Cases For Student Registered Nurses

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These cases are real-life cases, and they were first presented as a study material by MenCap organisation. This presentation is for nursing education purposes - to ensure that the patient's needs have been assessed and appropriate care is given.

Health & Medicine

Cases for Future Registered Nurses Good Nursing Makes Difference Kemi 2009-2010 Course 52P006

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1. Suzanne Jones, 76-year-old patient with COPD is admitted to the ICU. Mrs. Jones is placed on mechanical ventilation to assist with her breathing. After 2 days on the ventilator, Mrs. Jones is extubated and then transferred to a medical-surgical unit. The medication regimen is adjusted during the hospitalization. Mrs. Jones is discharged home after 6 days. She and her family are pleased with the care she receive in the hospital. (Learning Objectives 3 and 6) a. Describe the quality performance tools that may be used to demonstrate that the care and treatment rendered are both cost-efficient and of high quality. b. Describe the quality performance tools that may be used to demonstrate that the nursing care utilized is evidence-based care and high quality, resulting in patient satisfaction and good patient outcomes. 2. The registered nurse working in the cardiac care clinic is tasked with implementing quality improvement measures. To educate the clinic staff, the nurse plans an in-service program to introduce concepts of quality improvement and evidence-based practice. Additionally, the role of the case manager will be included in the presentation. The nurse plans on using care of the patient with Congestive Heart Failure as a template, and prepares sample clinical pathways, care maps, and multidisciplinary action plans. (Learning Objective 3) a. Describe how clinical pathways are used to coordinate care of caseloads of patients. b. What is the role of the case manager in evaluating a patient’s progress? c. What are examples of evidence-based practice tools used for planning patient care? . Mr. Jones, who is 74 years of age, is being discharged home after having a right knee replacement. The discharge orders from the orthopedic surgeon include: continuous passive motion (CPM) at the current setting of 0-degrees extension worn when walking with crutches (nonweight-bearing postdischarge day 1, and may begin weight-bearing postdischarge day 2); and home nurse visits, as needed. Physical therapy should begin the day after discharge at an orthopedic center. The orders will be faxed to the center. The following medications with prescriptions attached include: Lovenox (enoxaparin) 70 mg subcutaneously once daily for 7 days, Vicodin (hydrocodone bitartrate) 10 mg every 4 hours PRN, and Colace (docusate sodium) 100 mg every day. The patient is to follow up with the orthopedic surgeon in 3 weeks. His daughter plans to stay with him for several weeks to assist him with meals and household chores, and take him to physical therapy and the orthopedic surgeon for follow-up. Mr. Jones has three other children who live in other states. He is a widower and attends a local church. (Learning Objective 4) a. What preparations should the nurse make in advance before attaining necessary community resources and referrals before the patient is discharged? 1. What necessary community resources and referrals will the patient need? 2. Mrs. Johnson, a 67-year-old ...

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Case#1 A 24-year-old male graduate student without prior medical or psychiatric history is reported by his mother to have been very anxious over the past 6 months, with increasing concern that people are watching him. He now claims to “hearing voices,” telling him what must be done to “ fix the country.” Important workup ? thyroid-stimulating hormone TSH, rapid plasma reagain (RPR), and brain imaging. Questions: 1. What is the diagnosis of this patient? 2. What is the age onset of this disorder? 3. What socioeconomic group suffers from this disorder? 4. What is the subtype of this disorder in this patient ? 5. List five positive and negative symptoms that we can find in schizophrenia disorder> 6. What is the treatment? 7. What are five characteristics associated with better prognosis? Case#2 Ms. Torrez is a 17-year-old Caucasian woman without prior psychiatric history who is brought to the Emergency room by ambulance after her parents called 911 when they found her having a seizure in their living room. She was admitted to the medical intensive care units in status epilepticus and was quickly stabilized with intramuscular lorazepam and fosphenytoin loading. Her heigh is 5 feet 6 inches, she is of medium build, and her weight is 101 lbs. (BMI16.3kg/m2). She does not suffer any medical conditions, and this is her first seizure. Laboratory workup shows an electrolyte imbalance as the most likely cause of the seizures. Although initially reluctant, she admits to purging with the use of ipecac several times this week. She reports that although she normally restricts her daily caloric intake to 500 calories, she regularly induces vomiting if her weight is above 100 lbs. Her last menstrual cycle was 1 year ago. Psychiatric consultation is requested in order to confirm the diagnosis The on-call psychiatry notes in Terry’s chart Patient appears underweight and younger than her stated age. She is mild distress, has a nasogastric tube in place, and exhibits poor eye contact. She reports feeling “sad” and admitted to experiencing constant preoccupation about her physical appearance and says, “I am fat; I hate my body.” She also reports insomnia, low energy levels, and history of self-harm behavior by cutting her forearms. She reports that she is careful hiding her symptoms from her parents, whom she describes as strict disciplinarians. She also expresses concerns that she will disappoint them. Ms. Torrez’ parents describe her as a perfectionist. They say that she is involve in multiple school activities, takes advanced placement classes, and has been recently concerned about being accepted at her college of choice. They report that she maintains a 4.0 grade point average in high school, and they are expecting her to become a lawyer. Her parents have noticed that she is underweight and rarely see her eat but attributed this to stress from her many academic pursuits. Ms. Torrez’ mom was diagnosed with obsessive-compulsive disorder. Qu.

