What is a case study?

Nursing school exam questions place you in a clinical scenario where you must decide based on the information provided. Many times, these scenarios are robust and full of a lot of details such as vital signs, past medical history, and the patient’s signs and symptoms. When you have a complex scenario such as this, it is called a case study.

Case studies can be challenging for students for a few different reasons:

• They can be lengthy
• They contain a lot of information, much of it numerical data  They often contain distractors or irrelevant information.
• They may contain abbreviations or terms you don’t understand
• You might not be sure what to do with all the information provided.
• The key to conquering case studies is to use a systematic approach you follow every single time.

Ready to get started?

Step 1: Read

Read through the entire case study from start to finish. Do not analyze the data at this time. Just read.

Mr. Parsons presents to the emergency department with worsening shortness of breath, fatigue, and a cough with thick, tan sputum over the past 48 hours. He has a past medical history for COPD, former smoker, hypertension and type 2 diabetes. Home medications include albuterol inhaler, tiotropium bromide inhaler, amlodipine, lisinopril, and metformin. His vital signs are as follows: RR 28 bpm, HR 112 bpm, SpO2 84% on room air, BP 133/88, temp 38.6° C. Skin signs are flushed, capillary refill is less than three seconds. He’s fatigued but oriented x 4. Observation of the patient reveals that the tripod position increased WOB with accessory muscle use. He is answering questions in short bursts of 4 to 6 words. Initial lab results show WBC 13K, haemoglobin 18 g/dL, Na 138, K 3.7, BUN 13, Cr 0.8, glucose 193. Chest X-ray shows hyperinflation of the lungs and consolidation in the bases.

Remember! Even though it may be tempting, do not analyze the data now. Just read the case study thoroughly from start to finish.

Step 2: Identify

Identify any terms or abbreviations you don’t understand and see if you can figure them out based on context. For example, you might not know what “tiotropium bromide” is, but you see it’s some inhaler, which makes sense for someone with a history of COPD. Another one you might not understand is “WOB.” From the context of the scenario, you may be able to figure out this means “work of breathing.” If nothing else, the fact that it’s paired with accessory muscle use would lead you to understand this is not a good sign, even if you’re not sure exactly what the letters stand for.

Step 3: Add more context

Review the case study and add more context to the presented data. A key thing students struggle with here is all the numerical data, including things like vital signs and lab values. So, take the numbers out of it.

For example, if the SpO2 is 88% on room air, you don’t need to remember the exact number. The context for this is “too low.” If the SpO2 is 68%, the context is “waaaaaay too low.” If the patient’s potassium level is 3.7, the context is “ fine.” However, if the potassium level is 2.6, the context is “too low.”

Do the same with the patient’s signs and symptoms, classifying them as “good”, “bad” or “expected.” For example, a patient with no accessory muscle use is “good” while a patient gasping for air is “bad.” And, a patient with peripheral neuropathy with numbness and tingling in their feet is “expected.” Let’s break it down in our example below:

Mr. Parsons presents to the emergency department with worsening shortness of breath (BAD),

fatigue (BAD), and a cough (BAD) with thick, tan sputum (BAD) over the past 48 hours. He has a past medical history of COPD, a former smoker, hypertension and type 2 diabetes. Home medications include albuterol inhaler, tiotropium bromide inhaler, amlodipine, lisinopril, and metformin. His vital signs are as follows: RR 28 bpm (TOO HIGH), HR 112 bpm (TOO HIGH), SpO2 84% on room air (TOO LOW), BP 133/88 (FINE), temp.

38.6° C (TOO HIGH). Skin signs are flushed (BAD), and capillary refill is less than three seconds (FINE). He’s fatigued (BAD) but oriented x 4 (GOOD). Observation of the patient reveals tripod position (BAD), and increased WOB (BAD) with accessory muscle use (BAD). He answers questions in short bursts of 4 to 6 words (BAD). Initial lab results show WBC 13K (TOO HIGH), haemoglobin 18 g/dL (FINE), Na 138 (FINE), K 3.7 (FINE), BUN 13 (FINE), Cr0.8 (FINE), glucose 193 (TOO HIGH). Chest X-ray shows hyperinflation of lungs (EXPECTED WITH COPD) and consolidation in the bases (BAD).

As you go through this step you really start to see all the abnormal findings and identify potential distractors or data that isn’t particularly relevant.

Step 4: Interpret abnormal labs

On Next Gen NCLEX, lab reference ranges are provided, so it’s not enough to know that a lab result is abnormal. You must demonstrate that you understand the significance of the abnormal lab. So, let’s look at Mr. Parsons and interpret his abnormal labs:

  WBC 13K – Indicates an inflammatory process and/or infection

  Blood glucose 193 – Blood glucose is elevated in the body’s stress response. Yes, Mr.

