Brief Contents PART ONE MEDICAL-SURGICAL CASES, 1 Chapter 1 Cardiovascular Disorders, 1 Chapter 2 Respiratory Disorders, 83 Chapter 3 Musculoskeletal Disorders, 149 Chapter 4 Gastrointestinal Disorders, 189 Chapter 5 Genitourinary Disorders, 235 Chapter 6 Neurologic Disorders, 273 Chapter 7 Endocrine Disorders, 341 Chapter 8 Immunologic Disorders, 367 Chapter 9 Oncologic and Hematologic Disorders, 393 PART TWO PEDIATRIC, MATERNITY, AND PSYCHIATRIC CASES, 439 Chapter 10 Pediatric Disorders, 439 Chapter 11 Maternal and Obstetric Disorders, 505 Chapter 12 Women's Health Disorders, 533 Chapter 13 Psychiatric Disorders, 559 PART THREE OTHER/ADVANCED CASES, 591 Chapter 14 Alternative Therapies, 591 Chapter 15 Patients with Multiple Disorders, 599 Chapter 16 Emergency Situations, 625 Appendix: Abbreviations and Acronyms, 663 Illustration Credits, 669 5TH EDITION Winningham's Critical Thinking Cases In Nursing Medical-Surgical, Pediatric, Maternity, and Psychiatric MARIANN HARDING, MSN, RN Associate Professor Department of Nursing Kent State University at Tuscarawas New Philadelphia, Ohio JULIE S. SNYDER, MSN, RN-BC Adjunct Faculty School of Nursing Old Dominion University Norfolk, Virginia † BARBARA A. PREUSSER , PHD, FNPC Family Nurse Practitioner Veterans Administration Medical Center Salt Lake City, Utah †Deceased 3251 Riverport Lane St. Louis, Missouri 63043 WINNINGHAM'S CRITICAL THINKING CASES IN NURSING: MEDICAL-SURGICAL, PEDIATRIC, MATERNITY, AND PSYCHIATRIC ISBN: 978-0-323-08325-6 Copyright © 2013 by Mosby, Inc., an affiliate of Elsevier Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including p hotocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, m ethods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a p rofessional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most cur- rent information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or f ormula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own e xperience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any l iability for any injury and/or damage to persons or property as a matter of products liability, negligence or o therwise, or from any use or operation of any methods, products, instructions, or ideas contained in the m aterial herein. Previous editions copyrighted 2009, 2005, 2001, 1996 Library of Congress Cataloging-in-Publication Data Harding, Mariann. Winningham's critical thinking cases in nursing : medical-surgical, pediatric, maternity, and psychiatric / Mariann Harding, Julie S. Snyder, Barbara A. Preusser. – 5th ed. p. ; cm. Critical thinking cases in nursing Rev. ed. of: Critical thinking in medical-surgical settings / Maryl L. Winningham and Barbara A. Preusser. 2nd ed. c2011. Includes bibliographical references. ISBN 978-0-323-08325-6 (pbk. : alk. paper) I. Snyder, Julie S. II. Preusser, Barbara A. III. Winningham, Maryl Lynne, 1947–2001. Critical thinking in medical-surgical settings. IV. Title. V. Title: Critical thinking cases in nursing. [DNLM: 1. Nursing Process–Case Reports. 2. Nursing Process–Problems and Exercises. 3. Nursing Care– Case Reports. 4. Nursing Care–Problems and Exercises. WY 18.2] 610.73–dc23 2012003221 Executive Content Strategist: Lee Henderson Content Development Specialist: Jacqueline Twomey Publishing Services Managers: Hemamalini Rajendrababu & Deborah L. Vogel Project Managers: Anitha Sivaraj & John W. Gabbert Design Direction: Karen Pauls Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 To Drs. Maryl L. Winningham and Barbara A. Preusser Drs. Winningham and Preusser, authors of this text for the previous four editions, dedicated their lives to the care of others and the pursuit of excellence in nursing practice. They have bequeathed a nursing heritage of integrity, excellence, courage, and service to their students, c olleagues, and readers. This page intentionally left blank Contributors Ann Campbell, RN, MSN, CPNP Sara B. Forbus, MSN, RN Faculty Faculty School of Nursing School of Nursing Old Dominion University Old Dominion University Norfolk, Virginia Norfolk, Virginia Contributors to Previous Editions Elizabeth Jane Bell, MSN, ANPc Janet G. Madsen, PhD Lesley A. Black, BSN, MS, ANPc, CWOCN Debra Ann Mills, RN, MS Kent Blad, MS, FNPc, ACNP-C, FCCM Jeanie O'Donnell, MSN Jamie Clinton-Lont, BSN, FNPc Deb Plasman-Coles, PAc Susan L. Croft, BSN, MS Laura Lee Scott, MSN, FNPc Joyce Foster, PhD, CNM, FACNM, FAAN Mary Seegmiller, MSN Shellagh Gutke, BSN, CWOCN Sandra Smeeding, MS, FNPc Nancy Hayden, MSN, FNPc Deborah D. Smith, BSN Sondra Heaston, MS, FNPc, CEN Ann Speirs, BSN Janice Hulbert, RN, MS Ronald Ulberg, BSN, MSN Lisa Jensen, BSN, MS, APRN, CS Kristy Vankatwyk, MSN, FNPc Stephanie C. Kettendorf, MS, RN, CNS, NCBF Annette S. Wendel, BSN Julie Killebrew, BSN, MS Wendy Whitney, MSN, FNPc, CANP Karen Kone, BSN, ACRN Mary Youtsey, BSN, CDE Kathleen Kuntz, MSN, APRN, SANE Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. v Reviewers Diane K. Daddario, MSN, ACNS-BC, RN, Jamie Lynn Jones, MSN, RN BC, CMSRN Assistant Professor, Nursing Nurse Specialist University of Arkansas at Little Rock Geisinger Medical Center Little Rock, Arkansas Danville, Pennsylvania; Staff Nurse Tamara M. Kear, PhD, MSN, RN Evangelical Community Hospital Assistant Professor of Nursing Lewisburg, Pennsylvania; Villanova University Nursing Instructor Villanova, Pennsylvania Pennsylvania College of Technology Williamsport, Pennsylvania Cheryl A. Lehman, PhD, RN, CNS-BC, RN-BC, CRRN Jennifer Duhon, RN, MS CNS Program Coordinator Director of Health Services Department of Health Restoration & Lutheran Senior Services Care Systems Management (HRCSM) Peoria, Illinois Clinical Associate Professor The University of Texas Health Science Sara B. Forbus, MSN, RN Center at San Antonio Faculty San Antonio, Texas School of Nursing Old Dominion