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Nursing Process – SAMPLE Nursing Diagnosis NANDA (North American Nursing Diagnosis) Chronic Painrelated to unknown etiology as evidenced by self-reports of pain “I feel pain when sitting or lying down mostly at night” using a standardized pain scale, 4/10 on a 0 to 10 numeric rating scale. The patient reports an altered sleep-wake cycle. Patient Goal/Outcome Interventions Rationale for Interventions Evaluation of Each Goal/Intervention 1)The Patient’s pain will reduce and her sleep will promote by using nonpharmacological methods such as supplements or enhance pharmacological interventions within the next three months. 1a) RN will in addition to administering analgesics, support the client's use of nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of heat and cold. 1b) RN will ask the client to describe prior experiences with pain, effectiveness of pain management interventions, responses to analgesic medications (including occurrence of side effects), and concerns about pain and its treatment (e.g., fear about addiction, worries, anxiety) and informational needs. 1a) Evidence suggested efficacy and satisfaction when complementary therapies are integrated into pain treatment plans of older adults (Bruckenthal, 2016 as cited in Ackley et al., 2022, p. 723). 1b) Sleep disturbance and decreased physical activity are adverse effects of people with chronic pain. In a study of clients with chronic pain, those who participated in a 4 week multiprofessional program that included psychoeducation and training related to pain, sleep, exercise, and activity training had improvement in sleep quality and pain intensity (de la Vega, 2019, as cited in Ackley et al., 2022, p. 721). 1a) Goal partially met. Patient’s pain decreased to level 2/10, with relaxation therapy such as meditation and usage of heat pads. 1b) Goal met. Patients starts to drink Valerian root tea and states “It reduced the amount of time takes me to fall asleep and helped me sleep better.” Health history assignment part 1 Section 1: Biographic Data N.V is a 46-year-old married Iranian woman, who currently is a full-time financial manager at BMW company. She speaks fluent English and does not require an interpreter. Section 2: Source of History The patient provides the information herself. The patient seems reliable, as she is alert and oriented. Section 3: Reason for Seeking Care The patient states, “I am really exhausted and want to get rid of my leg pain. I have severe pain in my thighs and legs and it started six years ago.” Section 4: History of Present Illness (HPI) The patient’s thigh and leg pain began six years prior to the interview. Her pain started following the birth of her second child. The patient has frequent episodes, the last being three days ago. It has never been resolved. It is specially located in the thighs and .

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Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment Week 9 SOAP NOTE Doris Ofodile Walden University Nurs 6512 Advanced Health Assessment & Diagnostic Reasoning Dr Kristin Curcio July 31st, 2022 Patient Initials: T.J Age: 28 Gender: Female SUBJECTIVE DATA: Chief Complaint (CC): " I came in because I'm required to have a recent physical exam for the health insurance at my new job" History of Present Illness (HPI): Miss Jones is currently employed by Smith, Steven, Stewart, Silver & Company. Before she begins work, a pre-employment physical must be completed. Despite having a history of type 2 diabetes, in which she is able to control it by taking metformin, dieting, and doing physical activity. For the past 4-5 months, she has been compliant with metformin. By eating yogurt, Metformin has no longer caused any side effects for her. The last time she saw a doctor was for her gynecology appointment four months ago in which the doctor prescribed oral birth control pills to her after she was diagnosed with the polycystic ovarian syndrome. Although, according to her, she is in good health and does not have any acute health issues, or stressful events, and is looking forward to starting her new job. Medications: Metformin 850mg PO BID, the last dose taken this morning. Fluticasone propionate (Flovent) was 110 milligrams twice daily.( taken last in Albuterol (Proventil) 90mcg 2 puffs every four hours PRN.( taken three months ) Drospirenone/ethinyl estradiol (dosage unknown). It was taken this morning. Tylenol 500 mg PO PRN for headache, medication was taken last week. Ibuprofen 600mg PO TID PRN to alleviate period cramps, was taken six weeks ago. Zantac was taken for GERD (completed) Tetracycline was taken because of acne (completed) Allergies: Miss Jones is allergic to penicillin which causes an allergic reaction characterized by hives and a rash. She is also allergic to cats and dust which triggers an asthma attack causing her to itch, wheeze and sneeze. She denies allergic reactions to latex and foods. Past Medical History (PMH): During her second and a half years of life, Miss Jones was diagnosed with asthma. Her medication regimen includes Proventil and Flovent. A diagnosis of diabetes was made at the age of twenty-four. Metformin is the medication she uses to manage her diabetes, but she had trouble complying because she had side effects like gassiness, which was later relieved with yogurt. As a result, she is better able to monitor her blood sugar levels daily, which last read at 90. The patient also reports losing 10 pounds in four months. Also, she reported that she slipped and hit her right foot, resulting in a healed wound. At the age of 28, she was diagnosed with the polycystic ovarian syndrome which she manages by taking birth control pills. Miss Jone’s menstrual cycle flows for five days and is regular. No Sexually transmitted diseases or pregnancies have been reported. At 38.

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