Parsons has a history of type 2 DM, but he also takes metformin, which should provide adequate blood glucose control. A blood glucose level suggests a pathological process, such as infection.

Consider how these abnormal labs support or clarify what you understand going on with your patient in the scenario.

Step 5: To rescue or not?

Determine if the patient needs immediate rescuing at this time. Utilize the ABCs and your understanding of pathophysiology to make this determination.

For example, a patient with no respirations needs immediate rescue. On the other hand, a patient with a respiratory rate of 28 requires some intervention, but their condition is not immediately life-threatening. In that case, the intervention will be less invasive, and you will have more time to analyze the situation and act.

This is helpful because the questions associated with your case study will often ask you about your priority actions. If the patient requires rescue, these questions are actually pretty easy to answer since they follow the ABCs.

To make this determination, look back through your scenario, focusing on the “bad” or abnormal findings. Are they mildly, moderately, or severely compromised? In our scenario, Mr. Parsons does not need immediate rescue, though he certainly does need intervention. We’ll keep this in mind as we move forward.

Step 6: Identify the main problem

There is no need to get specific, but you want a general idea of the patient’s clinical situation. For example, do they appear to have a respiratory issue, a change in neuro status, or an infection? Note that the patient will often have multiple problems, but try to zero in on the main problem they are currently facing. For example, a patient with severe sepsis will be dealing with an infection (their main problem). However, as a consequence of sepsis, they could also have a neuro problem (decreased level of consciousness) and a respiratory problem if their infection is in the lungs.

To identify the patient’s main problem, look back at your scenario as a whole and focus on the abnormal data.

For Mr. Parsons, his abnormal data points are:

Shortness of breath

Cough with thick, tan sputum Tachypnea

Tachycardia Hypoxia Fever Fatigue

Tripod position

Increased WOB w/ accessory muscle use Speaking in short sentences

Elevated WBC

Elevated blood glucose Consolidation in the base

Again, you’ll use your knowledge of pathophysiology to determine the patient’s main problem. In this case, all clues point to a respiratory infection and subsequent COPD exacerbation.

Let’s break it down a bit further so you can see how we got to that conclusion:

Shortness of breath – This could be due to COPD, but could also be due to respiratory infection. We need more clues!

Cough with thick, tan sputum – Big clue for respiratory infection.

Tachypnea – Tachypnea is a response to infection and hypoxia so the causes could be both COPD and an infection.

Tachycardia – Infection can cause tachycardia, but so can hypoxia, possibly due to infection or a COPD exacerbation (or both!).

 Hypoxia – Hypoxia can certainly occur with COPD, but with the other clues, I’m highly suspicious it is also associated with infection.

 Fever – A big clue for infection!

Step 6: Cont’d

 Fatigue – Fatigue is often associated with infectious processes and the hypercapnia that occurs with COPD.

 Tripod position – This is a common position assumed by patients experiencing a COPD exacerbation, which can occur with an acute infection.

 Increased WOB with accessory muscle use – Both a COPD exacerbation and a respiratory infection could cause increased WOB and accessory muscle use.

 Speaking in short sentences – Patients who are significantly short of breath will have to pause and take a breath after a few words, so this is another clue there’s a respiratory problem, though it’s not specific to a respiratory infection. Good thing we have other clues!

  Elevated WBC – Another big clue for infection!

  Elevated blood glucose – This may just be due to his type 2 DM, but glucose is also elevated in infection. With the presence of so many other clues, this is the likely pathology.

  Consolidation in the bases – Another big clue for infection (specifically pneumonia).

See how all clues start leading you to a logical conclusion?

Step 7: Look at medications

Look at the patient’s medications and see if you can quickly identify what the medication is for and how it works. Often, follow-up questions will be about the patient’s medications, so it’s good to quickly categorize what each one is for as it pertains to your patient’s clinical scenario. And sometimes, if you’re unsure of the patient’s main problem, analyzing their medications can help!

 Albuterol inhaler: short-acting bronchodilator for COPD, used to reverse bronchospasm (sometimes called a “rescue” inhaler)

 Tiotropium bromide inhaler: long-acting medication for COPD, used to prevent bronchospasm

  Amlodipine: calcium channel blocker for hypertension  Lisinopril: ACE-inhibitor for hypertension

  Metformin: oral medication for blood glucose control

Now it’s time to pause, take a few slow, deep breaths and give your brain some time to process what you’ve learned so far.

Step 8: Time to think

Before you move forward and start reading the questions associated with the case study, think about two things.

