users, clients with hypercholesterolemia, and clients with a positive family history for early coronary disease (Zafari, 2015).

Review programmed increases in levels of activity. Educate the client regarding the gradual resumption of activities, e.g., walking, work, recreational and sexual activity. Provide guidelines for gradually increasing activity and instruction regarding target heart rate and pulse taking, as appropriate. These activities greatly increase cardiac workload and myocardial oxygen consumption and may adversely affect myocardial contractility and output. A Norwegian randomized trial found that aerobic interval training (treadmill) increased peak oxygen uptake more than the usual care rehabilitation (aerobic exercise training) after myocardial infarction (Zafari, 2015).

Identify alternative activities for “bad weather” days, such as measured walking around the house or shopping mall. Gradual increase in activity increases strength and prevents overexertion, may enhance collateral circulation, and allows a return to a normal lifestyle. Note: Sexual activity can be safely resumed once the client can accomplish activity equivalent to climbing two flights of stairs without adverse cardiac effects.

Review signs and symptoms requiring a reduction in activity and notification of healthcare provider. Pulse elevations beyond established limits, development of chest pain, or dyspnea may require changes in exercise and medication regimen. Physical conditioning is achieved gradually over time. Many times, clients will overdo it in an attempt to achieve their goals too rapidly. Clients are observed for chest pain, dyspnea, weakness, fatigue, and palpitations and are instructed to stop the exercise if any of these occur.

Differentiate between increased heart rate that normally occurs during various activities and worsening signs of cardiac stress (chest pain, dyspnea, palpitations, increased heart rate lasting more than 15 minutes after cessation of activity, and excessive fatigue the following day). Pulse elevations beyond established limits, development of chest pain, or dyspnea may require changes in exercise and medication regimen. Clients may be monitored for an increase in heart rate above the target heart rate, an increase in systolic or diastolic blood pressure of more than 20 mm Hg, a decrease in systolic blood pressure, onset or worsening of dysrhythmias, or ST-segment changes in the ECG.

Stress the importance of follow-up care, and identify community resources and support groups. This reinforces that this is an ongoing and continuing health problem for which support and assistance are available after discharge. After discharge, clients encounter limitations in physical functioning and often incur difficulty with emotional, social, and role functioning requiring ongoing support. The nurse making a home visit can assist the client with scheduling and keeping follow-up appointments and with adhering to the prescribed cardiac rehabilitation regimen. In addition, the home care nurse monitors the client’s adherence to dietary restrictions and to prescribed medications.

Emphasize the importance of contacting the healthcare provider if chest pain, change in anginal pattern, or other symptoms recur. Timely evaluation and intervention may prevent complications. The client must learn to recognize and take appropriate action for recurrent symptoms. A call must be placed to 911 if chest pressure or pain (or prodromal symptoms) is not relieved in 15 minutes by taking 3 nitroglycerin tablets at 5-minute intervals. The HCP should also be contacted if shortness of breath, fainting, slow or rapid heartbeat, or swelling of the feet and ankles occur.

Stress the importance of reporting the development of fever in association with diffuse and atypical chest pain (pleural, pericardial) and joint pain. A post-MI complication of pericardial inflammation (Dressler’s syndrome) requires further medical evaluation and intervention. Before the era of reperfusion, the incidence of post-myocardial infarction syndrome ranged from 1 to 5% after acute MI, but this rate has dramatically declined with the advent of thrombolysis and coronary angioplasty (Zafari, 2015).

Encourage the client and family members to share concerns and feelings. Discuss signs of pathological depression versus transient feelings frequently associated with major life events. Recommend seeking professional help if depressed feelings persist. Depressed clients have a greater risk of dying in 6 to 18 months following a heart attack. Timely intervention may be beneficial. Note: Selective serotonin reuptake inhibitors (SSRIs), paroxetine (Paxil), have been found to be as effective as tricyclic antidepressants but with significantly fewer adverse cardiac complications.

Stress the importance of proper dietary intake. Diet plays an important role in the development of CAD. Educate post-MI clients about the role of a low-cholesterol and moderate-salt diet. Educate clients about the American Heart Association (AHA) dietary guidelines. A dietitian should see and evaluate all clients post-MI prior to their discharge (Zafari, 2015).

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

case study with nursing care plan

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

case study with nursing care plan

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

case study with nursing care plan

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

case study with nursing care plan

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

case study with nursing care plan

  • Andriani, W. R., Suwanto, A. W., Wiratmoko, H., Hartanto, A. E., Antono, S. D., Purwaningsih, E., Hendrawati, G. W., Failasufi, M., & Cahyono, L. (2022, April). Exercise Habits and Family Disease History as Determinant of Activity Intolerance and ECG Patterns of Patients with Acute Coronary Syndrome (ACS). Health Notions , 6 (4).
  • Arumugham, V. B., & Shahin, M. H. (2022). Therapeutic Uses Of Diuretic Agents – StatPearls . NCBI. Retrieved February 7, 2023.
  • Burns , S. M. (Ed.). (2014). AACN Essentials of Critical Care Nursing, Third Edition . McGraw-Hill Education.
  • Casida, J. M., Wu, H.-S., Abshire, M., Ghosh, B., & Yang, J. J. (2016, August). Cognition and adherence are self-management factors predicting the quality of life of adults living with a left ventricular assist device. Journal of Heart and Lung Transplantation .
  • Cleveland Clinic. (2020, February 13). The Link Between Heart and Kidney Health. Cleveland Clinic Health Essentials .
  • Fang, X., Albarquoni, L., von Eisenhart Rothe, A.F., Hoschar, S., Ronel, J., & Ladwig, K.H. (2016, December). Is denial a maladaptive coping mechanism which prolongs pre-hospital delay in patients with ST-segment elevation myocardial infarction? Journal of Psychosomatic Research , 91 .
  • Farrell, M. (2016). Smeltzer & Bares Textbook of Medical-surgical Nursing (M. Farrell, Ed.). Lippincott Williams & Wilkins Pty, Limited.
  • Frazier, S. K., Moser, D. K., O’ Brien, J. L., Garvin, B. J., An, K., & Macko, M. (2002, November-December). Management of anxiety after acute myocardial infarction. Heart & Lung , 31 (6).
  • Gubrud, P., Bauldoff, G., & Carno, M.-A. (2019). LeMone & Burke’s Medical-surgical Nursing: Clinical Reasoning in Patient Care . Pearson Education, Incorporated.
  • Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing . Wolters Kluwer.
  • Kollet, D. P., Marenco, A. B., Belle, N. L., Barbosa, E., Boll, L., Eibel, B., Waclawovsky, G., & Lehnen, A. M. (2021, February 17). Aerobic exercise, but not isometric handgrip exercise, improves endothelial function and arterial stiffness in patients with myocardial infarction undergoing coronary intervention: a randomized pilot study – BMC Cardiovascular Disorders . BMC Cardiovascular Disorders. Retrieved February 7, 2023.
  • Meng, Q.-L., Sun, Y., He, H.-J., Wang, H., & Shan, G.-L. (2021, October). Non-invasive thoracic electrical bioimpedance technique-derived hemodynamic reference ranges in Chinese Han adults . NCBI. Retrieved February 6, 2023.
  • Mo, L., Xie, W., Pu, X., & Ouyang, D. (2018, April). Coffee consumption and risk of myocardial infarction: a dose-response meta-analysis of observational studies . NCBI. Retrieved February 6, 2023.
  • Mohan, J. (2021, February 2). Salt Consumption and Myocardial Infarction: Is Limited Salt Intake Beneficial? NCBI. Retrieved February 7, 2023.
  • Moorhouse, M. F., Murr, A. C., & Doenges, M. E. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span . F.A. Davis Company.
  • O Fisher-Hubbard, A., Kesha, K., Diaz, F., Njiwaji, C., Chi, P., & Schmidt, C. J. (2016, September). Commode Cardia-Death by Valsalva Maneuver: A Case Series. Journal of Forensic Sciences , 61 (6).
  • Perrin, K., & MacLeod, C. E. (2017). Understanding the Essentials of Critical Care Nursing . Pearson.
  • Ren, X. (2019, August 6). Cardiogenic Shock: Practice Essentials, Background, Pathophysiology . Medscape Reference. Retrieved February 7, 2023.
  • Shah, A. H., Puri, R., & Kalra, A. (2019, February). Management of cardiogenic shock complicating acute myocardial infarction: A review. Clinical Cardiology , 42 (4), 484-493.
  • Thygesen, K., Alpert, J. S., Jaffe, A. S., Chaitman, B. R., Bax, J. J., Morrow, D. A., & White, H. D. (2018). Fourth Universal Definition of Myocardial Infarction (2018). Circulation .
  • Zafari, A. M. (2015, September 15). Myocardial Infarction: Practice Essentials, Background, Anatomy . Medscape Reference. Retrieved February 1, 2023.
  • Zahara, R., Santoso, A., & Barano, A. Z. (2020, May). Myocardial Fluid Balance and Pathophysiology of Myocardial Edema in Coronary Artery Bypass Grafting. Cardiology Research and Practice , 2020 .
  • Zheng, C., Li, M., Kawada, T., Inagaki, M., Uemura, K., & Sugimachi, M. (2017, November 9). Frequent drinking of small volumes improves cardiac function and survival in rats with chronic heart failure . NCBI. Retrieved February 7, 2023.

8 thoughts on “8 Myocardial Infarction (Heart Attack) Nursing Care Plans”

Thanks.. it is helpful

Very educative and helpful! Thank you!

I cannot thank you enough…

I am very gratefull to the matt vera for such a great help for us. Robin

Thanks a lot..

I cant see activity intolerance

Hi Georgia, link is fixed. Sorry ’bout that!

Very educative. Thanks, matt Vera.

Leave a Comment Cancel reply

NurseStudy.Net

NurseStudy.Net

Nursing Education Site

nursing diagnosis for ocd

OCD Nursing Diagnosis and Nursing Care Plan

Last updated on December 2nd, 2022 at 10:32 am

OCD Nursing Care Plans Diagnosis and Interventions

OCD NCLEX Review and Nursing Care Plans

Obsessive-compulsive disorder (OCD) is a mental health condition that happens when a person becomes enmeshed in a chain of obsessions and compulsions.

Obsessions are intrusive, unwelcome ideas, desires, or visions that cause incredibly upsetting emotions. Compulsions are actions someone takes in an effort to suppress their obsessions and/or lessen suffering.

Individuals who do not have OCD experience upsetting ideas or repetitive activities. However, it rarely interferes with normal everyday life.

For those who have OCD, the symptoms are uncontrollable, take up at least an hour of each day, and significantly disrupt everyday life.

Signs and Symptoms of Obsessive-Compulsive Disorder (OCD)

Obsessions and compulsions are the two basic categories of OCD symptoms.

  • intolerance of contamination or dirt.
  • having doubts and difficulty accepting uncertainties.
  • requiring symmetry and order in everything.
  • ideas that are violent or horrifying about the loss of control and hurting oneself or others.
  • unfavorable ideas, such as those that are hostile or have sexual or religious issues.
  • continuous attention to breathing, and other bodily sensations.
  • suspicion of infidelity without solid evidence to support it.
  • cleaning and washing
  • orderliness
  • maintaining a strict schedule
  • requesting reassurance

Causes of Obsessive-Compulsive Disorder (OCD)

It is still unclear to the experts what the exact cause of the obsessive-compulsive disorder is. OCD is more common in females than in males. Young people and teenagers usually exhibit symptoms first. The principal theories on what causes OCD are:

  • Serotonin levels . The brain is a highly complicated part of the body. It has countless billions of nerve cells or Neurons as a result. For the body to work appropriately, they must coordinate and communicate with one another by exchanging signals electrically. Neurotransmitters are substances used in the transmission of these electrical signals. Serotonin is a neurotransmitter with numerous vital roles throughout the body, including regulating mood and sleep. According to some data, OCD may have something to do with how serotonin affects the brain.
  • Brain structure, and functioning. According to the National Institute of Mental Health, the illness has also been related to abnormal development and damage in specific brain regions. Some scientists suggest that OCD is caused by problems in the neural connections between the brain regions involved in planning and judgment and another region that filters communications that coordinate and give instructions to the body about movement and function.
  • Genetic factors. Additionally, there is data that suggests the possibility of parental transmission of OCD symptoms. The condition’s alleged causing genes, however, have not yet been found. According to its theory, there is a larger likelihood that a person will get OCD if a close family member does.

Risk Factors to Obsessive Compulsive Disorder (OCD)

The following factors raise the risk of developing OCD:

  • Stress. A person may be more likely to acquire OCD or experience worsening symptoms if they are under a lot of stress at their job, at school, at home, or in their personal relationships.
  • Personality. Specific personality traits, such as they struggle to cope with complexity, intense feelings of responsibility, or perfectionism, can be linked to OCD. However, there are strong disagreements on whether these are more malleable learned behaviors or rigid ones that cannot be modified.
  • Child Abuse. T he likelihood of acquiring OCD is higher in children who have experienced abuse or other highly traumatic events in their childhood, such as bullying.
  • Childhood acute neuropsychiatric symptoms. Some children get an illness followed by a quick onset of OCD. PANDAS, which stands for pediatric autoimmune neuropsychiatric diseases related to streptococcus, is the term used to describe this condition following a streptococcal infection. But symptoms might also be caused by other illnesses or infections.
  • Traumatic Brain Injury. A study published in 2021 reported that after a brain injury, OCD symptoms may manifest for the first time.
  • Other mental health conditions. OCD patients frequently have other mental health issues, including attention deficit hyperactivity disorder (ADHD), Tourette syndrome, major depressive disorder , eating disorders, and anxiety disorders being the most prevalent.

