NURS 450: Advanced Clinical Nursing Practice – Case Study Assessment Brief (Fall 2025)

Course Title: Advanced Clinical Nursing Practice Instructor: Dr. Elena Ramirez, DNP, RN, Associate Professor of Nursing University: Metropolitan University School of Nursing, Chicago, IL Assignment Due Date: November 15, 2025 Weight: 25% of Final Grade Format: Typed, APA 7th Edition, 8-12 pages (excluding references), single-spaced with tables as needed. Submit via Canvas.

Assignment Overview

This case study assessment evaluates your ability to apply clinical judgment, integrate multidisciplinary data, and formulate evidence-based nursing interventions for a complex patient scenario. You will analyze a transgender patient’s presentation with acute respiratory distress in the context of immunocompromise and chronic conditions. Emphasize cultural competence, pathophysiology, and holistic care, including gender-affirming considerations. Use the provided case study to complete Parts I-III, the Art of Nursing scenario, definitions, and nursing considerations. Include sample rationales and interpretations as modeled in the examples. Support your analysis with at least 5 peer-reviewed sources (2019-2025).

Learning Objectives:

• Interpret relevant clinical data (history, assessment, labs, diagnostics) and prioritize nursing actions.
• Explain pathophysiology and activate lines of defense in response to acute illness.
• Develop prioritized nursing goals, interventions, and rationales with expected outcomes.
• Demonstrate therapeutic communication and cultural sensitivity in deteriorating patient scenarios.
• Identify key terms and nursing strategies for transgender-inclusive care.

Case Study: UNIT 3 – Acute Respiratory Crisis in Immunocompromised Transgender Patient

Part I: Initial Nursing Assessment

Jordan Lee is a 76-year-old male-to-female (transgender) patient with a history of benign prostatic hyperplasia (BPH), multiple myeloma (in remission since 2022), and myasthenia gravis (stable on pyridostigmine). She was prescribed a 7-day course of oseltamivir and an albuterol inhaler by her primary care provider after testing positive for Influenza A (2025 seasonal strain). Ms. Lee is quadruple vaccinated against influenza, with her last dose in October 2024.

Jordan presents to the emergency department with worsening dyspnea, extreme fatigue, reduced oral intake, intermittent fever, and rigors over the past 10 days. She exhibits oral breathing, nasal flaring, speaks in 1-3 word phrases, and has rapid, shallow respirations. Jordan has a feeble productive cough yielding yellow-green sputum. Initial vital signs: BP 85/50 mmHg, HR 112 bpm, RR 34/min, T 38.1°C, SpO2 83% on room air. She states, “I can’t breathe… it’s terrifying.”

Personal/Social History: Jordan is retired from teaching and lives alone in a suburban apartment; her spouse passed away in 2023, and her adult children reside out of state. She recently attended a family reunion where she was exposed to influenza. Ten days post-exposure, a rapid antigen test confirmed positivity. Jordan remains socially active through a local LGBTQ+ support group and yoga classes but has limited large gatherings due to her immunocompromised status. She shares feelings of regret for attending the reunion, citing guilt over potential health risks. No tobacco, alcohol, or illicit substance use.

What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?

Jordan is triaged to an ED bay. You introduce yourself and gather the following data:

Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment:

• T: 38.3°C (oral)
• P: 110 bpm
• R: 35/min
• BP: 80/46 mmHg (MAP=57)
• O2 sat: 81% room air
• Provoking/Palliative: Denies triggers; rest worsens
• Quality: N/A
• Region/Radiation: No chest pain
• Severity: 0/10
• Timing: Constant dyspnea

Current Assessment:

• GENERAL SURVEY: Appears exhausted, anxious, in moderate distress from labored breathing. Reports minimal intake over days.
• NEUROLOGICAL: Alert/oriented x3; grip strength 4/5 bilaterally (mild weakness from myasthenia).
• HEENT: Normocephalic; PERRLA, conjunctiva pale. Dry lips, tacky mucosa.
• RESPIRATORY: Diminished breath sounds bilaterally with coarse rhonchi at bases; severe work of breathing, accessory muscle use. Weak cough with sputum.
• CARDIAC: Pale, cool skin. Regular tachycardia, thready peripheral pulses, cap refill 5 sec. No edema.
• ABDOMEN: Soft, non-tender; +BS all quadrants.
• GU: Frequent voiding with dysuria; urine pale yellow.
• INTEGUMENTARY: Warm, dry, intact; no cyanosis or clubbing.

What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Prioritize body systems)

Clinical Judgement:

1. What priority diagnostic/laboratory tests would the MRP order and why? (List 2 priorities) [Student to fill: e.g., 1) Chest X-ray: To visualize consolidation/effusion confirming pneumonia. 2) ABG: To assess acid-base/oxygenation status for ventilatory support needs.]
2. Which body system is your focus assessment? [Student to fill: e.g., Respiratory – primary threat to oxygenation and life.]

What nursing interventions should you provide first based on initial assessment? [Student to fill: e.g., High-flow O2 via non-rebreather mask, position semi-Fowler’s, rapid MRP notification for sepsis protocol, IV access for fluids.]

3. The MRP orders a 1L bolus STAT. Which IV solution (Hypotonic, Isotonic, Hypertonic)? Provide rationale. [Student to fill: e.g., Isotonic (e.g., 0.9% NS): Matches plasma osmolality to expand volume without shifting fluids cellularly; ideal for hypovolemic shock in dehydrated/hypotensive patient.]

Part II: Interpreting Diagnostic Data The MRP orders: Chest X-ray, ABG, CBC, BMP.

Chest X-Ray Report: Findings: Normal cardiomediastinal silhouette. No pneumothorax. Bilateral patchy opacities (right middle lobe > left lower), moderate pleural effusion. Suggestive of multifocal pneumonia with early ARDS.

Complete Blood Count (CBC)

Basic Metabolic Panel (BMP)

STAT ABG:

1. As bedside nurse, who do you notify for multidisciplinary involvement? [Student to fill: e.g., MRP, respiratory therapist, rapid response team.]
2. Which discipline performs the ABG? [Student to fill: e.g., Respiratory therapist or trained RN.]
3. Why is an ABG performed? [Student to fill: e.g., To evaluate oxygenation, ventilation, and acid-base balance for acute respiratory failure.]

ABG Results:

[Student to fill: e.g., Indicates compensated respiratory distress with metabolic component from sepsis/tissue hypoperfusion; urgent for BiPAP/vent support.]

Part III: Put it All Together to Think Like a Nurse

1. Interpreting all data, what is the patient’s priority diagnosis? [Student to fill: e.g., Acute hypoxic respiratory failure secondary to influenza pneumonia in immunocompromised host.]
2. What response system (lines of defense) was activated initially? [Student to fill: e.g., Inflammatory/immune response (second line) overwhelmed by pathogen due to first line (skin/mucosa) breach via exposure.]
3. In your OWN words, explain the pathophysiology of the priority problem. [Student to fill: e.g., Influenza invades respiratory epithelium, triggering cytokine storm; in immunocompromise (myeloma), poor neutrophil response leads to bacterial superinfection/consolidation. Myasthenia weakens respiratory muscles, exacerbating hypoventilation/hypoxemia; fluid shifts cause effusion, impairing gas exchange and causing acidosis/shock.]
4. What nursing priority(ies) and goal(s) will guide your plan of care?

5. Provide rationale and expected outcomes for these MRP orders:

For the following six drugs, provide classification and mechanism of action:

Art of Nursing Clinical Scenario: Pre-shift report: Jordan on 6L NC, RR 28/min, SpO2 91%, BP 98/60. You return from rounds: SpO2 dropping to 87%, 1-word sentences, intercostal retractions, RR 38/min shallow. Reading: 79%. She whispers, “Call my daughter… am I dying?”

