Nursing Case Studies

Nursing care is a dynamic field of practice. The way it looks today is far out greater intense and very structured. It advances itself by the use of nursing theories and evidence based practice. Policies and procedures constantly change with the advancement of technology and science. While caring for the patient in the given case studies, a nurse involved utilizes practical knowledge, a culture care model and transpersonal caring relationship to attain a caring environment (Smith & Parker, 2015).

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.

I was well versed with the patient’s medical history and current treatment, as I was the Long Call IM PGY – II Resident who supervised the medical intern when this patient was being downgraded from the ICU to the medical floor on 5/20/17 (and even suggested to the medical intern to add in her notes that the patient would benefit from statins, ACE inhibition and Spironolactone given CAD, CVA and HFrEF (LVEF < 35%.) The medical team subsequently started the patient on Atorvastatin 40 MG PO QHS, Lisinopril 10 MG PO QD and Spironolactone 12.5 MG PO QD.

BH reports that he takes his medications as prescribed and reports he has tried to adjust his diet in order to decrease his glucose, triglycerides, and cholesterol. He continues to consume

The patient tells me his last visit with Peter Dourdoufis, MD was just last week. I do not yet have a note from that visit. He says that he underwent an EKG and a stress test evaluation. To his knowledge, everything was okay, but he actually has an appointment tomorrow with Dr. Dourdoufis to review everything. No medication changes have been made per his report. He tells me that his blood pressures have been in a good range. Here today, his blood pressure is 126/76. He is not having problems with chest pain, shortness of breath, dyspnea on exertion or lower extremity swelling. He is still working

CHIEF COMPLAINT: This is a post op note from a procedure performed July 21, 2015 by David Lin, MD.

Demographics: Patient is a 32-year-old, moderately built Caucasian female; separated once with 2 children. She lives with her children in her mother’s town house in the North-eastern part of the province. She is currently unemployed and receiving disability from the state from sustained back injury. She has Medicaid insurance; speaks English and practices the Baptist religion.

DOI: 8/6/2015. Patient is a 51-year-old female licensed vocational nurse who sustained a work-related injury to her back and hips while moving a client. As per OMNI, she was diagnosed with muscle spasm, pain over the low back and thoracic region. She is status post right carpal tunnel release on 02/26/16.

4. From the investigations in section 2 of Chapter 5, there is reason to believe that

It is very important to monitor Mr. Cox’s response to therapy. Parameters that should be examined closely are Mr. Cox’s response to his blood transfusion, his lab values, and his response to iron therapy. Mr. Cox should return to the clinic in one month for follow up lab work, medication compliance, and assessment of current and comorbid diseases.

The member’s family requested that he be transferred to United Hospital in St. Paul, Minnesota. The documentation states the member is to be transferred via air ambulance as per the family requests. The treatment plan was neurology and neurosurgery care on the mainland. A repeat CT scan was planned for 03/21/2016. Additional medical problems include paroxysmal atrial fibrillation and benign essential hypertension. The member was seen and re-examined on 03/20/2016. There were no new complaints or new physical examination

Pregabalin 25mg PO two capsules at bedtime prescribed in 2016 to assist with chronic pain symptoms. She reports that this medication caused an abnormal skin sensation similar to that of insects crawling over or within the skin.

Congenital Adrenal Hyperplasia (CAH) refers to a complex series of rare but well-studied enzymatic errors of metabolism with deficient levels of different enzymes involved in the synthesis of cortisol (hydrocortisone).

History of Present Illness: Mr. A. O. a 66 year-old-African American male came in the clinic for a monthly routine follow up visit complaining of severe cluster frontal headaches that radiates to his left eye, pain level eight out of ten, on and off for three days lasting for 30 to 45 minutes. He stated that he takes Tylenol 1000mg orally every eight hours with mild relieve, and will like his blood pressure medications increased. Also, he complained of edema to the upper and lower extremities, and right hand pain when he tries to make a fist. However, he denied shortness of breath,