Overview
This lecture reviews an NGN-style nursing case study using the Clinical Judgment Measurement Model, focusing on clinical reasoning steps, case analysis, and appropriate interventions for a client with anxiety and possible panic disorder.
Clinical Judgment Measurement Model
- The Clinical Judgment Measurement Model (CJMM) assesses how well nursing students make bedside decisions.
- CJMM has six steps: Recognizing cues, Analyzing cues, Prioritizing hypotheses, Generating solutions, Taking action, and Evaluating outcomes.
- Each NGN case study question corresponds to one step of the CJMM.
Case Study: Client Assessment
- Client presents to the emergency department fearful of a heart attack with chest tightness, dizziness, and palpitations.
- Mentally, the client is fidgety, tearful, has a flat affect, but is logical without suicidal ideation.
- Physical findings: slightly elevated temperature, near-tachycardia, normal respiration, and normal oxygen saturation and blood pressure.
Identifying Immediate Concerns
- Immediate follow-up required for chest tightness, heart palpitations, and shortness of breath (prioritize ABCs—Airway, Breathing, Circulation).
- Flat affect and minimal eye contact are concerns but not immediate priorities.
Differential Diagnosis
- Findings like diaphoresis, trembling hands, heart palpitations, and shortness of breath may indicate hyperthyroidism, myocardial infarction, or panic disorder.
- Troponin levels and ECG are normal, helping to rule out myocardial infarction.
Prioritization and Risk Identification
- The client is at highest risk for developing agoraphobia, as evidenced by fear of future panic attacks.
- Heart failure and thyroid storm are less likely based on assessment data.
Nursing Interventions for Anxiety/Panic Disorder
- Indicated interventions: Encourage positive self-talk, ask about recent stressors, help recognize physical symptoms, reinforce abdominal breathing exercises.
- Contraindicated: Encouraging the client to spend time alone when anxious.
Patient Teaching: Medication
- Teach to avoid driving after taking alprazolam, report suicidal thoughts immediately, and not to abruptly stop alprazolam to avoid withdrawal.
- Sertraline should be taken daily, not only during panic attacks.
- Limit or avoid alcohol when taking alprazolam.
Follow-Up and Long-Term Therapy
- Discharge planning involves referral to outpatient mental health.
- At follow-up, needing to avoid triggers by changing lifestyle (e.g., working from home due to bus anxiety) indicates a need for additional therapy.
Key Terms & Definitions
- Clinical Judgment Measurement Model (CJMM) — Framework to assess clinical decision-making in nursing students.
- Agoraphobia — Anxiety about or avoidance of places/situations where escape might be difficult.
- Benzodiazepine (Alprazolam) — Medication for acute anxiety, can cause sedation and withdrawal if stopped abruptly.
- SSRI (Sertraline) — Antidepressant taken daily for anxiety or depression.
Action Items / Next Steps
- Review explanations for all case study questions to understand rationale for correct and incorrect choices.
- Practice additional NGN-style questions for exam preparation.
- Read about therapeutic interventions for anxiety and medication teaching strategies.