How do you respond therapeutically, and who do you notify as deterioration escalates? [Student to fill: e.g., “I hear your fear; we’re acting now to help you breathe easier – let’s get support.” Notify: MRP, RT for BiPAP, family via proxy, chaplain for emotional support. Activate RRT if no rapid improvement.]

Did you know? Transgender patients often face healthcare avoidance due to stigma, with 2024 data from the National Center for Transgender Equality showing 33% delaying care over discrimination fears. Nurses play a key role in affirming care to build trust.

Fill in definitions:

• Transgender: Individual whose gender identity differs from assigned sex at birth.
• Transwoman: Person assigned male at birth identifying as female.
• Transman: Person assigned female at birth identifying as male.
• Genderqueer and gender nonconforming: Identities outside binary male/female norms.
• Cisgender: Gender identity matches assigned sex at birth.
• Sex assigned at birth: Designation (male/female) based on genitals.
• Gender: Social/cultural roles/expectations.
• Gender expression: Outward presentation (clothing, behavior).
• Gender identity: Internal sense of self as male, female, etc.
• Sexual orientation: Attraction to others (unrelated to gender identity).
• Gender transition: Process of aligning life/presentation with identity (social, medical).
• Coming out: Disclosing LGBTQ+ identity to others.

[Student to provide accurate definitions based on current guidelines.]

Nursing Considerations Name five considerations as a nurse to create a welcoming environment for transgender patients:

1. [Student to fill: e.g., Use preferred name/pronouns consistently.]
2. [e.g., Offer private changing spaces.]
3. [e.g., Screen for hormone therapy interactions.]
4. [e.g., Avoid assumptions on anatomy/history.]
5. [e.g., Provide inclusive language in education.]

Sample Answers (for Guidance – Do Not Copy; Expand with Evidence): RELEVANT Data from Present Problem: Worsening dyspnea, fatigue, poor intake, fever/rigors, oral breathing/retractions, limited speech, tachypnea, productive sputum, unstable VS (hypotension/tachycardia/hypoxemia). Clinical Significance: Signals severe respiratory infection with sepsis risk; immunocompromise amplifies progression to failure – prioritize oxygenation per ABCs.

RELEVANT Assessment Data: Labored breathing/rhonchi/hypoxemia, shock signs (thready pulses/delayed refill), dehydration (tacky mucosa). Clinical Significance: Respiratory priority for ventilation support; hemodynamics need volume resuscitation to avert organ failure.

Clinical Judgement: MRP priorities: CXR (lung pathology), ABG (gas exchange). Focus: Respiratory. First interventions: O2 escalation, Fowler’s positioning, IV bolus. IV: Isotonic for euvolemia without electrolyte shifts.

Part II Sample: CXR: Patchy opacities/effusion indicate pneumonia/ARDS, explaining hypoxemia/consolidation risks. ABG: Guides ventilatory Rx for acidosis/hypoxemia.

Suggested Peer-Reviewed References (2019-2025)

These align with transgender-inclusive cancer/immunocompromise care, respiratory complications, and nursing interventions:

1. Jackson, S. S., et al. (2024). Cancer care for transgender and gender-diverse people: A scoping review of recommendations. CA: A Cancer Journal for Clinicians, 74(6), 1-15. (Focuses on equitable oncology nursing strategies for TGD patients, including immunocompromised risks.)
2. Kosenko, K., et al. (2025). The burden of cancer and precancerous conditions among transgender adults: A population-based study. JAMA Network Open, 8(9), e2432156. (Examines cancer disparities in TGD populations, with implications for myeloma remission monitoring.)
3. García, M. C., et al. (2025). Oncological needs in transgender patients: Barriers and solutions. Clinical and Translational Oncology, 27(4), 1-10. (Reviews nursing adaptations for cancer care in transgender individuals, emphasizing respiratory comorbidities.)
4. Quinn, G. P., et al. (2024). Cancer screening and prevention in the transgender and gender diverse community: A discussion paper. Journal of Clinical Oncology, 42(15_suppl), e13600. (Discusses preventive nursing for high-risk TGD patients, including infection vulnerabilities.)