Complications of Obsessive Compulsive Disorder (OCD)

The compulsive and obsessive symptoms of OCD may cause further problems such as secondary medical issues. These includes:

  • Depression. Patients with OCD frequently experience embarrassing emotions and stressful therapies, which can result in depression. Having to live with such a difficult and uncomfortable situation every day would lead to losing hope. Living can be remarkably tough for individuals with OCD, making them more prone to depression.
  • Isolation. The routine actions that emerge from obsessions and compulsions may cause isolation for many individuals suffering from OCD. Fear or the incapacity to fulfill compulsive behaviors outside of their residence may be the reason for this. Many additional mental health issues, such as depression and substance abuse problems, have been linked to isolation, according to studies.
  • Social problems. Social interaction is challenging for people suffering from OCD. This difficulty may appear as a problem keeping relationships as well as issues engaging in social events and fulfilling commitments. This might worsen the isolation already experience caused by obsessive-compulsive disorder.
  • Suicide. Both the emergence of other mental problems and the intensity of manifestations in OCD can increase the danger of committing suicide. OCD is a disorder that tends to cause disruption and significantly lowers the well-being of many individuals by interfering with daily life activities.
  • Physical difficulties. For patients with compulsions to clean or wash things, this particularly applies. Frequently taking showers or excessively scrubbing the skin may irritate the skin, severely dries the skin, and delayed healing.

Diagnosis of Obsessive Compulsive Disorder (OCD)

The sequence of obsessions and compulsions must become so extreme that it takes up too much time and interferes with important tasks that the person gains in order for an obsessive-compulsive disorder diagnosis to be decided.

However, just because other people possess obsessive thoughts and/or compulsive behaviors for some time in life doesn’t always mean that we suffer “some OCD.” Because OCD symptoms might resemble those of obsessive-compulsive personality disorder, anxiety disorders, depression, schizophrenia, or other mental health problems, diagnosing OCD can be challenging at times.

Following are some methods for diagnosing obsessive-compulsive disorder:

  • Psychological Assessment. In order to ascertain whether a person suffers from obsessions or compulsive behaviors that affect their quality of life, this involves talking about their thoughts, feelings, symptoms, and behavioral patterns. This may involve speaking with the families or friends with their consent.
  • OCD Diagnostic Standards. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) issued by the American Psychiatric Association may be used by the attending doctor.
  • Physical Examination. This could be done to look for any associated consequences and also to help rule out any other issues that could be the source of the symptoms. To assist rule out pharmaceutical side effects or other diseases, the doctor may also ask about the patient’s medical history, a list of the medications, and any further mental health or physical symptoms they may be experiencing. The patient and the doctor need to work together to achieve an accurate diagnosis and provide proper care and treatment.

Treatment for Obsessive Compulsive Disorder (OCD)

Treatment for obsessive-compulsive disorder can help put symptoms at bay so they don’t interfere with the patient’s everyday life, even if it may not be a solution. Some patients may require longer periods, persistent, or even more comprehensive treatment depending on how serious their OCD is. Psychotherapy and medications are the two main OCD treatments. Treatment is often most successful when these are used in combination.

  • Cognitive Behavioral Therapy. Among many patients with OCD, this therapy is effective. It involves being skilled at seeing and reframing undesirable or destructive ideas and behavior patterns.
  • Exposure and Response Prevention. ​​ This form of cognitive behavioral therapy (CBT) includes exposing patients to frightening scenarios or thoughts that cause obsessions or compulsions gradually. It teaches participants to control the suffering that obsessions bring about without reverting to compulsive behavior.
  • Mindfulness-based cognitive therapy. It entails practicing mindfulness techniques in order to deal with the distress brought on by my thoughts and feelings.
  • Medications. The obsessions and compulsions of OCD can be managed with the intervention of specific psychiatric medications. A psychiatric professional who can issue prescriptions might do so.
  • Antidepressant. Antidepressants are typically used initially. U.S. Food and Drug Administration (FDA) approved antidepressants are prescribed by the doctor to treat OCD symptoms.
  • Selective Serotonin Reuptake Inhibitors (SSRIs). By raising serotonin levels in the brain, SSRIs primarily assist people in managing diseases like depression.

Nursing Diagnosis for OCD

Nursing care plan for ocd 1.

Nursing Diagnosis: Anxiety as related to earlier life conflicts secondary to obsessive-compulsive disorder (OCD) as evidenced by a decline in social and role performance, repeated behaviors, and recurrent thoughts.

Desired Outcomes:

  • The patient will verbally express their knowledge of the importance of habitual actions and how they relate to anxiety.
  • The patient will demonstrate the capacity to handle stressful circumstances successfully without turning to compulsive or obsessive thoughts or behaviors.

Nursing Care Plan for OCD 2

Nursing Diagnosis: Social Isolation is related to past experiences of difficulty in interaction with others secondary to Obsessive Compulsive Disorder as evidenced by lack of confidence in public, inability to make eye contact, lack of communication, obsession with one’s own ideas; repetitious meaningless behavior.

  • The patient will voluntarily participate in treatment sessions with a reliable support person.
  • The client will freely partake in activities with other patients and staff members.
  • ​​The patient will express the desire to develop better relationships and to improve social and communication skills.
  • The patient will mention feeling more confident and having self-worth.

Nursing Care Plan for OCD 3

Nursing Diagnosis: Ineffective Coping related to situational crises secondary to obsessive-compulsive disorder as evidenced by obsessive conduct or ritualistic habits, failing to do something for basic necessities, failure to respond adequately to responsibilities, and poor problem-solving abilities

  • The patient will engage in a less ritualistic activity.
  • The patient will exhibit effective coping skills.
  • In order to keep OCD symptoms at a moderate level, the patient will express any indications and symptoms of growing OCD.
  • The patient will show that they are able to stop obsessive thoughts in their tracks and abstain from repetitive actions.

Nursing Care Plan for OCD 4

Nursing Diagnosis: Self-Care Deficit related to excessive ritualistic habits secondary to Obsessive Compulsive Disorder (OCD) as evideced by the refusal to practice self-hygiene, unclean clothes, uncombed hair, a bad body odor, lack of enthusiasm for choosing appropriate attire, and incontinence

  • The patient will express their wish to take charge of their own self-care.
  • The patient will be capable of taking care of their own ADLs and show that they are willing to do so.

Nursing Care Plan for OCD 5

Nursing Diagnosis: Deficient Knowledge related to unawareness of potential side effects and unfamiliarity with the drugs being utilized secondary to the new diagnosis of obsessive-compulsive disorder (OCD) as evidenced by verbally expressing a lack of knowledge or expertise or requesting information, conveys a false impression of one’s health, performs desired or recommended health behavior incorrectly.

Desired Outcome: The patient will be able to determine accurate information about drugs and their negative side effects.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Leave a Comment Cancel reply

This site uses Akismet to reduce spam. Learn how your comment data is processed .

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Advanced Search
  • Journal List
  • SAGE Open Nurs
  • v.7; Jan-Dec 2021

Case Study Analysis as an Effective Teaching Strategy: Perceptions of Undergraduate Nursing Students From a Middle Eastern Country

Vidya seshan.

1 Maternal and Child Health Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Gerald Amandu Matua

2 Fundamentals and Administration Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Divya Raghavan

Judie arulappan, iman al hashmi, erna judith roach, sheeba elizebath sunderraj, emi john prince.

3 Griffith University, Nathan Campus, Queensland 4111

Background: Case study analysis is an active, problem-based, student-centered, teacher-facilitated teaching strategy preferred in undergraduate programs as they help the students in developing critical thinking skills. Objective: It determined the effectiveness of case study analysis as an effective teacher-facilitated strategy in an undergraduate nursing program. Methodology: A descriptive qualitative research design using focus group discussion method guided the study. The sample included undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018. The researcher used a purposive sampling technique and a total of 22 students participated in the study, through five (5) focus groups, with each focus group comprising between four to six nursing students. Results: In total, nine subthemes emerged from the three themes. The themes were “Knowledge development”, “Critical thinking and Problem solving”, and “Communication and Collaboration”. Regarding “Knowledge development”, the students perceived case study analysis method as contributing toward deeper understanding of the course content thereby helping to reduce the gap between theory and practice especially during clinical placement. The “Enhanced critical thinking ability” on the other hand implies that case study analysis increased student's ability to think critically and aroused problem-solving interest in the learners. The “Communication and Collaboration” theme implies that case study analysis allowed students to share their views, opinions, and experiences with others and this enabled them to communicate better with others and to respect other's ideas which further enhanced their team building capacities. Conclusion: This method is effective for imparting professional knowledge and skills in undergraduate nursing education and it results in deeper level of learning and helps in the application of theoretical knowledge into clinical practice. It also broadened students’ perspectives, improved their cooperation capacity and their communication with each other. Finally, it enhanced student's judgment and critical thinking skills which is key for their success.

Introduction/Background

Recently, educators started to advocate for teaching modalities that not only transfer knowledge ( Shirani Bidabadi et al., 2016 ), but also foster critical and higher-order thinking and student-centered learning ( Wang & Farmer, 2008 ; Onweh & Akpan, 2014). Therefore, educators need to utilize proven teaching strategies to produce positive outcomes for learners (Onweh & Akpan, 2014). Informed by this view point, a teaching strategy is considered effective if it results in purposeful learning ( Centra, 1993 ; Sajjad, 2010 ) and allows the teacher to create situations that promote appropriate learning (Braskamp & Ory, 1994) to achieve the desired outcome ( Hodges et al., 2020 ). Since teaching methods impact student learning significantly, educators need to continuously test the effectives of their teaching strategies to ensure desired learning outcomes for their students given today's dynamic learning environments ( Farashahi & Tajeddin, 2018 ).

In this study, the researchers sought to study the effectiveness of case study analysis as an active, problem-based, student-centered, teacher-facilitated strategy in a baccalaureate-nursing program. This choice of teaching method is supported by the fact that nowadays, active teaching-learning is preferred in undergraduate programs because, they not only make students more powerful actors in professional life ( Bean, 2011 ; Yang et al., 2013 ), but they actually help learners to develop critical thinking skills ( Clarke, 2010 ). In fact, students who undergo such teaching approaches usually become more resourceful in integrating theory with practice, especially as they solve their case scenarios ( Chen et al., 2019 ; Farashahi & Tajeddin, 2018 ; Savery, 2019 ).

Review of Literature

As a pedagogical strategy, case studies allow the learner to integrate theory with real-life situations as they devise solutions to the carefully designed scenarios ( Farashahi & Tajeddin, 2018 ; Hermens & Clarke, 2009). Another important known observation is that case-study-based teaching exposes students to different cases, decision contexts and the environment to experience teamwork and interpersonal relations as “they learn by doing” thus benefiting from possibilities that traditional lectures hardly create ( Farashahi & Tajeddin, 2018 ; Garrison & Kanuka, 2004 ).

Another merit associated with case study method of teaching is the fact that students can apply and test their perspectives and knowledge in line with the tenets of Kolb et al.'s (2014) “experiential learning model”. This model advocates for the use of practical experience as the source of one's learning and development. Proponents of case study-based teaching note that unlike passive lectures where student input is limited, case studies allow them to draw from their own experience leading to the development of higher-order thinking and retention of knowledge.

Case scenario-based teaching also encourages learners to engage in reflective practice as they cooperate with others to solve the cases and share views during case scenario analysis and presentation ( MsDade, 1995 ).

This method results in “idea marriage” as learners articulate their views about the case scenario. This “idea marriage” phenomenon occurs through knowledge transfer from one situation to another as learners analyze scenarios, compare notes with each other, and develop multiple perspectives of the case scenario. In fact, recent evidence shows that authentic case-scenarios help learners to acquire problem solving and collaborative capabilities, including the ability to express their own views firmly and respectfully, which is vital for future success in both professional and personal lives ( Eronen et al., 2019 ; Yajima & Takahashi, 2017 ). In recognition of this higher education trend toward student-focused learning, educators are now increasingly expected to incorporate different strategies in their teaching.

This study demonstrated that when well implemented, educators can use active learning strategies like case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. This study is significant because the findings will help educators in the country and in the region to incorporate active learning strategies such as case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. Besides, most studies on the case study method in nursing literature mostly employ quantitative methods. The shortage of published research on the case study method in the Arabian Gulf region and the scanty use of qualitative methods further justify why we adopted the focus group method for inquiry.