  What other assessment data do you want to obtain?

What are your initial thoughts on appropriate interventions for this patient?

By thinking ahead about your key assessments and interventions, you’re less likely to get derailed by questions designed to lead you down the wrong path. Note that case study questions will often ask about the patient’s secondary problems, so you must also anticipate those. For example, Mr. Parsons has a history of type 2 DM and hypertension. However, for the most part, they should focus on the patient’s main problem, so let your mind focus there.

Let’s dive into each of these questions

What other assessment data do you want to obtain?

 Auscultate lungs – Think about what you’d expect to hear: diminished lung sounds in the bases, possibly some wheezing, and a long expiratory phase.

 Arterial blood gas – What would you expect to see? Even without understanding ABG analysis, you’d know that he’s likely to have an elevated PaCO2 and low PaO2.

 Sputum culture – Since it looks like Mr. Parsons has pneumonia, we need to get the sputum tested so antibiotics can be tailored specifically for him.

 Look at SpO2 trends, if available. Essentially, you want to know how far from his baseline Mr. Parsons is. Many patients with COPD have a normal SpO2 in the mid to upper 80s. If you saw that his normal SpO2 is 86%, you’d still be concerned about a level of 84%, but not nearly as concerned as if you saw his normal SpO2 was 95%.

 Ask Mr. Parsons if he uses oxygen at home. This will help you recognize when Mr. Parsons has returned to baseline. If he requires 2 L NC and uses 2 L NC at home, he’s at baseline for his oxygen requirements (provided WOB and RR are also at baseline).

  Lactate level – Mr. Parsons is showing signs of sepsis, so we should get a lactate level to see how severe it is. Note that patients with sepsis are not always initially hypotensive.

Hypotension is actually a later sign, so let’s catch this early if he is indeed septic!

 Look at blood glucose trends, if available. Again, you want to see if this is an abnormal spike for Mr. Parsons or if he always runs this high.

• HbA1C – Though Mr. Parsons isn’t in the ER for his diabetes, while he’s here it’s good to check and see how well his blood glucose is being controlled.

Step 8: Cont’d

What are your initial thoughts on appropriate interventions for this patient?

 Oxygen to maintain a SpO2 above MD parameters. The default is generally above 92% in the clinical setting, though this can vary. A patient with COPD with a baseline SpO2 that’s a bit lower may have lower parameters.

  Antibiotics – We generally start with broad-spectrum antibiotics once the MD has verified the presence of infection.

  Fluids – Fluids are essential to pneumonia treatment as they help thin secretions so they are easier to mobilize. And, if Mr. Parsons’ lactate level does come back elevated, fluids are a key component of prompt sepsis treatment.

Step 9: Read each question and all answers

Read each question associated with the case study and all the answers thoroughly before selecting your response. If needed, go back and reference the scenario to ensure you’re remembering the key points correctly. Make sure you notice which questions are single-choice and which are select-all-that-apply.

Look for keywords such as priority, initial, first, most, all, never, and except.

Step 10: Choose the best answer!

Use the ABCs, Maslow’s Hierarchy of Needs, and The Nursing Process to answer questions.

Focusing on the ABCs ensures you address the most important things first, which are issues with the airway, breathing, and circulation.

Maslow’s hierarchy ensures that high-priority physiological needs are met before lower-priority needs are met. For example, giving medication to increase blood pressure is a physiological need that would take priority over the patient’s need for emotional support.

The Nursing Process ensures you do things correctly – assess, diagnose or identify the problem, plan, intervene, and evaluate. The question’s wording will let you know where you are in the nursing process, and the answer will generally relate to the next step in that process. Let’s break that down on the next page!

Step 10: Cont’d

Assess – Noticing something is wrong with the patient and performing an assessment. This can include taking vital signs, performing a physical assessment, and reviewing diagnostic results such as lab values. This is what you did in Steps 3 and 4.

Diagnose or identify the problem – Essentially this is what you did in Step 6, when you identified the patient’s main problem.

Plan and intervene – Based on your assessment and understanding of the patient’s main problem, decide the most appropriate course of action and do it!

Evaluate – Evaluate if your intervention was successful. For example, if the patient’s SpO2 is 85% on RA and you place them on a 4 L nasal cannula, you would expect the SpO2 to increase. If it doesn’t, further assessment and intervention is necessary.

Does this approach work for all question types?

In a word, YES! Regardless of which type of question it is (multiple choice, bow tie, select-all-that-apply, etc…), if you systematically evaluate your case study scenario, you’ll think through the questions logically, eliminate distractions, apply critical thinking, and be ready to choose the best course of action.

Best of luck to you!