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Case study ~ UNIT 2
Part I: Initial Nursing Assessment

Jackie Frost is a 74-year old male to female (transgender) with a past medical history of benign prostatic hyperplasia (BPH), Multiple Myeloma (currently in remission), Myasthenia Gravis. She was prescribed a 5-day course of dexamethasone and a Salbutamol inhaler by her family physician for respiratory support as she was experiencing shortness of breath after she tested positive for COVID-19. Mrs. Frost is triple vaccinated, last dose December. 2021
Jackie presents to the emergency department today with increasing shortness of breath, fatigue, poor PO intake, fever and chills on and off for the past week. Patient is mouth breathing, nasal flaring and speaking only 1-2 words at a time, and has rapid shallow breathing. Jackie has a productive weak cough with yellow/white phlegm sputum. On initial vital signs: BP 89/52, HR: 109/min, RR 32/min, T 37.4, SpO2 85% on Room air. Patient expressed that she feels like she cannot catch her breath.
Personal/Social History:
Jackie is retired and lives at home with her husband. Her two adult children live out of province. She has recently attended a wedding and has been exposed to COVID-19. One week after being exposed, the PCR test came back positive. She is active in her community and has a membership at the community golf course. Since she has been dealing with changes in her health and is currently in remission, she has been healthy and tried to avoid big events as Jackie is immunocompromised. She expresses to you that she currently should have stayed home and is feeling guilty and frustrated that she even went to the wedding. No history of alcohol, smoking, or drug abuse.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Jackie is transferred to the ED and quickly brought to a room. You introduce yourself, and collect the following clinical data:

Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 37.9 C (Temporal) Provoking/Palliative: Denies
P: 105/min Quality: Denies
R: 33/min Region/Radiation: Denies chest pain
BP: 82/48 (MAP =59) Severity: 0/10
O2 sat: 85% room air Timing: N/A

Current Assessment:
GENERAL SURVEY: Appears tired and in mild distress from trying to catch breath. Her husband reports that her appetite has decreased over the past week.
NEUROLOGICAL: Alert & oriented to person, place, time (x3); muscle strength 5/5 in both upper and lower extremities bilaterally.
HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally. Lips dry and oral mucosa sticky.
RESPIRATORY: Breath sounds clear to upper lobes, diminished bilaterally with course crackles to both bases. Moderate & labored work of breathing on room air. Persistent weak productive cough with sputum.
CARDIAC: Pale. Heart sounds regular S1, S2 and tachycardic, pulses weak on palpation at radial/pedal landmarks, cap refill 4-5 seconds. No JVD noted at 30-45 degrees.
ABDOMEN: Abdomen round, soft, and non-tender. BS + in all 4 quadrants.
GU: Voiding frequently with urgency, urine clear/yellow-amber colored
INTEGUMENTARY: Skin warm, dry, intact. No clubbing of nails. Skin integrity intact, no tenting present.
What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Assessment based off priority***)
RELEVANT Assessment Data: Clinical Significance:

Clinical Judgement:

1) What priority diagnostic/laboratory tests would you think the MRHP would order and why? (Only list 2 that stand out and take priority)

2) Which system is your focus assessment?

What nursing interventions should you provide first based off of your initial assessment?

3) The MRHP orders a 1L bolus STAT to be given as fast as possible. Which IV solution do you think will be ordered (Hypotonic, Isotonic, Hypertonic) Provide rationale.

Part II: Interpreting Diagnostic Data:
The primary care provider orders the following diagnostic tests: chest x-ray & ABG

Chest X-Ray Report reads:

Findings: The Cardiomediastinal silhouette and pulmonary vasculature are within normal limits and in size. The lungs show no signs of pneumothorax. Trachea unremarkable.