A descriptive qualitative research design using focus group discussion method guided the study. The authors chose this method because it is not only inexpensive, flexible, stimulating but it is also known to help with information recall and results in rich data ( Matua et al., 2014 ; Streubert & Carpenter, 2011 ). Furthermore, as evidenced in the literature, the focus group discussion method is often used when there is a need to gain an in-depth understanding of poorly understood phenomena as the case in our study. The choice of this method is further supported by the scarcity of published research related to the use of case study analysis as a teaching strategy in the Middle Eastern region, thereby further justifying the need for an exploratory research approach for our study.

As a recommended strategy, the researchers generated data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and cased-based teaching approaches. The focus group interviews allowed the study participants to express their experiences and perspectives in their own words. In addition, the investigators integrated participants’ self-reported experiences with their own observations and this enhanced the study findings ( Morgan & Bottorff, 2010 ; Nyumba et al., 2018 ; Parker & Tritter, 2006 ).

Eligibility Criteria

In order to be eligible to participate in the study, the participants had to:

  • be a baccalaureate nursing student in College of Nursing, Sultan Qaboos University
  • register for Maternity Nursing Course in 2017 and 2018.
  • attend all the Case Study Analysis sessions in the courses before the study.
  • show a willingness to participate in the study voluntarily and share their views freely.

The population included the undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018.

The researcher used a purposive sampling technique to choose participants who were capable of actively participating and discussing their views in the focus group interviews. This technique enabled the researchers to select participants who could provide rich information and insights about case study analysis method as an effective teaching strategy. The final study sample included baccalaureate nursing students who agreed to participate in the study by signing a written informed consent. In total, twenty-two (22) students participated in the study, through five focus groups, with each focus group comprising between four and six students. The number of participants was determined by the stage at which data saturation was reached. The point of data saturation is when no new information emerges from additional participants interviewed ( Saunders et al., 2018 ).Focus group interviews were stopped once data saturation was achieved. Qualitative research design with focus group discussion allowed the researchers to generate data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and case-based teaching approaches. The focus group interviews allowed the study participants to express their perspectives in their own words. In addition, the investigators enhanced the study findings by integrating participants’ self-reported experiences with the researchers’ own observations and notes during the study.

The study took place at College of Nursing; Sultan Qaboos University, Oman's premier public university, in Muscat. This is the only setting chosen for the study. The participants are the students who were enrolled in Maternal Health Nursing course during 2017 and 2018. The interviews occurred in the teaching rooms after official class hours. Students who did not participate in the study learnt the course content using the traditional lecture based method.

Ethical Considerations

Permission to conduct the study was granted by the College Research and Ethics Committee (XXXX). Prior to the interviews, each participant was informed about the purpose, benefits as well as the risks associated with participating in the study and clarifications were made by the principal researcher. After completing this ethical requirement, each student who accepted to participate in the study proceeded to sign an informed consent form signifying that their participation in the focus group interview was entirely voluntary and based on free will.

The anonymity of study participants and confidentiality of their data was upheld throughout the focus group interviews and during data analysis. To enhance confidentiality and anonymity of the data, each participant was assigned a unique code number which was used throughout data analysis and reporting phases. To further assure the confidentiality of the research data and anonymity of the participants, all research-related data were kept safe, under lock and key and through digital password protection, with unhindered access only available to the research team.

Research Intervention

In Fall 2017 and Spring 2018 semesters, as a method of teaching Maternal Health Nursing course, all students participated in two group-based case study analysis exercises which were implemented in the 7 th and 13 th weeks. This was done after the students were introduced to the case study method using a sample case study prior to the study. The instructor explained to the students how to solve the sample problem, including how to accomplish the role-specific competencies in the courses through case study analysis. In both weeks, each group consisting of six to seven students was assigned to different case scenarios to analyze and work on, after which they presented their collective solution to the case scenarios to the larger class of 40 students. The case scenarios used in both weeks were peer-reviewed by the researchers prior to the study.

Pilot Study

A group of three students participated as a pilot group for the study. However, the students who participated in the pilot study were not included in the final study as is general the principle with qualitative inquiry because of possible prior exposure “contamination”. The purpose of piloting was to gather data to provide guidance for a substantive study focusing on testing the data collection procedure, the interview process including the sequence and number of questions and probes and recording equipment efficacy. After the pilot phase, the lessons learned from the pilot were incorporated to ensure smooth operations during the actual focus group interview ( Malmqvist et al., 2019 .

Data Collection

The focus group interviews took place after the target population was exposed to case study analysis method in Maternal Health Nursing course during the Fall 2017 and Spring 2018 semesters. Before data collection began, the research team pilot tested the focus group interview guide to ensure that all the guide questions were clear and well understood by study participants.

In total, five (5) focus groups participated in the study, with each group comprising between four and six students. The focus group interviews lasted between 60 and 90 min. In addition to the interview guide questions, participants’ responses to unanswered questions were elicited using prompts to facilitate information flow whenever required. As a best practice, all the interviews were audio-recorded in addition to extensive field notes taken by one of the researchers. The focus group interviews continued until data saturation occurred in all the five (5) focus groups.

Credibility

In this study, participant's descriptions were digitally audio recorded to ensure that no information was lost. In order to ensure that the results are accurate, verbatim transcriptions of the audio recordings were done supported by interview notes. Furthermore, interpretations of the researcher were verified and supported with existing literature with oversight from the research team.

Transferability

The researcher provided a detailed description about the study settings, participants, sampling technique, and the process of data collection and analyses. The researcher used verbatim quotes from various participants to aid the transferability of the results.

Dependability

The researcher ensured that the research process is clearly documented, traceable, and logical to achieve dependability of the research findings. Furthermore, the researcher transparently described the research steps, procedures and process from the start of the research project to the reporting of the findings.

Confirmability

In this study, confirmability of the study findings was achieved through the researcher's efforts to make the findings credible, dependable, and transferable.

Data Analysis

Data were analyzed manually after the lead researcher integrated the verbatim transcriptions with the extensive field notes to form the final data set. Data were analyzed thematically under three thematic areas of a) knowledge development; b) critical thinking and problem solving; and (c) communication and collaboration, which are linked to the study objectives. The researchers used the Six (6) steps approach to conduct a trustworthy thematic analysis: (1) familiarization with the research data, (2) generating initial codes, (3) searching for themes, (4) reviewing the themes, (5) defining and naming themes, (6) writing the report ( Nowell et al., 2017 ).

The analysis process started with each team member individually reading and re-reading the transcripts several times and then identifying meaning units linked to the three thematic areas. The co-authors then discussed in-depth the various meaning units linked to the thematic statements until consensus was reached and final themes emerged based on the study objectives.

A total of 22 undergraduate third-year baccalaureate nursing students who were enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018 participated in the study, through five focus groups, with each group comprising four to six students. Of these, 59% were females and 41% were males. In total, nine subthemes emerged from the three themes. Under knowledge development, emerged the subthemes, “ deepened understanding of content ; “ reduced gap between theory and practice” and “ improved test-taking ability ”. While under Critical thinking and problem solving, emerged the subthemes, “ enhanced critical thinking ability ” and “ heightened curiosity”. The third thematic area of communication and collaboration yielded, “ improved communication ability ”; “ enhanced team-building capacity ”; “ effective collaboration” and “ improved presentation skills ”, details of which are summarized in Table 1 .

Table 1.

Objective Linked Themes and Student Perceptions of Outcome Case Study Analysis.

Theme 1: Knowledge Development

In terms of knowledge development, students expressed delight at the inclusion of case study analysis as a method during their regular theory class. The first subtheme related to knowledge development that supports the adoption of the case study approach is its perceived benefit of ‘ deepened understanding of content ’ by the students as vividly described by this participant:

“ I was able to perform well in the in-course exams as this teaching method enhanced my understanding of the content rather than memorizing ” (FGD#3).

The second subtheme related to knowledge development was informed by participants’ observation that teaching them using case study analysis method ‘ reduced the gap between theory and practice’. This participant's claim stem from the realization that, a case study scenario his group analyzed in the previous week helped him and his colleagues to competently deal with a similar situation during clinical placement the following week, as articulated below:

“ You see when I was caring for mothers in antenatal unit, I could understand the condition better and could plan her care well because me and my group already analyzed a similar situation in class last week which the teacher gave us, this made our work easier in the ward”. (FGD#7).

Another student added that:

“ It was useful as what is taught in the theory class could be applied to the clinical cases.”

This ‘theory-practice’ connection was particularly useful in helping students to better understand how to manage patients with different health conditions. Interestingly, the students reported that they were more likely to link a correct nursing care plan to patients whose conditions were close to the case study scenarios they had already studied in class as herein affirmed:

“ …when in the hospital I felt I could perceive the treatment modality and plan for [a particular] nursing care well when I [had] discussed with my team members and referred the textbook resource while performing case study discussion”. (FGD#17).

In a similar way, another student added:

“…I could relate with the condition I have seen in the clinical area. So this has given me a chance to recall the condition and relate the theory to practice”. (FGD#2) .

The other subtheme closely related to case study scenarios as helping to deepen participant's understanding of the course content, is the notion that this teaching strategy also resulted in ‘ improved test taking-ability’ as this participant's verbatim statement confirms:

“ I could answer the questions related to the cases discussed [much] better during in-course exams. Also [the case scenarios] helped me a great deal to critically think and answer my exam papers” (FGD#11).

Theme 2: Critical Thinking and Problem Solving

In this subtheme, students found the case study analysis as an excellent method to learn disease conditions in the two courses. This perceived success with the case study approach is associated with the method's ability to ‘ enhance students’ critical thinking ability’ as this student declares:

“ This method of teaching increased my ability to think critically as the cases are the situations, where we need to think to solve the situation”. (FGD#5)

This enhanced critical thinking ability attributed to case study scenario analysis was also manifested during patient care where students felt it allowed them to experience a “ flow of patient care” leading to better patient management planning as would typically occur during case scenario analysis. In support of this finding, a participant mentioned that:

“ …I could easily connect the flow of patient care provided and hence was able to plan for [his] management as often required during case study discussion” (FGD#12)

Another subtheme linked with this theme is the “ heightened curiosity” associated with the case scenario discussions. It was clear from the findings that the cases aroused curiosity in the mind of the students. This heightened interest meant that during class discussion, baccalaureate nursing students became active learners, eager to discover the next set of action as herein affirmed:

“… from the beginning of discussion with the group, I was eager to find the answer to questions presented and wanted to learn the best way for patient management” (FGD#14)

Theme 3: Communication and Collaboration

In terms of its impact on student communication, the subtheme revealed that case study analysis resulted in “ improved communication ability” among the nursing students . This enhanced ability of students to exchange ideas with each other may be attributed to the close interaction required to discuss and solve their assigned case scenarios as described by the participant below:

“ as [case study analysis] was done in the way of group discussion, I felt me and my friends communicated more within the group as we discussed our condition. We also learnt from each other, and we became better with time.” (FGD#21).

The next subtheme further augments the notion that case study analysis activities helped to “ enhance team-building capacity” of students as this participant affirmatively narrates:

“ students have the opportunity to meet face to face to share their views, opinion, and their experience, as this build on the way they can communicate with each other and respect each other's opinions and enhance team-building”. (FGD#19).

Another subtheme revealed from the findings show that the small groups in which the case analysis occurs allowed the learners to have deeper and more focused conversations with one another, resulting in “ an effective collaboration between students” as herein declared:

“ We could collaborate effectively as we further went into a deep conversation on the case to solve”. (FGD#16).

Similarly, another student noted that:

“ …discussion of case scenarios helped us to prepare better for clinical postings and simulation lab experience” (FGD#5) .

A fourth subtheme related to communication found that students also identified that case study analysis resulted in “ improved presentation skills”. This is attributed in part to the preparation students have to go through as part of their routine case study discussion activities, which include organizing their presentations and justifying and integrating their ideas. Besides readying themselves for case presentations, the advice, motivation, and encouragement such students receive from their faculty members and colleagues makes them better presenters as confirmed below:

“ …teachers gave us enough time to prepare, hence I was able to present in front of the class regarding the finding from our group.” (FGD#16).

In this study, the researches explored learner's perspectives on how one of the active teaching strategies, case study analysis method impacted their knowledge development, critical thinking, and problem solving as well as communication and collaboration ability.

Knowledge Development

In terms of knowledge development, the nursing students perceived case study analysis as contributing toward: (a) deeper understanding of content, (b) reducing gap between theory and practice, and (c) improving test-taking ability. Deeper learning” implies better grasping and retention of course content. It may also imply a deeper understanding of course content combined with learner's ability to apply that understanding to new problems including grasping core competencies expected in future practice situations (Rickles et al., 2019; Rittle-Johnson et al., 2020 ). Deeper learning therefore occurs due to the disequilibrium created by the case scenario, which is usually different from what the learner already knows ( Hattie, 2017 ). Hence, by “forcing” students to compare and discuss various options in the quest to solve the “imbalance” embedded in case scenarios, students dig deeper in their current understanding of a given content including its application to the broader context ( Manalo, 2019 ). This movement to a deeper level of understanding arises from carefully crafted case scenarios that instructors use to stimulate learning in the desired area (Nottingham, 2017; Rittle-Johnson et al., 2020 ). The present study demonstrated that indeed such carefully crafted case study scenarios did encourage students to engage more deeply with course content. This finding supports the call by educators to adopt case study as an effective strategy.

