1. Jenkins, Peggy MSN, RN, CMSRN

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Clinical educators have many opportunities to provide learning experiences for staff both formally through teaching classes, mentoring students, or developing independent study activities and informally through conversing with staff, participating in committee work, and leading by example. The following case study highlights how a clinical educator used an informal, teachable moment to encourage a novice nurse to look past the patient's laboratory values and review the patient situation holistically.


As a clinical educator, I offer individual mock codes on monthly basis to afford staff a one-on-one learning opportunity and competency validation in the cardiac arrest process. Facilitating these mock codes enables me to interact with nurses on an individual basis, providing information related to the code situation and assisting nurses with "hands on" practice of techniques that are not often used. This learning experience affords the nurse time to speak of their past patient care experiences. Many share situations where patients had a change in condition and the Rapid Response Team was called to assist in the management of the patient care. The following is one such example.


A novice registered nurse (RN) arrived for the annual mock code competency assessment. I had worked closely with her during her employment as a Graduate Nurse and through her early days as a staff nurse assisting her with daily organizational skills. She had the clinical knowledge but was unable to organize her nursing care in an efficient and effective fashion. Through multiple sessions, using a round robin technique of discussing patient scenarios for the day and establishing priorities, she began to incorporate the planning processes into her day instead of focusing on requests and physician orders. Because we shared this experience and had established a trusting relationship, following completion of her mock code, she shared the following patient situation when she used the Rapid Response Team for patient evaluation.


A 79-year-old man with multiple myeloma was admitted to a medical surgical floor with shortness of breath via the emergency room where he was diagnosed with a right pleural effusion and anemia.


This RN cared for the patient for several days, had a day off, and returned to care for him. After returning from her day off, she noted a dramatic changed in his mental status; the patient was lethargic, and she was unable to arouse him. She notified the Rapid Response Team. During the evaluation, it was found that the patient's ammonia level was 148 (healthy adults: 15-45 [mu]g/dl). The patient was given lactulose in order to decrease the ammonia level and had further blood work drawn. The patient's ammonia level did not respond to administration of lactulose, and blood work revealed that the patient had normal liver function tests. Through further testing, it was determined that the cause of the patient's elevated ammonia level was related to his diagnosis of multiple myeloma. The patient was transferred to a cancer care unit and was discharged to home with the hospice.


While reviewing this case, the nurse remained focused on the elevated ammonia level and stated that she was surprised that the house physician even ordered the blood test because the patient had no history of liver disease. I then began to ask questions about the rationale for the use of the Rapid Response Team. The nurse stated that the patient was lethargic and she could not arouse him, and just the other day, he was sitting in the chair eating lunch when she took care of him. It was the dramatic change in the patient's mental status that prompted her to use the Rapid Response Team. I suggested that this case study would be an appropriate Nursing Grand Rounds presentation, and the nurse agreed to present with my assistance.


As we prepared the presentation, we reviewed the medical record, focusing specifically on documentation of neuroassessments. We determined the patient's baseline neuroassessment from the medical record. We then identified any documented deviations from the baseline prior to the incidence of lethargy. I wanted her to identify that this was a gradual deterioration, not an acute event. I discussed with her the signs and symptoms of delirium and contributing factors that put patients at risk, specifically the contributing factors this patient had.


This patient was at risk for the development of delirium during the course of his hospital stay; we did identify subtle changes in the patient's mental status documented prior to the day that the nurse was unable to arouse him. We then decided she would present the case study and I would present the physiologic portion, focusing my presentation on delirium, its signs and symptoms, and nursing care practices to prevent it.


When I prepared the research to present during this case, I focused on the important factors to include for a bedside nurse-precipitating factors and assessment. Delirium is a syndrome of symptoms that are initiated by an underlying cause. Approximately 10-30% of patients older than 65 years will have an episode of delirium during a hospital stay. The onset of symptoms is acute; initially, patients may experience periods of restlessness and exhibit fluctuations in lucidity with symptoms typically becoming worse at night. During my presentation, I referred back to the documentation that noted the change in the patient's behavior, especially at night, and noted that these were subtle clues pointing to this man's changing condition.


I then discussed treatment and prevention of delirium, including identifying the underlying cause of the delirium and treating it, which begins with a thorough history.