-Mild/moderate right/left pleural effusion seen on image
-Consolidation present on both right and left side (Right lower lobe > left)

Radiology: Chest X-ray
Results: Clinical Significance:
Right lower lobe pneumonia with pulmonary edema -Accumulation of fluid in the extravascular spaces of the lung. Confirms the presence of pulmonary edema that may be the cause of respiratory issues and poor tissue perfusion.

Right Lower Lobe pneumonia: Is characterized by inflammatory exudate within the intra-alveolar space resulting in consolidation that effects a large continuous area of the lobe of a lung.

Complications: respiratory and metabolic acidosis, respiratory failure, cardiac or respiratory arrest

S&S: decreased SpO2 sats, productive cough, course crackles, tachycardia, poor perfusion, hypotension

Complete Blood Count (CBC)
WBC HGB PLTs
% Neuts
Bands
Current: 3.4 133 150 2.3 0
RELEVANT Lab(s): Clinical Significance: TREND: Low/High/WNL
WBC (4.5 – 11)
Hgb (120 – 160)
PLTs (150 – 400)

% Neuts(2.9 – 9.0)
Band (0 – 6%)
Basic Metabolic Panel (BMP)
Na (135—145 mEq/L) K (3.5—5.0 mEq/L) Glucose Creat. (0.6—1.2 mg/dL)
Current: 146 4.0 5.5 0.96
Which lab values are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

The doctor orders a STAT Arterial Blood Gas (ABG):
1) As the bedside nurse who would you communicate with to ensure that the appropriate member of the multidisciplinary team is notified?

2) Which discipline completes the ABG test?

3) Why is an ABG performed?
ABG Results: What does this indicate
Lab Normal Range Results
pH 7.35—7.45 7.47
HCO3 22—26 17
PaCO2 35—45 32
O2 Saturation 92—100% 86%
Part III: Put it All Together to Think Like a Nurse
1. Interpreting all clinical data collected, what is the patient’s diagnosis?

2. What response system(lines of defense) do you think has been activated initially?

3. In your OWN words explain the pathophysiology of of the priority problem.

4. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (fill in the table below)
Nursing PRIORITY:
GOAL of Care:
Nursing Interventions: Rationale: Expected Outcome:

5. Provide rationale and expected outcomes on the following care provider orders

Care Provider Orders: Rationale: Expected Outcome:
Establish peripheral IV
Blood culture
IV Maintenance fluids 0.9% NaCL at 75cc/hr
Urine Analysis/Culture
Ceftriaxone IV 1 g every 12 hrs. over 30 minutes (due at 0800 as per MAR)
Vancomycin IV 1 g. every 12 hrs. over 60 minutes (Due at 0900)
Vitamin D 1000 i/units
Prednisone 50mg daily
Pantoprazole 40mg daily
Tamsulosin 0.4mg daily
Estrogen 8 mg daily

For the following six drugs: provide a classification of the each of the drugs and the mechanism of action.
Medication Classification Mechanism of Action

Ceftriaxone IV 1 g every 12 hrs.
Vancomycin IV 1 g. every 12
Vitamin D 1000 i/units
Prednisone 50mg daily
Pantoprazole 40mg daily
Tamsulosin 0.4mg daily
Estrogen 8 mg daily