Another finding that case study analysis method helps in “ reducing the gap between theory and practice ” implies that the method helps students to maintain a proper balance between theory and practice, where they can see how theoretical knowledge has direct practical application in the clinical area. Ajani and Moez (2011) argue that to enable students to link theory and practice effectively, nurse educators should introduce them to different aspects of knowledge and practice as with case study analysis. This dual exposure ensures that students are proficient in theory and clinical skills. This finding further amplifies the call for educators to adequately prepare students to match the demands and realities of modern clinical environments ( Hickey, 2010 ). This expectation can be met by ensuring that student's knowledge and skills that are congruent with hospital requirements ( Factor et al., 2017 ) through adoption of case study analysis method which allows integration of clinical knowledge in classroom discussion on regular basis.

The third finding, related to “improved test taking ability”, implies that case study analysis helped them to perform better in their examination, noting that their experience of going through case scenario analysis helped them to answer similar cases discussed in class much better during examinations. Martinez-Rodrigo et al. (2017) report similar findings in a study conducted among Spanish electrical engineering students who were introduced to problem-based cooperative learning strategies, which is similar to case study analysis method. Analysis of student's results showed that their grades and pass rates increased considerably compared to previous years where traditional lecture-based method was used. Similar results were reported by Bonney (2015) in an even earlier study conducted among biology students in Kings Borough community college students, in New York, United States. When student's performance in examination questions covered by case studies was compared with class-room discussions, and text-book reading, case study analysis approach was significantly more effective compared to traditional methods in aiding students’ performance in their examinations. This finding therefore further demonstrates that case study analysis method indeed improves student's test taking ability.

Critical Thinking and Problem Solving

In terms of critical thinking and problem-solving ability, the use of case study analysis resulted in two subthemes: (a) enhanced critical thinking ability and (b) heightened learner curiosity. The “ enhanced critical thinking ability” implies that case analysis increased student's ability to think critically as they navigated through the case scenarios. This observation agrees with the findings of an earlier questionnaire-based study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh, that showed 81% of respondents agree that case study analysis develops critical thinking ability and enables students to do better problem analysis ( Muhiuddin & Jahan, 2006 ). This observation agrees with the findings of an earlier study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh. The study showed that 81% of respondents agreed that case study analysis facilitated the development of critical thinking ability in the learners and enabled the students to perform better with problem analysis ( Muhiuddin & Jahan, 2006 ).

More recently, Suwono et al. (2017) found similar results in a quasi-experimental research conducted at a Malaysian university. The research findings showed that there was a significant difference in biological literacy and critical thinking skills between the students taught using socio-biological case-based learning and those taught using traditional lecture-based learning. The researchers concluded that case-based learning enhanced the biological literacy and critical thinking skills of the students. The current study adds to the existing pedagogical knowledge base that case study methodology can indeed help to deepen learner's critical thinking and problem solving ability.

The second subtheme related to “ heightened learner curiosity” seems to suggest that the case studies aroused problem-solving interest in learners. This observation agrees with two earlier studies by Tiwari et al. (2006) and Flanagan and McCausland (2007) who both reported that most students enjoyed case-based teaching. The authors add that the case study method also improved student's clinical reasoning, diagnostic interpretation of patient information as well as their ability to think logically when presented a challenge in the classroom and in the clinical area. Jackson and Ward (2012) similarly reported that first year engineering undergraduates experienced enhanced student motivation. The findings also revealed that the students venturing self-efficacy increased much like their awareness of the importance of key aspects of the course for their future careers. The authors conclude that the case-based method appears to motivate students to autonomously gather, analyze and present data to solve a given case. The researchers observed enhanced personal and collaborative efforts among the learners, including improved communication ability. Further still, learners were more willing to challenge conventional wisdom, and showed higher “softer” skills after exposure to case analysis based teaching method. These findings like that of the current study indicate that teaching using case based analysis approach indeed motivates students to engage more in their learning, there by resulting in deeper learning.

Communication and Collaboration

Case study analysis is also perceived to result in: (a) improved communication ability; (b) enhanced team -building capacity, (c) effective collaboration ability, and (d) enhanced presentation skills. The “ improved communication ability ” manifested in learners being better able to exchange ideas with peers, communicating their views more clearly and collaborating more effectively with their colleagues to address any challenges that arise. Fini et al. (2018) report comparable results in a study involving engineering students who were subjected to case scenario brainstorming activities about sustainability concepts and their implications in transportation engineering in selected courses. The results show that this intervention significantly improved student's communication skills besides their higher-order cognitive, self-efficacy and teamwork skills. The researchers concluded that involving students in brainstorming activities related to problem identification including their practical implications, is an effective teaching strategy. Similarly, a Korean study by Park and Choi (2018) that sought to analyze the effects of case-based communication training involving 112 sophomore nursing students concluded that case-based training program improved the students’ critical thinking ability and communication competence. This finding seems to support further the use of case based teaching as an effective teaching-learning strategy.

The “ enhanced team-building capacity” arose from the opportunity students had in sharing their views, opinions, and experiences where they learned to communicate with each other and respect each other's ideas which further enhance team building. Fini et al. (2018) similarly noted that increased teamwork levels were seen among their study respondents when the researchers subjected engineering students to case scenario based-brainstorming activities as occurs with case study analysis teaching. Likewise, Lairamore et al. (2013) report similar results in their study that showed that case study analysis method increased team work ability and readiness among students from five health disciplines in a US-based study.

The finding that case study analysis teaching method resulted in “ effective collaboration ability” among students manifested as students entered into deep conversation as they solved the case scenarios. Rezaee and Mosalanejad (2015) assert that such innovative learning strategies result in noticeable educational outcomes, such as greater satisfaction with and enjoyment of the learning process ( Wellmon et al., 2012 ). Further, positive attitudes toward learning and collaboration have been noted leading to deeper learning as students prepare for case discussions ( Rezaee & Mosalanejad, 2015 ). This results show that case study analysis can be utilized by educators to foster professional collaboration among their learners, which is one of the key expectations of new graduates today.

The finding associated with “improved presentation skills” is consistent with the results of a descriptive study in Saudi Arabia that compared case study and traditional lectures in the teaching of physiology course to undergraduate nursing students. The researchers found that case-based teaching improved student’ overall knowledge and performance in the course including facilitating the acquisition of skills compared to traditional lectures ( Majeed, 2014 ). Noblitt et al. (2010) report similar findings in their study that compares traditional presentation approach with the case study method for developing and improving student's oral communication skills. This finding extends our understanding that case study method improves learners’ presentation skills.

The study was limited to level third year nursing students belonging to only one college and the sample size, which might limit the transferability of the study findings to other settings.

Implications for Practice

These study findings add to the existing body of knowledge that places case study based teaching as a tested method that promotes perception learning where students’ senses are engaged as a result of the real-life and authentic clinical scenarios ( Malesela, 2009 ), resulting in deeper learning and achievement of long-lasting knowledge ( Fiscus, 2018 ). The students reported that case scenario discussions broadened their perspectives, improved their cooperation capacity and communication with each other. This teaching method, in turn, offers students an opportunity to enhance their judgment and critical thinking skills by applying theory into practice.

These skills are critically important because nurses need to have the necessary knowledge and skills to plan high quality care for their patients to achieve a speedy recovery. In order to attain this educational goal, nurse educators have to prepare students through different student- centered strategies. The findings of our study appear to show that when appropriately used, case-based teaching results in acquisition of disciplinary knowledge manifested by deepened understanding of course content, as well as reducing the gap between theory and practice and enhancing learner's test-taking-ability. The study also showed that cased based teaching enhanced learner's critical thinking ability and curiosity to seek and acquire a deeper knowledge. Finally, the study results indicate that case study analysis results in improved communication and enhanced team-building capacity, collaborative ability and improved oral communication and presentation skills. The study findings and related evidence from literature show that case study analysis is well- suited approach for imparting knowledge and skills in baccalaureate nursing education.

This study evaluated the usefulness of Case Study Analysis as a teaching strategy. We found that this method of teaching helps encourages deeper learning among students. For instructors, it provides the opportunity to tailor learning experiences for students to undertake in depth study in order to stimulate deeper understanding of the desired content. The researchers conclude that if the cases are carefully selected according to the level of the students, and are written realistically and creatively and the group discussions keep students well engaged, case study analysis method is more effective than other traditional lecture methods in facilitating deeper and transferable learning/skills acquisition in undergraduate courses.

Conflict of Interest: The authors declare no conflict of interest.