University Casey Norris, MSN, BSN Norfolk, Virginia Adjunct Instructor, Nursing South College Mimi Haskins, MS, RN, CMSRN Pulmonary Clinical Nurse Specialist Nursing Staff Development Instructor East Tennessee Children's Hospital Roswell Park Cancer Institute Knoxville, Tennessee Buffalo, New York Brenda K. Shelton, MS, RN, CCRN, AOCN Suzanne Jed, MSN, APRN-BC The Sidney Kimmel Cancer Center at Johns Clinical Instructor, Family Medicine Hopkins Keck School of Medicine Baltimore, Maryland University of Southern California Los Angeles, California irypoC if fa na , ybsoM yb 3 1 02 © thg il veslE fo eta i .cnI re vi irypoC if fa na .cnI , 02 © thg ybsoM yb ,69 02 ,90 1 ,1 02 ,50 0 il veslE fo eta iir lA .cnI re vreser sthg .de Introduction There is an urgent need for nurses with well-practiced critical thinking skills. As new graduates, you will make decisions and take actions of an increasingly sophisticated nature. You will encoun- ter problems you have never seen or heard about during your classroom and clinical experiences. You are going to have to make complex decisions with little or no guidance and limited resources. We want you to be exposed to as much as possible during your student days, but more impor- tantly, we want you to learn to think. You cannot memorize your way out of any situation, but you can think your way out of any situation. We know that students often learn more and faster when they have the freedom to make mistakes. This book is designed to allow you to experiment with finding answers without the pressure of someone's life hanging in the balance. We want you to do well. We want you to be the best. It is our wish for you to grow into confident, competent profes- sionals. After all, someday we will be one of those people you care for, and when that day comes, we want you to be very, very good at what you do! What Is Critical Thinking? Critical thinking is not memorizing lists of facts or the steps of procedures. Instead, critical think- ing is an analytical process that can help you think through a problem in an organized and efficient manner. Five steps are involved in critical thinking. Thinking about these steps may help you when you work through the questions in your cases. Here are the five steps with an explanation of what they mean. 1. Recognize and define the problem by asking the right questions: Exactly what is it you need to know? What is the question asking? 2. Select the information or data necessary to solve the problem or answer the question: First you have to ask whether all the necessary information is there. If not, how and where can you get the additional information? What other resources are available? This is one of the most difficult steps. In real clinical experiences, you rarely have all of the information, so you have to learn where you can get necessary data. For instance, patient and family interviews, nursing charting, the patient medical chart, laboratory data on your computer, your observations, and your own physical assessment can help you identify important clues. Of course, information can rapidly become outdated. To make sure you are accessing the most current and accurate information, you will occasionally need to use the Internet to answer a question. 3. Recognize stated and unstated assumptions; that is, what do you think is or is not true? Sometimes answers or solutions seem obvious; just because something seems obvious doesn't mean it is correct. You may need to consider several possible answers or solutions. Consider all clues carefully and do not dismiss a possibility too quickly. Remember, “You never find an answer you don't think of.” irypoC if fa na , ybsoM yb 3 1 02 © thg il veslE fo eta i .cnI re irypoC if fa na .cnI , 02 © thg ybsoM yb ,69 02 ,90 1 ,1 02 ,50 0 il veslE fo eta iir lA .cnI re vreser sthg .de vii I N T R O D U C T I O N .4 Formulate and select relevant and/or potential decisions. Try to think of as many possibilities as you can. Consider the pros and cons of the consequences of making each decision. What is the best answer/solution? What could go wrong? This requires considering many different angles. In today's health care settings, decision-making often requires balancing the well- being needs of the patient, the preferences and concerns of the patient and caregiver, and financial limitations imposed by the reimbursement system. In making decisions, you need to take into account all relevant factors. Remember, you may need to explain why you rejected other options. 5. Draw a valid, informed conclusion: Consider all data; then determine what is relevant and what makes the most sense. Only then should you draw your conclusion. It may look as if this kind of thinking comes naturally to instructors and experienced nurses. You can be certain that even experienced professionals were once where you are now. The rapid and sound decision-making that is essential to good nursing requires years of practice. The practice of good clinical thinking leads to good thinking in clinical practice. This book will help you practice the important steps in making sound clinical judgments until the process starts to come naturally. The practice of good clinical thinking leads to good thinking in clinical practice. hT e oH“ w to ” of Case tS du ies When you begin each case, read through the whole story once, from start to finish, getting a general idea of what it is about. Write down things you have to look up. This will help you move through the case smoothly and get more out of it. How much you have to look up will depend on where you are in your program, what you know, and how much experience you already have. Preparing cases will become easier as you advance in your program. Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. viii Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.