PART I
Directions: The case study below contains many concepts, some of which are highlighted in red. There are additional concepts within the case study that are not highlighted. There are also highlighted phrases that refer to phenomena which may contain several concepts.
Identify three additional concepts contained in the case study. Add them to the list that follows the case study.
Until the afternoon of March 16th Mr. Ramos would have told you he had fulfilled his family responsibilities. He was born in Mexico, the second oldest of six children. His father worked three jobs to make sure his family had all their basic needs met. Mr. Ramos always had great respect for his father and admired how hard he worked for his family. Mr. Ramos’s mother would take odd jobs she could do at home so she could stay with the children. In the years since, Mr. Ramos would reflect on how he had benefited from her constant presence. There was always much love in his family and these close relationships persisted into adulthood.
When he was 16 Mr. Ramos dropped out of high school to work while his father recovered from an illness. It was in high school that he had met Yvette whom he would marry five years later. Although not finishing his high school education was always a regret for Mr. Ramos he had managed to purchase his own auto repair business three years ago and enjoyed a loyal clientele. Now at 34 he was a father of four and took great pride in his ability to provide for his family in a way that allowed Yvette to stay home with the children. He had a satisfying life.
That was until 1630 on March 16th. Mr. Ramos was finishing work on a 1994 Volvo when the vehicle slipped off its jack and landed on his left chest and abdomen. He was discovered 20 minutes later by a customer who immediately called 911. Mr. Ramos presented to the Emergency Room at 1802 with complaints of dyspnea and diminished breath sounds bilaterally (left worse than right). His respiratory rate was 32/minute, breaths were shallow and his O2 saturation was 89% on room air. His pulse was 122/minute and irregular. His blood pressure was 105/59. His temperature was 99.8° F. Mr. Ramos was conscious and oriented to person, place and time. His bowel sounds were hypoactive. His abdomen was distended, firm and painful upon palpation. Diagnostic tests revealed a large amount of blood in his abdomen, a collapsed lung and a fractured left hip. Mr. Ramos was immediately taken to surgery where he was discovered to have a ruptured spleen that was subsequently removed. A left-sided hemothorax was found to be the cause of his collapsed left lung and required chest tube placement. During the operation he was transfused with 4 units of packed red blood cells. Mr. Ramos was transferred to the ICU where he remained in critical condition. When his condition had stabilized he returned to surgery and underwent an internal fixation of his fractured left hip.

Two days later Mr. Ramos was transferred to the floor with a patient controlled analgesia pump (PCA). When his nurse attempted to assess his knowledge about how he could self medicate his pain he replied, “I don’t need medicine.” His nonverbal cues, specifically facial grimaces upon deep inhalation, guarding behaviors and a resistance to being moved led to the suspicion that Mr. Ramos was in significant pain. The nurse checked the historical record of his PCA pump and found that he had not initiated any dose in the last 24 hours. When asked if he was in pain he replied, “I’m a strong man and can take it.” The nurse knew that his self-care abilities were compromised at this time but that he needed to maintain his independence so she communicated her understanding of what he was saying and then provided patient education regarding the importance of pain management to facilitate healing, telling him that decreasing his pain would help him to get better and return home sooner.

The next day Mr. Ramos’ wife came to visit and placed a number of religious objects around the room. She looked exhausted and very distraught. The nurse overheard her crying and voicing concerns about how the hospital bills could ever be paid. She was worried that she now needed to find a job because he could not work. She asked, “Who is going to care for the children while I’m working and you’re still sick? What’s going to happen to our business? How is our family going to survive? I must leave it all to God; he knows what is best and what burdens we can bear. Later that evening the nurse entered Mr. Ramos’ room and observed that there were wads of tissue on the floor and his eyes were puffy and red. He denied any distress or the need for intervention. The nurse responded with empathy and felt that it would be important to maintain Mr. Ramos’s dignity, gently asking him if he simply wished to talk about anything. He did not. He remained awake all night. In the morning his doctors came to speak with him and he turned away saying “leave me alone.” He refused his morning and afternoon meals. When the hospital chaplain came to visit Mr. Ramos replied, “You are wasting your time. Prayers are of no use. God has abandoned me.” He refused to speak to the chaplain further.

When being interviewed by the hospital’s nurse discharge planner Mr. Ramos stated he had limited health insurance and no short or long term disability insurance. Before assessing how much instrumental support he had at home, the discharge planner wanted to assess Mr. Ramos’ coping skills, knowing that even with support, he would be experiencing emotions such as …..as he dealt with dependence, changed level of function, role transition, loss. His family currently lives in a second floor apartment in a building with no elevator. His children range in age from 18 months to nine years old. His extended family is always ready to do whatever is necessary to help each other even though they live out of town. His father and mother were coming from southern California next week to work at his garage and help take care of the children. His wife had found work as a waitress and would start as soon as his parents arrived. He felt as if he had not been able to protect or provide for his family and was upset at having to need other people to do what he no longer could do. He said, “Now I am only a burden to my family as I am useless.”

• Adapted from a case study used by Santa Fe Community College Nursing Programs, 2002.

Concept List
Directions: After you have added the 3 additional concepts you identified in the case study, complete Part II below.
Individual
Family, Extended family
Ethnicity
Cultural background
Respect
Presence
Love
Life satisfaction
Physiological instability
Physiological stressor
Pain
Psychological stressor
Self-medication
Nonverbal communication
Stoicism
Self-care abilities
Independence
Religious beliefs
Faith
Hopelessness, despair
Denial
Empathy
Dignity
Instrumental support
Coping skills
Independence
Level of function
Role transition
Loss

PART II

1. Identify 3 concepts that you might be interested in studying or exploring further. These can be from the list above, from your worldview assignment or from your own ideas or experiences.

List them here and see if you can identify anything that they have in common. For example, they may all be related to psychosocial needs, or to responses to changes in physiologic function, or they may refer to interaction between patient and family or patient and health provider. They may be related to other broad concepts such as health, communication or stress.

Concept 1:

Concept 2:

Concept 3:

What they have in common:

1. Make each of the concepts you identified more specific to your interest by adding a situation or population of people. For example, “dignity” can become “dignity among men experiencing job loss” or “enhancement of dignity among the chronic mentally ill”.

Concept 1:

Concept 2:

Concept 3:

1. For each concept, identify two ways you could reliably observe for the presence of the concept OR two ways to measure it. Think of how researchers identify or measure phenomena.

Concept 1:

1.


2.

Concept 2:

1.


2.

Concept 3:

1.


2.

1. Take the concept you are most interested in and write a definition for it that clearly communicates its essential features to other nursing professionals.