ORCID iD: Judie Arulappan https://orcid.org/0000-0003-2788-2755

  • Ajani K., Moez S. (2011). Gap between knowledge and practice in nursing . Procedia-Social and Behavioral Sciences , 15 , 3927–3931. 10.1016/j.sbspro.2011.04.396 [ CrossRef ] [ Google Scholar ]
  • Bean J. C. (2011). Engaging ideas: The professor’s guide to integrating writing critical thinking and active-learning in the classroom (2nd ed.). Jossey-Bass. [ Google Scholar ]
  • Bonney K. M. (2015). Case study teaching method improves student performance and perceptions of learning gains . Journal of Microbiology & Biology Education , 16 ( 1 ), 21–28. 10.1128/jmbe.v16i1.846 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Braskamp L. A., Ory J. C. (1994). Assessing faculty work: Enhancing individual and institutional performance . Jossey-Bass Higher and Adult Education Series. Jossey-Bass Inc. [ Google Scholar ]
  • Centra J. A. (1993). Reflective faculty evaluation: Enhancing teaching and determining faculty effectiveness . Jossey-Bass. [ Google Scholar ]
  • Chen W., Shah U. V., Brechtelsbauer C. (2019). A framework for hands-on learning in chemical engineering education—training students with the end goal in mind . Education for Chemical Engineers , 28 , 25–29. 10.1016/j.ece.2019.03.002 [ CrossRef ] [ Google Scholar ]
  • Clarke J. (2010). Student centered teaching methods in a Chinese setting . Nurse Education Today , 30 ( 1 ), 15–19. 10.1016/j.nedt.2009.05.009 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Eronen L., Kokko S., Sormunen K. (2019). Escaping the subject-based class: A Finnish case study of developing transversal competencies in a transdisciplinary course . The Curriculum Journal , 30 ( 3 ), 264–278. 10.1080/09585176.2019.1568271 [ CrossRef ] [ Google Scholar ]
  • Factor E. M. R., Matienzo E. T., de Guzman A. B. (2017). A square peg in a round hole: Theory-practice gap from the lens of Filipino student nurses . Nurse Education Today , 57 , 82–87. 10.1016/j.nedt.2017.07.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Farashahi M., Tajeddin M. (2018). Effectiveness of teaching methods in business education: A comparison study on the learning outcomes of lectures, case studies and simulations . The International Journal of Management Education , 16 ( 1 ), 131–142. 10.1016/j.ijme.2018.01.003 [ CrossRef ] [ Google Scholar ]
  • Fini E. H., Awadallah F., Parast M. M., Abu-Lebdeh T. (2018). The impact of project-based learning on improving student learning outcomes of sustainability concepts in transportation engineering courses . European Journal of Engineering Education , 43 ( 3 ), 473–488. 10.1080/03043797.2017.1393045 [ CrossRef ] [ Google Scholar ]
  • Fiscus J. (2018). Reflection in Motion: A Case Study of Reflective Practice in the Composition Classroom [ Doctoral dissertation ]. Source: http://hdl.handle.net/1773/42299 [ Google Scholar ]
  • Flanagan N. A., McCausland L. (2007). Teaching around the cycle: Strategies for teaching theory to undergraduate nursing students . Nursing Education Perspectives , 28 ( 6 ), 310–314. [ PubMed ] [ Google Scholar ]
  • Garrison D. R., Kanuka H. (2004). Blended learning: Uncovering its transformative potential in higher education . The internet and higher education , 7 ( 2 ), 95–105. 10.1016/j.iheduc.2004.02.001 [ CrossRef ] [ Google Scholar ]
  • Hattie J. (2017). Foreword . In Nottingham J. (Ed.), The learning challenge: How to guide your students through the learning pit to achieve deeper understanding . Corwin Press, p. xvii. [ Google Scholar ]
  • Hermens A., Clarke E. (2009). Integrating blended teaching and learning to enhance graduate attributes . Education+ Training , 51 ( 5/6 ), 476–490. [ Google Scholar ]
  • Hickey M. T. (2010). Baccalaureate nursing graduates’ perceptions of their clinical instructional experiences and preparation for practice . Journal of Professional Nursing , 26 ( 1 ), 35–41. 10.1016/j.profnurs.2009.03.001 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Hodges C., Moore S., Lockee B., Trust T., Bond A. (2020). The difference between emergency remote teaching and online learning . Educause review , 27 , 1–12. [ Google Scholar ]
  • Jackson N. R., Ward A. E. (2012). Curiosity based learning: Impact study in 1st year electronics undergraduates. 2012 International Conference on Information Technology Based Higher Education and Training (ITHET), Istanbul, pp. 1–6. 10.1109/ITHET.2012.6246005. [ CrossRef ] [ Google Scholar ]
  • Kolb A. Y., Kolb D. A., Passarelli A., Sharma G. (2014). On becoming an experiential educator: The educator role profile . Simulation & Gaming , 45 ( 2 ), 204–234. 10.1177/1046878114534383 [ CrossRef ] [ Google Scholar ]
  • Lairamore C., George-Paschal L., McCullough K., Grantham M., Head D. (2013). A case-based interprofessional education forum improves students’ perspectives on the need for collaboration, teamwork, and communication . MedEdPORTAL, The Journal of Teaching and learning resources , 9 , 10.15766/mep_2374-8265.9484 [ CrossRef ] [ Google Scholar ]
  • Majeed F. (2014). Effectiveness of case based teaching of physiology for nursing students . Journal of Taibah University Medical Sciences , 9 ( 4 ), 289–292. 10.1016/j.jtumed.2013.12.005 [ CrossRef ] [ Google Scholar ]
  • Malesela J. M. (2009). Case study as a learning opportunity among nursing students in a university . Health SA Gesondheid (Online) , 14 ( 1 ), 33–38. 10.4102/hsag.v14i1.434 [ CrossRef ] [ Google Scholar ]
  • Malmqvist J., Hellberg K., Möllås G., Rose R., Shevlin M. (2019). Conducting the pilot study: A neglected part of the research process? Methodological findings supporting the importance of piloting in qualitative research studies . International Journal of Qualitative Methods , 18 . 10.1177/1609406919878341 [ CrossRef ] [ Google Scholar ]
  • Manalo E. (ed.). (2019). Deeper learning, dialogic learning, and critical thinking: Research-based strategies for the classroom . Routledge. [ Google Scholar ]
  • Martinez-Rodrigo F., Herrero-De Lucas L. C., De Pablo S., Rey-Boue A. B. (2017). Using PBL to improve educational outcomes and student satisfaction in the teaching of DC/DC and DC/AC converters . IEEE Transactions on Education , 60 ( 3 ), 229–237. 10.1109/TE.2016.2643623 [ CrossRef ] [ Google Scholar ]
  • Matua G. A., Seshan V., Akintola A. A., Thanka A. N. (2014). Strategies for providing effective feedback during preceptorship: Perspectives from an Omani Hospital . Journal of Nursing Education and Practice , 4 ( 10 ), 24. 10.5430/jnep.v4n10p24 [ CrossRef ] [ Google Scholar ]
  • Morgan D. L., Bottorff J. L. (2010). Advancing our craft: Focus group methods and practice . Qualitative Health Research , 20 ( 5 ), 579–581. 10.1177/1049732310364625 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • MsDade S. A. (1995). Case study pedagogy to advance critical thinking . Teaching psychology , 22 ( 1 ), 9–10. 10.1207/s15328023top2201_3 [ CrossRef ] [ Google Scholar ]
  • Muhiuddin G., Jahan N. (2006). Students’ perception towards case study as a method of learning in the field of business administration’ . The Chittagong University Journal of Business Administration , 21 , 25–41. [ Google Scholar ]
  • Noblitt L., Vance D. E., Smith M. L. D. (2010). A comparison of case study and traditional teaching methods for improvement of oral communication and critical-thinking skills . Journal of College Science Teaching , 39 ( 5 ), 26–32. [ Google Scholar ]
  • Nottingham J. (2017). The learning challenge: How to guide your students through the learning pit to achieve deeper understanding . Corwin Press. [ Google Scholar ]
  • Nowell L. S., Norris J. M., White D. E., Moules N. J. (2017). Thematic analysis: Striving to meet the trustworthiness criteria . International Journal of Qualitative Methods , 16 ( 1 ). 10.1177/1609406917733847 [ CrossRef ] [ Google Scholar ]
  • Nyumba T., Wilson K., Derrick C. J., Mukherjee N. (2018). The use of focus group discussion methodology: Insights from two decades of application in conservation . Methods in Ecology and evolution , 9 ( 1 ), 20–32. 10.1111/2041-210X.12860 [ CrossRef ] [ Google Scholar ]
  • Onweh V. E., Akpan U. T. (2014). Instructional strategies and students academic performance in electrical installation in technical colleges in Akwa Ibom State: Instructional skills for structuring appropriate learning experiences for students . International Journal of Educational Administration and Policy Studies , 6 ( 5 ), 80–86. [ Google Scholar ]
  • Park S. J., Choi H. S. (2018). The effect of case-based SBAR communication training program on critical thinking disposition, communication self-efficacy and communication competence of nursing students . Journal of the Korea Academia-Industrial Cooperation Society , 19 ( 11 ), 426–434. 10.5762/KAIS.2018.19.11.426 [ CrossRef ] [ Google Scholar ]
  • Parker A., Tritter J. (2006). Focus group method and methodology: Current practice and recent debate . International Journal of Research & Method in Education , 29 ( 1 ), 23–37. 10.1080/01406720500537304 [ CrossRef ] [ Google Scholar ]
  • Rezaee R., Mosalanejad L. (2015). The effects of case-based team learning on students’ learning, self-regulation and self-direction . Global Journal of Health Science , 7 ( 4 ), 295. 10.5539/gjhs.v7n4p295 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Rickles J., Zeiser K. L., Yang R., O’Day J., Garet M. S. (2019). Promoting deeper learning in high school: Evidence of opportunities and outcomes . Educational Evaluation and Policy Analysis , 41 ( 2 ), 214–234. [ Google Scholar ]
  • Rittle-Johnson B., Star J. R., Durkin K., Loehr A. (2020). Compare and discuss to promote deeper learning. Deeper learning, dialogic learning, and critical thinking: Research-based strategies for the classroom . Routlegde, p. 48. 10.4324/9780429323058-4 [ CrossRef ] [ Google Scholar ]
  • Sajjad S. (2010). Effective teaching methods at higher education level . Pakistan Journal of Special Education , 11 , 29–43. [ Google Scholar ]
  • Saunders B., Sim J., Kingstone T., Baker S., Waterfield J., Bartlam B., Burroughs H., Jinks C. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization . Quality & Quantity , 52 ( 4 ), 1893–1907. 10.1007/s11135-017-0574-8 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Savery J. R. (2019). Comparative pedagogical models of problem based learning . The Wiley Handbook of Problem Based Learning , 81–104. 10.1002/9781119173243.ch4 [ CrossRef ] [ Google Scholar ]
  • Shirani Bidabadi N., Nasr Isfahani A., Rouhollahi A., Khalili R. (2016). Effective teaching methods in higher education: Requirements and barriers . Journal of Advances in Medical Education & Professionalism , 4 ( 4 ), 170–178. [ PMC free article ] [ PubMed ] [ Google Scholar ]
  • Streubert H. J., Carpenter D. R. (2011). Qualitative research in nursing: Advancing the humanistic imperative . Wolters Kluwer. [ Google Scholar ]
  • Suwono H., Pratiwi H. E., Susanto H., Susilo H. (2017). Enhancement of students’ biological literacy and critical thinking of biology through socio-biological case-based learning . JurnalPendidikan IPA Indonesia , 6 ( 2 ), 213–220. 10.15294/jpii.v6i2.9622 [ CrossRef ] [ Google Scholar ]
  • Tiwari A., Lai P., So M., Yuen K. (2006). A comparison of the effects of problem-based learning and lecturing on the development of students’ critical thinking . Medical Education , 40 ( 6 ), 547–554. 10.1111/j.1365-2929.2006.02481.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Wang V., Farmer L. (2008). Adult teaching methods in China and bloom's taxonomy . International Journal for the Scholarship of Teaching and Learning , 2 ( 2 ), n2. 10.20429/ijsotl.2008 [ CrossRef ] [ Google Scholar ]
  • Wellmon R., Gilin B., Knauss L., Linn M. I. (2012). Changes in student attitudes toward interprofessional learning and collaboration arising from a case-based educational experience . Journal of Allied Health , 41 ( 1 ), 26–34. [ PubMed ] [ Google Scholar ]
  • Yajima K., Takahashi S. (2017). Development of evaluation system of AL students . Procedia Computer Science , 112 , 1388–1395. 10.1016/j.procs.2017.08.056 [ CrossRef ] [ Google Scholar ]
  • Yang W. P., Chao C. S. C., Lai W. S., Chen C. H., Shih Y. L., Chiu G. L. (2013). Building a bridge for nursing education and clinical care in Taiwan—using action research and confucian tradition to close the gap . Nurse Education Today , 33 ( 3 ), 199–204. 10.1016/j.nedt.2012.02.016 [ PubMed ] [ CrossRef ] [ Google Scholar ]

College of Nursing

Leadership for an innovative practice role: the dually certified nurse practitioner.

View as pdf A later version of this article appeared in  Nurse Leader ,  Volume 21, Issue 6 , December 2023 . 

Nurse leaders have repeatedly called for an expansion of nursing education, research, and clinical practice to identify and meet the social and healthcare needs of diverse and vulnerable populations. The National Institute of Nursing Research’s mission calls for optimizing health and advancing health equity through five lenses, as reflected in their new strategic plan: Health Equity, Social Determinants of Health, Population and Community Health, Prevention and Health Promotion, and Systems and Models of Care. 1 Further, the National Academy of Medicine’s (formerly the Institute of Medicine) reports on the Future of Nursing specifically call for nurses to provide care and to lead or contribute to solutions for vulnerable populations. These national nursing priorities build upon a foundation established by Berwick and colleagues 4 which advanced our understanding that access to culturally- based care should be provided where people live and be available when they need it.

Programs preparing nurse practitioners are ideally suited to respond to these calls to action. Important innovations are emerging in Doctor of Nursing Practice (DNP) programs. These changes are due to three main factors: First, growing market demands, especially the dearth of psychiatric providers; second, an increasing number of registered nurses entering DNP programs who wish to pursue dual certification; and finally, more current nurse practitioners (NPs) are returning to earn post-master’s degree certification in a second specialty. 5,6 Dual certification DNP curricula are comprehensive and challenging. Successful graduates have the knowledge, expertise, and skills to positively impact patient outcomes within the increasingly complex healthcare infrastructure. Although there are many plans of study for dual certification, of particular interest for this article are NPs with dual certification in primary care and psychiatry (PC/PMHNP). These NPs are exceptionally well qualified to provide and lead care for patients across the lifespan and with varying levels of acuity as well as high needs/high-cost patients 7 in institutional and community-based settings. Primary care settings and rural communities with compromised accessibility to specialty care such as psychiatry stand to benefit from incorporating a dually certified PC/PMHNP.  The purpose of this paper is to inform nurse leaders about this emerging role and provide tangible ways on how nurse leaders can support implementation. 

Introducing the Dually Certified Practitioner Role  

Nationally, approximately 20% of Americans experience a mental illness yearly, but only half are treated 8 Lack of care is a consequence of many factors including costs/coverage, too few care providers, and the stigma of receiving psychiatric care. The consequences of having a mental illness are high and include increased comorbidity risks for cardiovascular and metabolic diseases, substance use disorders, and other illnesses adversely affecting quality of life. Moreover, the COVID-19 pandemic amplified preexisting psychiatric disorders and increased anxiety and depression in the general public.

Access to mental health care is particularly challenging due to limited available mental health facilities. Dual PC/PMHNP providers in primary care settings increase access to mental health services by reducing the stigma attached to seeking services in a psychiatric setting, reducing wait times associated with referrals, and decreasing the need for persons seeking mental health care to negotiate additional schedules and relationships. National data indicate a decrease in primary care physicians’ growth by approximately 7% while nurse practitioner growth is expected to increase by 40% over the next decade, particularly amongst the care of rural and underserved populations. 9  Consequently, NPs have unique opportunities to address common challenges for practicing in rural settings in the care of patients with complex chronic physical and mental health conditions.

NPs are a source of affordable, quality, and trustworthy healthcare and are recognized for their expertise in preventive care. They are also highly effective at optimizing the patient experience, improving patient outcomes, and minimizing costs for the care of complex patients.  Dual-track NP programs that combine primary care and psychiatric mental health care by advanced practice nurses were first developed in 1997. 10 The combination of primary care and psychiatric mental health NP preparation enables the integration of medical and behavioral health care promotion, prevention, and management. The integration of primary and mental health care also facilitates holistic care, allowing providers to evaluate the effectiveness of medical and psychiatric therapies on the whole patient. 11

NP academic program curricula follow closely the National Organization of Nurse Practitioner Faculty (NONPF) Core Competencies that provide a foundation for NP role expectations and are aligned with the American Association of College of Nursing (AACN) Essentials for graduate nursing education. 12,13 Population-specific competencies (e.g., FNP, PMHNP) are also provided by NONPF to ensure clinical expertise preparation required for certification and entry into practice. 14 Curriculum design for dual NP programs has not been standardized, allowing academic institution flexibility in program design. Moreover, there is a lack of consensus amongst nursing academicians about the structure and makeup of a dual NP program.  Many regulatory bodies (state boards of nursing and certification bodies) do not track whether individuals have more than one NP certification, or if they do, make it publicly available. 

