Nursing Case Studies

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.

Attached are chiropractic and PT notes. Patient has been previously denied with same request on 12/01/15 (Review

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

On the statement of medical necessity on the MG2 form dated 06/08/16, PT is requested at a rate of twice per week for 6 weeks for her left knee and secondarily, the left hip pain that is related directly to her altered gait.

Blood pressure -138/88, HR 71, Lung sounds –clear, temperature 98.8 F, radial pulse and pedal pulses +1 bi-laterally, normoactive bowel sounds. No history of smoking, drugs, alcohol use or diabetes; takes no daily medications. Surgical history: Hernia surgery September 2016 and cataract surgery September 2013. Moderately active, walks every day, sometime incorporating hand weights. Patient presents with minimal trembling unilaterally, (left side) when fingers stretched out, reports movements have been slower than normal. Patient’s wife reports “He’s been eating more slowly and it has been taking longer for him to get dressed in the morning.”. Upon examination it was determined that patient has reduced arm swing, slight stiffness in neck, difficulty rising from sitting position in the chair, masked facial features and deteriorated balance. No signs or symptoms of stroke.

Mr. Brann is a 42-year-old male here today for followup from his left cerebellar stroke and left vertebral artery dissection, status post hospitalization in May of 2015

DOI: 9/30/2014. Patient is a 28-year-old female research assistant who alleges pain and weakness in her hands/wrist as a result of repetitive scooping dirt from soil barrels. As per OMNI entry, the patient was diagnosed with cervicobrachial syndrome (diffuse), right carpal tunnel syndrome and insomnia. She is status post endoscopic carpal tunnel release (CTR) on 09/24/2015 for the right and on 06/02/2015 for the left side.

Based on the medical report dated 02/01/16, the patient presents for a routine follow-up visit regarding her chronic neck pain with radiation down the left upper extremity into the thumb with numbness and tingling. She reports no change in her pain since her last follow-up visit. She states she stopped taking the Lyrica because it was making her feel weird and her head felt cloudy. She did wean off of it as instructed without problems. Authorization for acupuncture treatments was denied by the insurance because it stated the left hand pain was not part of her claim. Patients hand pain only developed after she had the neck surgery, which was anterior cervical discectomy and fusion (ACDF) at C5-C6.

Per previous review (Review 267658), the patient has attended a total of 36 sessions of both cognitive behavioral therapy and biofeedback.

He reports no major changes in his condition, since his last visit. His pain is rated as 3-6/10, described as dull, hard, aching or worse. Pain is increased with sitting, standing, walking, lifting, looking up and down, turning to the sides, bending, and twisting. He is unable to work. He is very limited physically. He has to modify or avoid social and recreational activities to manage the pain. He feels like his quality of life is severely affected. His pain is 80% in the neck and 20% in the upper extremities, mostly on the

Based on the progress report dated 03/01/16 by Dr. Ahmed, the patient continues to complain of constant lower back pain radiating to her left leg which she describes as sharp with pins, and needles and intermittent numbness and weakness.

Based on the medical report dated 12/29/16, the patient is having flare-up in his bilateral shoulders with pain on the left 6/10 and on the right 8/10. It is worse with reaching up and certain other activities. He is avoiding medications. He has had very good experience with physical therapy in the past and would like some sessions to treat his flare-up. He also needs

DOI: 5/12/2016. Patient is a 30-year-old female “WNA 2” who sustained an injury while she was driving, a vehicle rear-ended their vehicle and she injured her back, neck and right arm. As per OMNI notes, the patient is diagnosed with cervical/thoracic/lumbar strain and right upper limb pain.

The patient is an 87-year-old female who was recently hospitalized here at St. Joseph's Medical Center and discharge to rehabilitation spent approximately 3 weeks in the rehabs setting and was home for a day before she represented to the emergency room complaining of inability to move, profound weakness, right hip pain and right thigh swelling, as well as bilateral leg edema. The patient's medical history is significant for afib, coronary disease, congestive heart for diabetes mellitus, GERD, thyroid disease, sick sinus syndrome with permanent pacemaker. She has undergone CABG, nausea, profound vascular disease, anemia, severe gastroparesis, as well as having had polio, she presents with profound weakness and she is essentially bedbound.

Based on the progress report dated 11/08/16 by Dr. Yuan, the patient reports that her upper back pain has gotten worse on the last 2 days, since the last visit. Pain is described as sharp and intermittent, rated as 6/10. Hs e is taking medications with little benefits and applying lotion with benefits. She has not been coming to therapy because she does not like the service/therapist. She reports that gel seem to help. She has been taking over-the-counter ibuprofen. She wants