Nursing Case Report

The aim of this study is to provide a detailed account of the nursing care for a patient who is experiencing a breakdown in health. One aspect of their care will be discussed in relation to the nursing process. The model used to provide an individualised programme of care will be discussed and critically analysed.

1. The nurse is asked to implement a new, complex, and invasive procedure and is concerned that this may violate the state’s nurse practice act.

When I arrive to the Trauma ICU 4800 unit, all of the nurses were already being followed by other students. The nurse in charge had me follow several different nurses, so I was able to observed several different patient cases. The first patient had received a triple bypass open-heart surgery. The patient had received a creatinine blood test. The patient had a dialysis machine next to them, which was used to function as the kidneys since the patient’s kidneys were not functioning correctly. Also, the patient’s body temperature was lowered from having a taken cool liquids so the nurses were keeping him warm with a bair hugger, which was a machine that helped regulate the patient's’ body temperatures.

He underwent an interlaminar injection in May 2015 which improved his lower extremity pain by 99%. This has lasted him up until 1 month when he has had recrudescences of pain emanating from the low back radiating intermittently into the left lower extremity in a sharp shooting fashion, average pain 5/10, and worse pain 81/0. The pain is frequent and is associated with numbness and tingling. There is some difficulty with walking. Over the past 1 month, the pain has been severe. Home exercises and nonsteroidal anti-inflammatory medications (NSAIDS) have not been effective in reducing his pain and the pain is severe at times and limiting his ability to lift and sit. Walking, exercise and standing increased the pain. Lying down reduce the

He is total care with his ADLS, he is able to verbalized his needs but unable to perform them. He reports that he had a colostomy placed in 2011 and urostomy placed in 2014. His father provides hygiene care and changes for both his colostomy and urostomy bag. He has bilateral arm/hand contractures and he has gotten weaker. He is getting OT and PT from kindred home health. He uses a hospital bed with air mattress and his father changes his position every 3 hours. He reports pain in his legs and back that is constant, dull and aching. His pain is worse with movement and dressing change. His current pain level is 8/10 on a pain scale. His pain regimen consists of fentanyl 75 mcg patch every 72 hours and oxycodone 5 mg p.o every 6 hours as needed for breakthrough pain. He has been taking 2 prn doses daily because he did not want to run out of medication. He states that 2 prn dose is not effective in relieving his breakthrough pain. He previously was getting his medication from his PCP but since his condition has deteriorated his parent who are elderly is not able to get him to the

Medical Concerns: Client reports recent car crash that lead to back spasms and a slip disc, that still causes pain, headaches. Client also reports seeing a chiropractor weekly for treatment. Client also reports the bending at his job may even be prolonging the pain, but no surgeries have been scheduled.

One afternoon a 67 year-old man presented to the emergency department of a small, rural hospital complaining of severe left leg and hip pain following a fall at home. The patient had no past history of falls. He had a history of impaired glucose intolerance, prostate cancer, hypercholesterolemia and hyperlipidemia. The patient’s current medications were atorvastatin and oxycodone for chronic back pain. The patient stated his pain was ten out of ten on a scale of one to ten with ten being the worst. The left leg appeared shorter than the right, edema was present in the calf, as was ecchymosis and he had limited range of motion. After an evaluation in triage by a registered nurse and a subsequent examination by the emergency department physician, a plan was established to sedate the patient using moderation sedation protocol and perform a manual reduction of the hip.

Mr. S is a 25 year old male of Haitian descent, who was diagnosed with schizophrenia and assigned to the FEPP (First Episode Psychosis Program) after a two month stay in the inpatient unit. Mr. S was first admitted to the ER after being brought in by police for “bizarre” behavior, which included walking the streets responding to auditory and visual hallucinations; unable to concentrate or pay attention, while denying any hallucinations, but still accepting the treatment. Mrs. S kept to himself throughout the hospital stay, being very socially isolative. Mr. S had been living on the streets for 4 years prior to admission, receiving his meals from organizations such as “dans la rue” or “chez pops”. Mr. S’ roommate had originally kicked Mr. S

The worker met with Mrs. Marilyn Beaird on 8/18/15. She is bed and wheelchair bound and requires two assists when transported. Mrs. Beaird has diagnoses of Vascular Dementia and is unable to answer questions

In addition, CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. As noted above, this is an appeal to the previously denied request on 02/09/16. The appeal letter states that the patient has low back pain. MRI report showed disc bulge at L5-S1 with left neural foramina narrowing. However, 01/06/16 progress report noted that there was no radiculopathy with a negative SLR on exam. The guidelines require documentation of radiculopathy on exam. In addition, there is no documentation of a trial or failure of conservative treatment, including PT, as recommended by the guidelines. Furthermore, there is no documentation of any focal neurological deficits on the exam that would indicate nerve pathology. The motor and sensory exam was normal. Medical necessity has not been established. Recommend

R.O. is a 43-year-old female Latino patient who has been living at home alone since she got divorced three months ago. She does not have any living or available family in the United States. She is the oldest of three children. Her parents died of an accident when she was little. Two of her sisters live in Mexico. She has lost contact with her family in Mexico when she got married and move to the United States. She also has stopped communicating with her ex husband since they got divorced. Although she does not have any support from her family, she states that her church member has been very supportive. Moreover, R.O. states she was a homemaker until the divorce. Currently, she has been working as a dishwasher near her house.

On August 27, 2016 worker received a letter from Dr. Andrew Duxbury, MD, Mr. Walker’s doctor at the VA Medical Center. The letter stated Mr. Walker has both physical and mental limitations that render him dependent on a third party for care. He is unable to understand normal decisions for daily living and patient’s need for 24-hour care and supervision was discussed with family on June 9, 2016 during home visit.

On admission, Mr. Fountain complained of low back pain, ranging in intensity between 7 and 10, on a pain scale where 0 is no pain and 10 is the worst possible pain. He subjectively described this pain as a constant ache that permeates down into both legs, anteriorly and posteriorly, but at times can be stabbing, sharp, and burning. Sitting, standing, walking or lying down for prolonged periods can aggravate his back pain, while treatment modalities such as medications, nerve block injections, medical cannabis, TENS therapy, massage, and application

He reported difficulty lifting objects, mobility limitations, problems using his hands or fingers, completing tasks, and getting along with people. He was unable to do house chores, had constant back pain, and ambulated with a cane.

Nurses can work as case managers for many different reasons. According to Clark (2015) case management is “a collaborative process between the case manager and the client and his or her family designed to identify and meet health care needs through quality, cost effective services” (287). In the case of Maria Flores, members of the team include a community health nurse/case manager, public health nurse, department of social services, obstetrician, school counselor, and Maria Flores and her parents. There are five key principles of case management that apply to the case of Maria Flores. The first principle is “case management addresses a variety of determinants of health” (Clark, 2015, p.289).