The University of Iowa College of Nursing has offered dual-track NP programming amongst the 8 specialty tracks since 2015 with 18 BSN-DNP dual graduates and specifically 13 PC/PMHNP graduates at the time of this publication.  Evaluations from graduates reveal high satisfaction with dual-track preparation with few disadvantages that included additional rigor and tuition requirements. 6 A pilot program, supported by funding from a Telligen Community grant in 2022, developed and implemented additional coursework and practicum experiences with a focus on integrative care for PC/PMHNP dual program students.  

The remainder of the paper focuses on benefits, barriers, and implementation of the dually certified PC/PMHNP role. Content is based on the literature and authors’ clinical experiences in the role. We include illustrative examples that reflect our practice observations and leadership in developing and implementing the role. 

Benefits Associated with the Dual Practitioner Role

Systems that employ dually certified nurse practitioners receive many benefits. These include a holistic approach, decreased stigma, patient empowerment through education and relationships, cross-system care across the care trajectory, and consultant expertise, as described next.  

Holistic approach

Many patients with physical conditions have co-occurring psychiatric conditions which impact both hospitalization and cost. 15, 16  The PC/PMHNP can address both the psychiatric and physical conditions yielding less fragmentation. 

The visit becomes holistic when the patient is empowered to think, “What do I need today?” For example, the visit might be for psychiatric medication management follow-up, but the patient says, “My meds are doing well, but my throat is sore and my knee is bothering me.”  The NP can shift and let the patient drive the visit. This is particularly important for people with serious mental illness (SMI) and substance use disorder whose most frequent contact is with psychiatry. If I were working only in a psychiatry office, I could only address psychiatric concerns, whereas in an integrated practice, I can address the whole person. We know physical health concerns are often underreported and under-addressed in people with SMI, so having the capacity for patients to bring up other health concerns is helpful. It reduces visits, builds trust and I can pick up on what might be a small issue before it becomes something bigger.

Streamlined care fosters efficiency, safety, and cost-effectiveness

Patients with co-occurring physical and psychiatric symptoms have higher healthcare utilization and thus are more costly to treat. 17 Further, they may be unaware of the connection between mental health symptoms and somatic expressions, or of how mental health symptoms can worsen medical conditions and vice versa. As a result, they are at risk for duplication of services and polypharmacy.  

Consider the case of a woman with post-traumatic stress disorder (PTSD) and major depressive disorder who was seen after a negative workup in the ER for chest discomfort. The NP and the woman worked together to process the episode, evaluating a recent trigger attributed to her PTSD. Moving forward the NP and the patient have a new way of talking about physical symptoms and PTSD-related anxiety. The NP can investigate any future somatic concerns and conduct a physical exam and, as appropriate, link somatic symptoms, (e.g., headache, chest pain) to increased anxiety. This reduces duplication of services, multiple visits and decreases the risk of inappropriate polypharmacy. 

Streamlined care can also benefit the larger system. Mergers are happening between hospital systems and community mental health. NPs can seamlessly move between community systems (e.g., residential care facilities, group homes, family settings) and institutionally based settings such as hospitals and nursing homes. Further, they can advocate and communicate with many disciplines as patients move across care settings. Additionally, dually certified NPs can serve as consultants, provide case reviews and collaborate with other health professionals within the health care system.

A more streamlined approach to care means patients do not work as hard to get what they need. 17 Having only one healthcare provider can minimize confusion, increase trust, and promote appropriate engagement in healthcare which may diminish ER visits and hospitalizations. This has the potential to lower costs, but rigorous cost evaluation studies are needed. 

Stigma reduction

Persons with mental illness are particularly vulnerable to the adverse effects of stigma such as shame, isolation, hopelessness, and discrimination. 18  

People are embarrassed to bring up their psychiatric concerns but when they know that I am also a psychiatric provider, they are relieved. I see the mental health concerns and can normalize symptoms and come up with a plan. Further, they are seeing me in a primary care office and don’t have to go to the psychiatry office, which is destigmatizing.

Dually certified PC/PMHNP are “empowerment enablers”

Patient empowerment 19 can be enhanced through working with a dually certified PC/PMHNP. As described below, the NP’s holistic lens contributed to efficiency, patient empowerment, and enhanced job satisfaction.  

I have seen growth in patient self-awareness and understanding of their own health. Nursing excels at taking time to provide patient education and promote self-management, but when we approach this through dual role/holistic services, patients gain an understanding of how their symptoms or day-to-day health is not an isolated representation of one problem, but rather a whole-body expression of what is going on. For example, if a patient living with diabetes and depression presents with an increase in average blood sugar readings they have a better understanding of how the two are interconnected --it sets us up to have a very different conversation as provider and patient than if I was only treating one condition and not the other. It is very rewarding to see patients empowered by understanding their own body/health. 

Barriers to Implementing the Role

Several issues arise as barriers in the implementation of the dual cert role. These include constraints in the practice environment, practice logistics, and issues with full practice authority.

Practice environment

Because many healthcare administrators are unaware of this emerging role, it takes creativity and vision to inform them of the benefits of hiring a dually certified NP. One effective means to eliminate/minimize this barrier is to engage a physician or medical director champion.  

The medical director quickly realized my vision for the dual role. If he hadn’t embraced the full capacity of the dual-prepared NP provider, I could have been reduced to primarily serving as either an FNP or PMHNP rather than the opportunity to use both at the same time.

Practice logistics

Issues with scheduling, appointment times, electronic health records, billing, and reimbursement may impede dually certified NP in maximizing their role. The NP often sees complex patients who require longer than a 15-minute appointment, especially when there is a need for collaboration with other disciplines. Further, some electronic health records may have automatic access restrictions on psychiatric notes which poses a barrier to communication for enacting full team-based care. 

Another barrier that dual-certified NPs face is changing the paradigm from volume-based to quality and value-based reimbursement. Billing and coding professionals based in primary care may not be prepared to support the added coding capacities that the dual cert NP possesses such as the counseling codes available to the psychiatric provider.

Full practice authority

Lack of full practice authority is a barrier to implementation of the dual cert role. In states where NPs require collaborative practice agreements, the NP with dual certification would require two physicians of varied specialties to practice. 

Facilitating Role Awareness and Adoption

Although there are many benefits to this role, it is still not well recognized nor understood.  Before this role can be widely adopted, an evidence base of improved clinical outcomes and cost-effectiveness must be provided to healthcare system leaders.  None of the currently published manuscripts on the dually certified role address cost nor systematically evaluate outcomes of the role. 

The dually certified NP must be able to confidently articulate their emerging role to health system administrators, medical leadership, members of the healthcare team, and patients.

It’s about owning the role and educating. When I am meeting with a patient for the first time, I introduce myself stating, “I am fully certified for family practice and psychiatric mental health. I have some patients I see for one or the other and some patients I see for both.” Often the patient is coming to me for one or the other because they don’t even know that such a thing exists. So, taking 20-30 seconds to explain my role to patients in this way has grown my dual/holistic practice. They often respond, “Oh, I didn’t know you could do that.” And typically, by the end of the visit they have decided to establish care with me for both services. 

Dually prepared nurse practitioners have an obligation to enhance awareness through the dissemination of information about the role. Dissemination can be by presentations, discussions, and publications in arenas where nurse executives and hospital administrators are likely to read and convene. 

NPs must also collect data on their own practice. Data on patient outcomes and satisfaction and cost savings will help validate the effectiveness of their role. NPs can also collect data on their insurance reimbursements using psychiatric counseling codes (e.g., 90833) to demonstrate the value of allowing extended appointment times and the financial benefits of quality over quantity. Partnering with health system administration leadership, schools of nursing and health services researchers is essential to foster role adoption and needed policy changes.

Future Directions

This is a new role that requires a vision of non-fragmented care for high-cost, complex patients with co-occurring mental health and physical health care needs. Nurse leaders can impact implementation of the role through a variety of means. These include advocating to Medicaid for dual-certified NP-led demonstration projects for high-cost patients, such as people with schizophrenia; expansion of dual cert programs at colleges of nursing nationwide; and promoting presentations/ posters related to dual cert roles and outcome studies at professional conferences. Nursing regulatory leaders in state and national boards of nursing, certification centers, and credentialing bodies play a particularly important role in assisting with gathering data on those NPs who maintain dual certification. Nurse leaders must also spearhead efforts to establish full practice authority through working in collaboration with their state and national boards of nursing, professional nursing organizations, and legislators. In states where there is already full scope of practice, they must remain vigilant for encroachments into full scope of practice.

As noted, national reports such as the Future of Nursing, encouraged the provision of care by nurses especially to vulnerable populations. Dually certified NPs are ideally prepared to provide care to high-needs/high-cost patients. 

This article is a beginning step to elucidating the dual certification role. Much more is needed to expand educational programs and the full practice of dually certified NPs. Most particularly we lack an evidence base on cost-effectiveness and patient outcomes. This is where nursing leaders in academic, regulation, and healthcare systems can collaborate to pave the way and expand program offerings, enhance awareness, and promote employment of dual certified NPs.

Acknowledgment

The authors wish to acknowledge Christopher Sang for his support in editing the manuscript.  

  • The National Institute of Nursing Research 2022–2026 Strategic Plan (2022).  https://www.ninr.nih.gov/aboutninr/ninr-mission-and-strategic-plan
  • Medicine IoM. The Future of Nursing: Leading Change, Advancing Health . 2011. 

National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030, Flaubert JL, Le Menestrel S, Williams DR, Wakefield MK, eds. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity . Washington (DC): National Academies Press (US); May 11, 2021.

Berwick DM, Beckman AL, Gondi S. The Triple Aim applied to correctional health systems. JAMA . Mar 9 2021;325(10):935-936. doi:10.1001/jama.2021.0263

Conley V, Judge-Ellis T. Disrupting the system: An innovative model of comprehensive care. J Nurse Pract . 2020;17(1):32-36. doi:10.1016/j.nurpra.2020.09.012

Wesemann D, Dirks M, Van Cleve S. Dual track education for nurse practitioners: Current and future directions. J Nurse Pract . 2021;17(6):732-736. doi:10.1016/j.nurpra.2021.01.024

Long P, Abrams M, Milstein A, Anderson G, Apton K, Dahlberg M, Whicher, D. (Eds). Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health . National Academy of Medicine. 2017.  https://nam.edu/wp-content/uploads/2017/06/Effective-Care-for-High-Need-Patients.pdf

Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health (Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration) (2022).  https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report

Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners (U.S. Department of Labor) (2023).   https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm

Dyer JG, Hammill K, Regan-Kubinski MJ, Yurick A, Kobert S. The psychiatric-primary care nurse practitioner: a futuristic model for advanced practice psychiatric-mental health nursing. Arch Psychiatr Nurs . Feb 1997;11(1):2-12. doi:10.1016/s0883-9417(97)80044-1

Blount A. Introduction to integrated primary care. In: Blount A, ed. Integrated Primary Care: The Future of Medical and Mental Health Collaboration . 1st ed. Norton; 1998:1-43.

Faculties NOoNP. NONPF’s Nurse Practitioner Role Core Competencies . 2022. https://www.nonpf.org/general/custom.asp?page=NP_Role_Core_CompetenciesAmerican

Nursing AoCo. The Essentials: Core Competencies for Professional Nursing Education . 2021. https://www.aacnnursing.org/essentials

Faculties NOoNP. NONPF’s Population-Focused Nurse Practitioner Competencies . 2013. www.nonpf.org/resource/resmgr/np_competencies_&_ntf_standards/compilation_pop_focus_comps.pdf

Figueroa JF, Phelan J, Orav EJ, Patel V, Jha AK. Association of mental health disorders with health care spending in the medicare population. JAMA Netw Open . Mar 2 2020;3(3):e201210. doi:10.1001/jamanetworkopen.2020.1210

Launders N, Dotsikas K, Marston L, Price G, Osborn DPJ, Hayes JF. The impact of comorbid severe mental illness and common chronic physical health conditions on hospitalisation: A systematic review and meta-analysis. PLoS One . 2022;17(8):e0272498. doi:10.1371/journal.pone.0272498

Ezell JM, Cabassa LJ, Siantz E. Contours of usual care: meeting the medical needs of diverse people with serious mental illness. J Health Care Poor Underserved . Nov 2013;24(4):1552-73. doi:10.1353/hpu.2013.0158

Pescosolido BA, Halpern-Manners A, Luo L, Perry B. Trends in public stigma of mental illness in the US, 1996-2018. JAMA Netw Open . Dec 1 2021;4(12):e2140202. doi:10.1001/jamanetworkopen.2021.40202

Bailo L, Guiddi P, Vergani L, Marton G, Pravettoni G. The patient perspective: investigating patient empowerment enablers and barriers within the oncological care process.  Ecancermedicalscience . 2019;13:912. Published 2019 Mar 28. doi:10.3332/ecancer.2019.912

Return to College of Nursing Winter 23/24 Newsletter

Effects of Case Studies and Simulated Patients on Students' Nursing Care Plan

Affiliations.

  • 1 Faculty of Health Sciences, Department of Nursing, Gazi University, Ankara, Turkey.
  • 2 Tokat Health College, Department of Nursing, Gaziosmanpasa University, Tokat, Turkey.
  • PMID: 25773922
  • DOI: 10.1111/2047-3095.12080

Purpose: The aim of this study is to determine the effects of using case studies and simulated patients in teaching students to plan their nursing care.

