Clinical Judgment Case Studies: Basic Care and Comfort

The Next Generation NCLEX (NGN) emphasizes clinical judgment through case studies that unfold over time. This section presents NGN-style scenarios to help you practice the six cognitive skills of the NCSBN Clinical Judgment Measurement Model (NCJMM).

Understanding the NCJMM

The Clinical Judgment Measurement Model guides how nurses think through patient care:

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Case Study 1: Mrs. Johnson - Nutrition and Hydration

Patient History: Mrs. Johnson is a 78-year-old female admitted for hip replacement surgery 2 days ago. She has a history of type 2 diabetes, hypertension, and mild dementia. She lives alone and her daughter visits weekly.

Current Assessment:

• Temperature: 99.2°F (37.3°C)
• Heart rate: 96 bpm
• Blood pressure: 108/68 mmHg (baseline 138/82)
• Dry mucous membranes
• Poor skin turgor on forehead
• Urine output: 180 mL over 8 hours (dark amber)
• Oriented to person only
• Refused breakfast and lunch, stating "I'm not hungry"
• Blood glucose: 186 mg/dL

Using the NCJMM:

1. Recognize Cues: What findings are significant?

• Decreased blood pressure from baseline
• Decreased urine output (below 30 mL/hour)
• Dark, concentrated urine
• Dry mucous membranes and poor skin turgor
• Low-grade fever
• Decreased orientation
• Refusing meals

2. Analyze Cues: What do these findings suggest?

• Signs consistent with dehydration: poor skin turgor, dark urine, low urine output, dry mucous membranes, tachycardia, hypotension
• Low-grade fever may indicate infection OR dehydration
• Confusion may be worsened by dehydration (especially concerning with dementia history)
• Elevated blood glucose may be related to poor intake or stress response

3. Prioritize Hypotheses:

• Most likely: Dehydration related to decreased oral intake
• Also consider: Possible infection (UTI, surgical site), medication effect

4. Generate Solutions:

• Encourage oral fluid intake
• Notify RN of assessment findings
• Monitor intake and output strictly
• Continue frequent vital sign monitoring
• Assess for other infection sources

5. Take Action:

• Report findings to RN immediately (significant change in condition)
• Offer preferred fluids in small amounts frequently
• Document assessment findings

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Case Study 2: Mr. Chen - Mobility and Skin Integrity

Patient History: Mr. Chen is a 65-year-old male with a T10 spinal cord injury following a motor vehicle accident 1 week ago. He has paraplegia and is unable to move his lower extremities. He is alert, oriented, and anxious about his condition.

Current Assessment:

• Weight: 185 lbs, Height: 5'10"
• Braden Scale score: 12 (high risk)
• Skin: 2 cm reddened area over sacrum that does not blanch with pressure
• Right heel: Slight redness that blanches
• Bowel sounds present, last bowel movement 4 days ago
• Bladder: Indwelling catheter in place
• Diet: Eating 50% of meals
• States: "I just want to lie still—moving is so uncomfortable"

Using the NCJMM:

1. Recognize Cues:

• Non-blanchable erythema over sacrum (Stage 1 pressure injury)
• Blanchable redness on right heel (at risk)
• High risk for pressure injuries (Braden score 12)
• Immobility due to spinal cord injury
• No bowel movement in 4 days
• Poor appetite (eating only 50%)
• Reluctant to reposition

2. Analyze Cues:

• Sacral area: Stage 1 pressure injury already present
• Heel redness: Early warning sign, not yet injured
• Immobility + poor nutrition + incontinence risk = high pressure injury risk
• Constipation developing (no BM in 4 days with reduced intake)
• Psychological factors affecting participation in care

3. Prioritize Hypotheses:

• Primary concern: Existing pressure injury at risk of worsening
• Secondary concerns: Developing constipation, inadequate nutrition, heel at risk

4. Generate Solutions: For pressure injury prevention/treatment:

• Reposition every 2 hours (or more frequently)
• Use pressure-redistributing mattress
• Float heels off surface
• Keep skin clean and dry
• Optimize nutrition

For constipation:

• Increase fluids
• Bowel program initiation
• Possible stool softeners as ordered

5. Take Action:

• Implement strict turning schedule
• Place pillows to float heels
• Document and report sacral injury to RN
• Encourage fluids and high-protein foods
• Address patient's concerns about repositioning
• Report need for bowel program to RN

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Case Study 3: Ms. Williams - Elimination

Patient History: Ms. Williams is a 45-year-old female admitted with multiple sclerosis (MS) exacerbation. She uses a wheelchair and has had urinary incontinence for the past year. An indwelling urinary catheter was inserted 5 days ago due to urinary retention.

Current Assessment:

• Temperature: 101.2°F (38.4°C)
• Heart rate: 88 bpm
• Urine: Cloudy with sediment, foul odor
• Complains of lower abdominal discomfort and back pain
• States "I feel like I need to urinate even though the catheter is in"
• Catheter insertion site: No redness or drainage
• Urine output: 350 mL over 8 hours
• WBC: 14,500/mm³ (elevated)

Using the NCJMM:

1. Recognize Cues:

• Fever (101.2°F)
• Cloudy, foul-smelling urine
• Urinary urgency sensation despite catheter
• Lower abdominal and back pain
• Catheter in place for 5 days
• Elevated WBC
• Decreased urine output

2. Analyze Cues:

• Classic signs of catheter-associated urinary tract infection (CAUTI):
  • Fever
  • Cloudy, malodorous urine
  • Urgency/discomfort
  • Elevated WBC
• Risk factor: Indwelling catheter for 5 days
• Decreased urine output may indicate bladder spasm or obstruction

3. Prioritize Hypotheses:

• Most likely: Catheter-associated UTI
• Consider: Need to assess for catheter patency/obstruction

4. Generate Solutions:

• Report findings to RN immediately
• Collect urine specimen for culture if ordered
• Assess catheter for patency and obstruction
• Increase fluids if not contraindicated
• Monitor vital signs closely
• Anticipate antibiotic therapy

5. Take Action:

• Notify RN of assessment findings (fever, cloudy urine, elevated WBC)
• Check catheter tubing for kinks or obstruction
• Ensure drainage bag is below bladder level
• Obtain urine culture specimen as ordered
• Document findings

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Practice Questions: Clinical Judgment

Use these questions to test your application of clinical judgment to the case studies above.