As nurses, we often have to put the pieces of a puzzle together, using all our resources to determine the patient's baseline assessment and if the current assessment is a change from the baseline. This includes a thorough reconciliation of a patient's home medications. The audience then shared many of their experiences with patients who exhibited symptoms of delirium and what the underlying causes were. Many staff members from the unit on which the nurse was based attended the Grand Rounds and identified that the population of patients they care for have many of the predisposing factors for delirium, especially postoperatively. I noted that pain management plays an important role in preventing symptoms of delirium by promoting comfort and sleep.



A 71-year-old man with a PMH of MI, Pacemaker/AICD, atrial fibrillation, CHF, nephrectomy, and ulcerative colitis was admitted via the emergency room with acute right-sided abdominal pain. His home medications included coumadin, digoxin, imdur, asacol, prednisone, zocor, lopressor, and 6-mercaptopurine. His preoperative diagnosis was perforated sigmoid colon secondary to diverticulosis and ulcerative colitis. The surgical procedure performed was laparotomy with subtotal colectomy, ileostomy, splenectomy, and repair of umbilical hernia. Postoperatively, he was diagnosed with lymphoma. This man had many of the predisposing factors for delirium. What nursing interventions did the staff (especially those who attended Grand Rounds) initiate to prevent an episode of delirium during the course of his hospitalization? Following chart review, paying close attention to neuroassessments and pain management documentation, I found that despite this individual's 2-week hospital stay and multiple predisposing factors for delirium, he remained cognitively intact without signs of delirium. When his comfort goal was not in target range, both pharmacologic and nonpharmacologic nursing measures were used to assist the patient to reach his comfort goal level. These nursing measures included relaxation techniques, back massage, and repositioning. By maintaining this patient's comfort goal, promoting sleep, and individualizing patient care, the staff added to the prevention of a possible episode of delirium on a patient with multiple predisposing factors.



According to Benner (2001), Level IV nurses are proficient practitioners who have in-depth knowledge of nursing practice and perceive each situation as a whole and comprehend the significant elements based on their own previous experience. They develop effective relationships with the healthcare team in formulating integrated approaches to care. Benner also identified the domains in which these nursing practices are demonstrated.


An in-depth knowledge of nursing practice was demonstrated by presenting the physiology of delirium in the Nursing Grand Round format, while the nursing process was highlighted as well. The foundation of documentation is usually developed from a legal perspective. However, the medical record is also a means of communication from caregiver to caregiver and between disciplines. Structuring educational programs to provide rational for routine nursing tasks and highlighting the positive impact and benefit on patient outcomes promote change. As professionals, we should not be practicing by completing tasks, but by contributing to outcomes. Educators guide the nurses' perspective away from viewing their work as tasks and toward a realization that these nursing actions lay the foundation for the patient's recovery.


Educators also demonstrate an in-depth knowledge of educational principals by capturing teachable moments, using realistic case scenarios to emphasize points, and structuring educational information to meet the developmental needs of nurses with a vast range of experiences. The content must be relevant, applicable, and reach the frame of reference of each learner.


Challenging the RN to look past the laboratory values and look at the subtle changes in the patient's neuroassessments, especially at night, over several days, not just when the patient exhibited a dramatic change in condition, took the focus from a laboratory report to the whole situation. Encouraging the RN to involve the family in the assessment of baseline neurological function promoted a perception of the situation as a whole. The nurse's presentation of these elements provided a meaningful message for her colleagues, which reflected "real" and not just ideological, theoretical nursing. By highlighting her limitations as a new nurse, she helped all nurses to identify opportunities to enhance patient outcomes and to augment their own clinical foundations.


Through previous experience, I have learned that an accurate patient history is essential in order to have a baseline for comparison especially when caring for the surgical patient whom you may be "seeing" for the first time postoperatively. I included this experience in both the formal Nursing Grand Rounds presentation and question-and-answer session that followed. Looking at the patient as a whole, identifying early changes, and involving family for validation of information were all nursing skills I learned through my previous experiences.


I also rely on my many years of previous patient care delivery experience to coach nurses to look past the documentation parameters that exist in the computer network. Whereas structuring documentation through computers helps the nurse complete all essential elements, it also creates "habitual" documentation. As a nurse focused on postoperative patients with very short lengths of stay, this nurse did not often encounter patients who suffered from more complex complications such as delirium. It was not part of her routine documentation process to include such detailed accounting of neurological responses. By shifting the focus of nursing care from required documentation to critical thinking, I can help nurses grow into more accomplished clinicians.


Nursing administrators, case managers, and educators may not directly administer a therapeutic intervention, but they affect that intervention in a supportive role. A nurse educator's role both formally and informally influences the development of individual nurses and patient care at the bedside.




Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall Health. [Context Link]