Methods: The study sample consisted of 70 second-year nursing students. Study data were collected using a questionnaire and by evaluating students' nursing care plans.

Results: The highest percentages of diagnoses identified were altered oral mucous membrane, ineffective breathing pattern, disturbed sleep pattern: less than body requirement, impaired tissue integrity, pain, and risk for infection.

Conclusions: The use of simulated patients in nursing education appears to help students evaluate realistic medical cases and clinical problems, and plan their nursing care.

Keywords: Education; nursing diagnosis; patient care planning.

© 2015 NANDA International, Inc.

  • Education, Nursing, Baccalaureate / organization & administration*
  • Patient Care Planning*
  • Patient Simulation*
  • Students, Nursing*
  • Young Adult

Case study: Automotive group sees increased engagement with a type 2 diabetes-specific health plan

To help employees better control their type 2 diabetes, Gurley Leep started offering the Level2 Health Plan by UnitedHealthcare.

Treating employees like family

At Gurley Leep’s 23 dealerships across the Midwest, 1,300+ employees work as salespeople, service technicians, general managers, service advisors, painters, body shop technicians and more.

“Gurley Leep started as a family business, and even though it’s grown from one dealership to 23, the owners still consider it a family business,” says Bobbi Imel, human resources director for Gurley Leep.

That family feel extends to the company’s benefit offerings. Whether it’s the “Make a Memory” matching vacation fund or dependent college scholarship support, Gurley Leep offers its workforce a competitive suite of benefits that also includes an HDHP and HSA to which Gurley Leep contributes up to $600 per quarter for eligible employees.

In 2023, Gurley Leep also added Level2—a health plan that guaranteed them 5% savings in the first year, 5% savings in the second year and 6% savings in the third year.

case study with nursing care plan

Providing specialized diabetes support

Through annual wellness screenings, Gurley Leep discovered that a number of employees were dealing with type 2 diabetes, which affects 1 in 10 Americans and accounts for 1 in 4 health care dollars.¹ For many employers like Gurley Leep, continuing at that cost trend is unsustainable. 

Gurley Leep initially contracted with a vendor to help its employees manage their type 2 diabetes. Unfortunately, “we just didn’t have a lot of traction with the program,” Imel says.

As a result, the company decided to switch course and offer employees the Level2 Health Plan in 2023.

Level2 by UnitedHealthcare is a different kind of health plan that provides coverage to employees and families who are managing a type 2 diabetes diagnosis — even when just one family member has type 2 diabetes. Offering no-cost access to Level2 Specialty Care teams who focus on improving type 2 diabetes treatment with wearable technology, personalized insights and expert care, Level2 is designed to drive better health outcomes and help employees and employers save money.

Members who activate the Level2 Specialty Care program can earn 100% coverage on common type 2 diabetes medication and supplies, lab work and primary care visits to high-value physicians by engaging in activities that will help manage their type 2 diabetes. For instance, employees can wear a continuous glucose monitor (CGM), which can help them understand how specific foods and activities impact their glucose levels.

Increasing engagement

In its first 6 months of offering Level2, Gurley Leep experienced higher engagement among employees than they had with their previous diabetes management program. In fact, 97% of verified type 2 diabetes members activated the Level2 Specialty Care program — and nearly 80% of those connected their CGM.

Part of that engagement can be attributed to the open enrollment resources and materials provided by Level2 that Imel says were easy to slot into their email communications and employee intranet forum.

“Looking forward, it would be nice if we could reach 100% participation,” says Imel, adding that they anticipate additional sign-ups in coming years.

Gurley Leep Benefits Manager Teresa Grace sees Level2 as a small but powerful picture of how the company cares for its workforce.

“This company really does care about their employees,” Grace says. “They want the best for them. When employees don’t have to worry about their benefits, they can really focus on the work they need to do for the company.”

More articles

Broker - page template - more news experience fragment, current broker or employer group client.

Access uhceservices to check commissions, manage eligibility, request ID cards and more.

Burnout, stress and retirement causing nearly 900,000 nurses nationwide to quit

No retreat seen in nurse shortage; study says another 800,000 quitting on top of 100,000 that already left workforce.

case study with nursing care plan

More nurses are expected to quit the profession including a sizable number under the age of 40, according to new national data about the ongoing nursing shortage.

Stress, burnout and retirement during the COVID-19 pandemic accelerated nurses leaving the profession and that trend continues today, according to the National Council on State Boards of Nursing.

The independent and nonprofit organization represents state nursing regulatory bodies.

Roughly 600,000 registered nurses say they plan to leave the workforce by 2027, according to the organization.

Avoiding manpower shortages: Healthcare, hospitality employers act on workforce housing scarcity to aid worker recruitment

Unemployment down: Job market remains strong in Southwest Florida, despite Hurricane Ian

Add to the problem: 189,000 registered nurses under the age of 40 plan to leave their jobs in the next four years.

Both figures are separate from the 100,000 registered nurses who already left their jobs during the COVID-19 pandemic.

Combined it means nearly 900,000 nurses, or almost one-fifth of the nation’s 4.5 million registered nurses, have or plan to call it quits, the data shows.

In a retiree-haven state like Florida where health care services are in high demand and care is big business, the nursing shortage has been a mainstay and competition fierce to recruit and retain nurses from a shrinking pool.

The Florida Hospital Association projects the state will face a deficit of 60,000 nurses by 2035.

“You have to think differently how you can attract and retain staff, not just nurses,” Renee Thigpen, chief human resources officer for the NCH Healthcare System in Collier County, said.

For patients in hospitals and other healthcare settings, the shortage of nurses means risk to quality of care and safety.

“The data is clear: the future of nursing and that of the U.S. health care ecosystem is at an urgent crossroads,” Maryann Alexander, the organization’s chief officer of nursing regulation, said in a statement.

Hospitals, policymakers and academic leaders need to act and “address these challenges and maximize patient protection in care into the future,” she said.

What the data shows is eye-opening.

The new numbers released by the national council is part of a workforce study done every two years.

More than 53,000 nurses were involved. A breakdown shows roughly 29,500 are registered nurses and advanced nurse practitioners while 24,000 are licensed practical nurses.

Here’s what they said about why they want to quit:

  • 51% are “emotionally drained.”
  • 56% are “used up.”
  • 50% are “fatigued.”
  • 45% are “burned out.”
  • 29% are “at the end of the rope” every day or few times a week.

The study found these issues are more pronounced among nurses with 10 years or less experience.

Licensed practical nurses who tend to work in long-term care settings caring for the elderly have seen their ranks decline by nearly 34,000 since the beginning of the pandemic.

The report did not say how many licensed practical nurses there are nationwide or the number employed in long-term care settings.

Also of note is a finding that newly-minted nurses may not be as clinically prepared in the workplace as hoped.

Early career data suggest a dip in practice skills and proficiency during assessments. 

That’s tied to disruptions at nursing schools during the pandemic when students were forced to switch to online training, according to the national council.

Here’s what local hospitals say

Southwest Florida hospitals are always fine-tuning their recruitment and retention initiatives to attract sought-after nurses.

On a positive note, their dependency on expensive traveling nurses which was crucial during the COVID-19 pandemic is subsiding.

Lee Health , the publicly-operated system in Lee County and one of the largest in Florida, has more than 3.500 bedside registered nurses with 550 open positions, according to Kristy Rigot, director of recruitment and retention.

More: Temp nurses cost hospitals big during the pandemic. Lawmakers are now mulling limits.

The lack of affordable housing in Lee has added to the recruitment challenge along with the overall shortage of nurses across the country.

On the plus side, Rigot said the Florida lifestyle is an appeal.

“The state also doesn’t collect an individual income tax and many consider that to be a perk of living here as well,” she said in an email.

Lee Health has four acute care hospitals with a combined 1,865 beds and it operates a regional children’s hospital with 134 beds.

In the past year, the bedside registered nurse vacancy rate has gone down to 14%, Rigot said. It was at nearly 20% a year ago.

 NCH is seeing a positive trend in hiring, Thigpen, chief human resource officer, said.

The private nonprofit system in Collier has two acute care hospitals with a combined 713 beds. For this year it has 1,023 bedside registered nurse positions; in 2022 it had 948.

The voluntary turnover rate in March 2022 was nearly 22% and is now down to below 20%, Thigpen said.

The vacancy rate today is 6% with 65 openings and 958 positions filled. The vacancy rate was 15% a year ago in March with 141 openings and 807 positions filled.

Social media is a health care recruiting tool

Both Lee Health and NCH say social media is an important recruitment tool in addition to the traditional job fairs and other methods.

Lee Health’s strategy includes a branding campaign, Rigot said.

Social media is an avenue for sourcing, for career sites, chat bots, job boards and an applicant tracking system, she said.

“In addition, we attend and host various career days and hiring events to promote Lee Health and its internships, workforce development and residency programs,” she said.

 “We also use recruitment incentives, such as sign-on bonuses, relocation and employee referral bonuses,” Rigot said.

NCH uses social media, including TikTok, and the mainstay methods such as job fairs but Thigpen said what’s critical is re-evaluating benefits and incentives to keep employees once they come.

“You have to get to the core of what keeps them happy,” she said.

Another program is an enhanced mentoring program that is key for the new generation of nurses, Thigpen said.

Travel nurses: Temp nurses cost hospitals big during the pandemic. Lawmakers are now mulling limits.

More: An Ohio mom couldn't find a home care nurse for her preemie baby — so she's becoming one

Are travel nurses still a necessity in the region?

Both Lee Health and NCH are seeing their need for travel nurses drop as the extraordinary demand of hands-on help during the pandemic has ended.

While filling a critical need, travel nurses are costly and put huge stains on manpower budgets.

“Lee Health has reduced utilization of travelers by approximately 23% over the past few months,” Rigot said. “This has been achieved through retention efforts and effective staffing management.

At one point, Lee Health had 700 travel nurses, Ben Spence, chief financial officer, said last September. The system spent roughly $163 million on contract labor in 2022, with 95% of that for travel nurses, he said.

NCH had 200-plus travel nurses at a high point during the pandemic and its now down to five with contracts ending at the end of June, Thigpen said.

The budget for the travel nurses was “in the multi-millions,” she said.

“We had a lot of great travelers but their allegiance isn’t to the organization,” she said. “They are filling a need.”

One reason for the nurse shortage is that some nurses opted to become travel nurses because its lucrative and because some of them can if they don’t have family obligations, she said.

“It’s a great opportunity and I don’t blame them but it hurts when you have a hospital base and need the nurses,” she said.

What nursing schools are doing

The nursing shortage isn’t lost on nursing schools in Florida which have faced constraints to expand enrollment because there are not enough instructors and costs.

After the state hospital association released its report in late 2021 that the state would face a deficit of 60,000 nurses by 2035, Keiser University formed a nursing advisory council with 34 leaders from around the state.

Keiser has 21 campuses in the state with nearly 20,000 students, including locations in Lee and Collier, and two international sites.

U.S. News rankings: Keiser among top 10 Florida colleges and universities for 2022-23

Last month the group presented a series of solutions for both the immediate future and long term to state lawmakers, according to Keiser.

“Florida has one of the highest percentages of elderly residents in the U.S.” Christine Mueller, chief nurse administrator for Keiser’s College of Nursing said, in an email. “This population typically requires more healthcare services which are overwhelmingly provided by nurses.”

 The nursing shortage is exacerbated by high turnover of new nurses, she said.

“The devastating truth is that greater than 50% of new nurses leave in their first two years of employment,” she said. “Some leave the profession all together and some leave for higher paying jobs, like travel nursing.”

Muller said it’s difficult to train new nurses when the long-term employees have left or retired and there is no one to mentor incoming nurses.

In January, Gov. Ron DeSantis announced $79 million for nursing education and for training partnerships to help with a pipeline of new nurses.

The funding rewards nursing programs with matching funds to scholarship awards, for faculty recruitment, equipment and other support.

The Keiser advisory council recommendations are designed to help remove barriers for growing the nursing workforce, to help with affordable housing, burn out, a lack of nurse educators and the limitations on clinical training for advanced nursing students.

wjxt logo

  • River City Live
  • Newsletters

Studies cited in case over abortion pill are retracted due to flaws and conflicts of interest

Laura Ungar And Matthew Perrone

Associated Press

A medical journal has retracted two studies claiming to show the harms of the abortion pill mifepristone, citing conflicts of interest by the authors and flaws in their research.

Two of the three studies retracted by medical publisher Sage Perspectives were cited in a pivotal Texas court ruling that has threatened access to the pill. The U.S. Supreme Court will take up the case next month, with a decision expected later this year. The court's ruling could impact nationwide access to mifepristone, including whether it continues to be available by mail.

Medication abortion accounts for more than half of all abortions in the U.S., and typically involves two drugs: mifepristone and misoprostol .

Here's what to know about the retractions:

WHAT DO THE STUDIES SAY?

Both studies cited in the court ruling were published in the journal Health Services Research and Managerial Epidemiology. They were supported by the Charlotte Lozier Institute, part of an advocacy group that seeks to end access to abortion.