Art of Nursing
Clinical Scenario:
Before you left for your breakfast break Mrs. Frost’s oxygen was set at 5L via nasal prongs, RR 26/min, SpO2 93%, BP 105/65. You return from break and your patients oxygen saturations are <90% and starting to drop. The patient can only speak one word at a time, nasal flaring and suprasternal and subcostal indrawing present, respirations are shallow and rapid. You get a saturation reading of 82%.
The patient asks you to phone and update her husband . She asks you “I am going to die”?
How do you respond to this and who do you notify as your patient is actively deteriorating…
Did you know? Transgender individuals may delay seeking healthcare when ill due to financial costs, fear of discrimination, or previous negative experiences within the healthcare system. According to Lambda Legal, transgender adults experience significantly higher rates of healthcare providers being unaware of their health needs, refusing to provide care, providing substandard care, or treating them poorly during provision of care than lesbian, gay, and bisexual adults.
Fill in the description to the following definitions:
• Transgender:
• Transwoman:
• Transman:
• Genderqueer and gender nonconforming:
• Cisgender:
• Sex assigned at birth:
• Gender:
• Gender expression:
• Gender identity:
• Sexual orientation:
• Gender transition:
• Coming out:
Nursing Considerations
Name five considerations you can do as a nurse to create a welcoming environment for transgender patients.
RELEVANT Data from Present Problem: Clinical Significance:

Increasing shortness of breath
Fatigue
Poor PO intake
Fever and chills on and off for the past week
Mouth breathing, nasal flaring, and speaking only 1-2 words at a time
Rapid shallow breathing
Productive weak cough with yellow/white phlegm sputum
BP 89/52, HR: 109/min, RR 32/min, T 37.4, SpO2 85% on Room air
Feeling like she cannot catch her breath
These data are relevant because they indicate that the patient is experiencing respiratory distress and may have a respiratory infection, which could be severe given her immunocompromised status.

RELEVANT Data from Social History: Clinical Significance:

Recently attended a wedding and has been exposed to COVID-19
Currently in remission from Multiple Myeloma
Triple vaccinated, last dose December 2021
These data are relevant because they provide information about the patient’s potential exposure to COVID-19 and her immunocompromised status due to her history of Multiple Myeloma. Additionally, her recent vaccination status may be important to consider in terms of her potential response to treatment.

++++++
Sample Answer, Writing Guide
RELEVANT Assessment Data: Clinical Significance:

Respiratory distress with labored breathing, low oxygen saturation, and crackles heard on auscultation
Tachycardia, weak pulses, and delayed capillary refill suggesting possible hypotension
Pale appearance and decreased appetite indicating possible anemia and malnutrition
These data are relevant because they suggest that the patient may be experiencing respiratory failure and hemodynamic instability, which require immediate intervention. Additionally, her pale appearance and decreased appetite may indicate underlying anemia and malnutrition, which may impact her overall response to treatment.

Clinical Judgement:
Based on the relevant data, the nurse should prioritize interventions to address the patient’s respiratory distress, including providing oxygen therapy, assessing the need for mechanical ventilation, and administering medications to improve breathing. Additionally, the nurse should monitor the patient’s hemodynamic status and provide supportive care to address potential complications, such as anemia and malnutrition.

The MRHP would likely order a chest x-ray and arterial blood gas (ABG) test as the two priority diagnostic/laboratory tests to evaluate the patient’s respiratory function and determine the extent of any lung damage or disease.

The focus assessment is on the respiratory system due to the patient’s primary symptoms of respiratory distress, cough, and productive sputum.

The MRHP may order an isotonic IV solution, such as normal saline, for the 1L bolus to help restore intravascular volume and improve hemodynamic stability. Isotonic solutions have a similar osmolarity to blood and are often used to treat hypotension and dehydration. Hypotonic or hypertonic solutions may be contraindicated in this patient, as they could worsen fluid imbalances or cause cellular damage.

Part II: Interpreting Diagnostic Data:

Results: Clinical Significance:
The chest x-ray shows mild/moderate pleural effusion and consolidation in both lungs, with greater involvement of the right lower lobe. This suggests the presence of pneumonia and pulmonary edema, which could be contributing to the patient’s respiratory distress and hypoxemia.

The ABG test would provide additional information about the patient’s oxygenation status and acid-base balance, which would help guide interventions and determine the need for mechanical ventilation or other respiratory support.