A 2021 paper looked at 423,000 abortions and more than 121,000 emergency room visits following medication abortions and abortions done through a medical procedure from 1999 to 2015. Researchers concluded medication abortions are “consistently and progressively associated with more postabortion ER visit morbidity” than the other type.

A 2022 paper concluded that failure to identify a prior abortion during an ER visit — either by a doctor or because a patient concealed it — is “a significant risk factor for a subsequent hospital admission.”

HOW DO THESE STUDIES RELATE TO THE MIFEPRISTONE CASE?

U.S. District Judge Matthew Kacsmaryk cited the studies in a controversial legal ruling that will go before the U.S. Supreme Court next month.

Essentially, Kacsmaryk sided with a conservative Christian medical group, arguing that mifepristone’s original approval by U.S. regulators was flawed because it overlooked serious safety issues with the pill.

He cited one of the retracted studies in claiming that mifepristone causes “many intense side effects.” The ruling also cited the second retracted paper in explaining why anti-abortion physicians had the legal standing to bring their lawsuit — instead of showing they were directly harmed by a product, the judge said medical abortions cause “enormous pressure and stress" to physicians.

Many legal experts and medical professionals were deeply skeptical of the arguments and statistics cited in Kacsmaryk's decision, and a federal appeals court overturned parts of the ruling last summer.

The Food and Drug Administration's original 2000 approval of mifepristone is not in question, but the Supreme Court could roll back recent changes that made the drug easier to obtain, including via mail order.

WHY WERE THE STUDIES RETRACTED?

In a retraction notice, Sage Perspectives said a reader contacted the journal with concerns about the presentation of some of the data, possible “defects” in the selection of the data and whether authors’ affiliations with anti-abortion advocacy organizations present conflicts of interest that should have been disclosed.

Sage said in a statement that it asked two experts to conduct an independent post-publication peer review, which found the conclusions “were invalidated in whole or in part" for several reasons, including problems with the study design and methodology and errors in the analysis of the data.

The studies’ lead author, James Studnicki, said in an emailed statement that the publisher's actions are a “baseless attack on our scientific research and studies." Studnicki is a vice president at the Charlotte Lozier Institute.

Retractions of research papers have been on the rise, with more than 10,000 last year, according to Ivan Oransky, who teaches medical journalism at New York University and co-founded the Retraction Watch blog. About 1 in 500 papers is retracted, he said, compared with 1 in 5,000 two decades ago.

WHAT DOES THE SCIENCE SAY ABOUT MIFEPRISTONE?

Ushma Upadhyay, a professor of public health at the University of California, San Francisco, said medication abortions are extremely safe, with less than a third of 1% being followed by a serious adverse event. She pointed out that mifepristone has been used for more than two decades. The FDA says it has been used by about 6 million people for abortions.

She said one of the major flaws of the retracted research is that the authors conflate ER visits with serious adverse events and don’t confirm whether patients received treatment.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

Copyright 2024 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed without permission.

Click here to take a moment and familiarize yourself with our Community Guidelines.

IMAGES

  1. Nursing Case Study

    case study with nursing care plan

  2. FREE 10+ Nursing Case Study Templates in PDF

    case study with nursing care plan

  3. Family Nursing Care Plan in Case Study

    case study with nursing care plan

  4. FREE 10+ Nursing Case Study Templates in PDF

    case study with nursing care plan

  5. How To Write A Clinical Case Study Nursing

    case study with nursing care plan

  6. 10+ Nursing Case Study Examples in PDF

    case study with nursing care plan

VIDEO

  1. Nursing care plan & Case study :basic format

  2. Case Study/Nursing Education in hindi/Guidance and Counselling

  3. case study/ nursing care plan / pneumonia

  4. Case study on Ectopic pregnancy #obg #viral #shorts #casestudy #nursing #gnm

  5. Care plan on Dementia,#careplan, #casepresentation most important NCP on dementia in mental health

  6. case study on shock #nursing #bsc #ncp #case study# nursing student

COMMENTS

  1. 5 Nursing Case Study Examples + Answer Guide

    5 Nursing Case Study Examples + Answer Guide — smart'n - NextGen Learning Support for Nurses NGN Discover real-life nursing case studies with different patient scenarios and diagnoses, and learn from their outcomes and solutions.

  2. Case Study: Community Nursing Care Plan for a Man With Functional and

    Case Study: Community Nursing Care Plan for a Man With Functional and Psychosocial Problems Following a Stroke Pedro Ruyman Brito-Brito RN, MSc, PhD, Domingo Angel Fernandez-Gutierrez RN, MSc, Los Cristianos Clinical Case Work Group, Hilary M. Smith RN First published: 13 March 2015 https://doi.org/10.1111/2047-3095.12084 Citations: 1

  3. 400+ Nursing Care Plan Examples [Ultimate Guide]

    Example 1: Example 2: Short vs. Long-Term Goals Nursing Interventions Tips for Effective Care Planning Care Plan Examples Cardiac Endocrine & Metabolic Gastrointestinal Genitourinary Hematologic & Lymphatic Infectious Diseases Integumentary Maternal & Newborn Mental Health & Psychiatric Musculoskeletal

  4. Nursing Care Plans (NCP): Ultimate Guide and List

    Step 1: Data Collection or Assessment Step 2: Data Analysis and Organization Step 3: Formulating Your Nursing Diagnoses Step 4: Setting Priorities Step 5: Establishing Client Goals and Desired Outcomes Short-Term and Long-Term Goals Components of Goals and Desired Outcomes Step 6: Selecting Nursing Interventions Types of Nursing Interventions

  5. Nursing Care Plan Examples

    9 Cesarean Birth Nursing Care Plans Use this nursing care plan guide to create nursing diagnosis for cesarean birth or cesarean section. Maternal and Newborn Care Plans , Nursing Care Plans 7 Preeclampsia & Gestational Hypertensive Disorders Nursing Care Plans and Management

  6. Nursing Care Plans Based on NANDA, Nursing Interventions Classification

    Nursing care plans are vehicles for communication, records for the provided care, and constitute essential tools for everyday care. ... and (d) case studies, allowing in this way the application of theoretical knowledge in real‐life situations, ... A conceptual framework to study the use of nursing care plans. International Journal of Nursing ...

  7. Case Study: Community Nursing Care Plan for a Man With ...

    Case Study: Community Nursing Care Plan for a Man With Functional and Psychosocial Problems Following a Stroke Psychosocial problems complicate the management of a patient with functional consequences after a stroke. This fact has high impact on people who are going through this process.

  8. How to Write a Nursing Care Plan in 5 Steps

    Step 1: Assessment. The first step in writing an organized care plan includes gathering subjective and objective nursing data. Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable. This information can come from,

  9. Case study: community nursing care plan for an elderly patient with

    Purpose: The purpose of this paper is to show nursing procedures and standardized languages in care provided by community nurses to a patient affected by urinary incontinence after a prostatectomy. Data sources: Data were extracted from patient interviews during various consultations with the community nurse, and from electronic health records.

  10. Connection, Regulation, and Care Plan Innovation: A Case Study of Four

    Abstract. We describe how connections among nursing home staff impact the care planning process using a complexity science framework. We completed six-month case studies of four nursing homes. Field observations ( n = 274), shadowing encounters ( n = 69), and in-depth interviews ( n = 122) of 390 staff at all levels were conducted.

  11. Free Nursing Case Studies & Examples

    59 Lessons The nursing case studies account for over 37 hours of virtual clinical time. Each case study outlines anticipated completion time. Practicing Nurses All case studies are created by practicing ED/ICU nurses with Masters Degrees (like all NURSING.com content). Critical Thinking

  12. Nursing Care Plan Case Study Example for student sample

    Nursing Care Plan Case Study Example for student sample. Course. Healing practices for practical nurse (PNH401) 5 Documents. Students shared 5 documents in this course. University Geneva College. Academic year: 2019/2020. Uploaded by: Nima shah. University of Northern Iowa. 0 followers. 1 Uploads 90 upvotes.

  13. Standardized nursing care plan: a case study on developing a ...

    Standardized nursing care plan: a case study on developing a tool for clinical research 2008 Aug;30 (5):578-87. doi: 10.1177/0193945907312976. 10.1177/0193945907312976 The National Institutes of Health have developed a new organizational consortium through a funding mechanism called the Clinical and Translational Science Award.

  14. Application Scenarios for Artificial Intelligence in Nursing Care

    This study synthesizes literature on application scenarios for AI in nursing care settings as well as highlights adjacent aspects in the ethical, legal, and social discourse surrounding the application of AI in nursing care. Methods

  15. NUR 101 Case Study and Template for Nursing Care Plan

    Respiratory System Lab 2021 Pharmacology ATI Nclex Questions L. G. is a 45-year-old male who is a long-term smoker (100 pack years) who has arrived at the hospital with significant shortness of breath. He does not have any insurance so has not seen a health care provider in 25 years.

  16. How To Complete A Nursing Case Study With An Actual Patient Scenario

    Nursing Care Plan: Describe the care plan you developed, including the interventions and goals. Implementation and Evaluation: Discuss how you implemented the care plan, any modifications made, and the patient's response. Conclusion: Summarize the key takeaways from the case study and reflect on the overall experience. Conclusion

  17. Next Generation NCLEX Study Tips for Case Studies

    Conclusion of Study Tips for NGN Case Studies. In summary, the best way to prepare for the case studies on the Next Generation NCLEX is to actually understand the disease holistically, which means digging into the pathophysiology first, and then allowing that to flow to the signs and symptoms, medications, patient education, and so forth.

  18. Scenario Case Study for Nursing Process Care Plan 2 (2)

    CASE STUDY (COPD) - NURSING PROCESS CARE PLAN SCENARIO. D., a 65-year-old man, is admitted to your medical floor for exacerbation of chronic obstructive pulmonary disease (COPD). He has a past medical history of hypertension, which has been well controlled by enalapril (Vasotec) for the past 6 years.

  19. Using Reverse Case Studies for Clinical Learning

    For either method, students develop complete case study scenarios following prescriptive faculty guidelines. A nursing care plan or other form of care planning document used in your nursing program can be incorporated for creating the case scenarios and care planning. Examples of these two methods follow, along with some suggested guidelines ...

  20. 8 Myocardial Infarction (Heart Attack) Nursing Care Plans

    This comprehensive care plan guide focuses on the essential nursing assessment, interventions, nursing care plans and nursing diagnoses for effectively managing patients with myocardial infarction. ... in a study, only 15 subjects (15%) had documented that the ... Cautiously consider recommending and discussing alcohol use on a case-by-case ...

  21. OCD Nursing Diagnosis and Nursing Care Plan

    OCD Nursing Care Plans Diagnosis and Interventions. Obsessive-compulsive disorder (OCD) is a mental health condition that happens when a person becomes enmeshed in a chain of obsessions and compulsions. Obsessions are intrusive, unwelcome ideas, desires, or visions that cause incredibly upsetting emotions. Compulsions are actions someone takes ...

  22. Leveraging implementation science with using decision support

    View as pdf A later version of this article appeared in Nurse Leader, Volume 21, Issue 6, December 2023.. Abstract. Technology, such as clinical decision support, can play a role in supporting nurses' decision making, but understanding the complexity and current challenges in nurse decision-making is needed to guide the implementation of technology interventions focused on supporting ...

  23. Case Study Analysis as an Effective Teaching Strategy: Perceptions of

    Case Study Analysis as an Effective Teaching Strategy: Perceptions of Undergraduate Nursing Students From a Middle Eastern Country Vidya Seshan, 1 Gerald Amandu Matua, 2 Divya Raghavan, 1 Judie Arulappan, 1 Iman Al Hashmi, 1 Erna Judith Roach, 1 Sheeba Elizebath Sunderraj, 1 and Emi John Prince 3

  24. Leadership for an innovative practice role: the dually certified nurse

    Successful graduates have the knowledge, expertise, and skills to positively impact patient outcomes within the increasingly complex healthcare infrastructure. Although there are many plans of study for dual certification, of particular interest for this article are NPs with dual certification in primary care and psychiatry (PC/PMHNP).

  25. Effects of Case Studies and Simulated Patients on Students' Nursing

    Purpose: The aim of this study is to determine the effects of using case studies and simulated patients in teaching students to plan their nursing care. Methods: The study sample consisted of 70 second-year nursing students. Study data were collected using a questionnaire and by evaluating students' nursing care plans. Results: The highest percentages of diagnoses identified were altered oral ...

  26. Case study: Automotive group sees increased ...

    To help employees better control their type 2 diabetes, Gurley Leep started offering the Level2 Health Plan by UnitedHealthcare.

  27. How are Southwest Florida hospitals tackling spike in nurse shortage?

    A breakdown shows roughly 29,500 are registered nurses and advanced nurse practitioners while 24,000 are licensed practical nurses. Here's what they said about why they want to quit: 51% are ...

  28. Studies cited in case over abortion pill are retracted due ...

    FILE - A patient prepares to take the first of two combination pills, mifepristone, for a medication abortion during a visit to a clinic in Kansas City, Kan., on, Oct. 12, 2022. On Wednesday, Feb ...