Nursing Case Summary Essay

William Smith is a 68-year old man who was transferred to the Palliative Care ward from a surgical ward three days ago. The patient was admitted on January 26, 2013 for removal of a sacral abscess that had been a source of a lot of pain to him. Following his surgery, his future management was evaluated and it was decided that he would be transferred to the Palliative Care ward since he could not be discharged home. The palliative assessment of Smith would require the development of a suitable nursing care plan that would help deal with the condition. The nursing plan requires an understanding of the patient’s social history, medical history, physical assessment upon admission, and palliative care unit admission assessment.

This is an 82-year-old gentleman, who was referred from Dr. Gretchen Marsh’s office because the patient’s BUN and creatinine were high, as he has acute kidney injury. The patient went to Dr. Marsh’s office yesterday and was having generalized weakness. He does not have any vomiting. No diarrhea. No fever. No cough with expectoration. No sharpness. No wheezing. No headache. No dizziness. No passing out. No rectal bleeding. No hematemesis. No abdominal pain. No sore throat. No stuffy nose. No cough with expectoration. No burning, frequency, or

Mrs. P is a 63-year-old female who was not feeling well for a couple of weeks. She went to her Primary Care Physician (PCP) complaining of increased dyspnea on exertion, weakness, nausea, headaches, loss of appetite and periods of confusion. Since she has an extensive medical history that included pulmonary hypertension and emphysema, blood work was obtained. She was told that she had leukocytosis, hyponatremia (Sodium 126 mEq/L ), hypokalemia (Potassium 2.5 mEq/L) and an acute kidney injury (AKI). She was told to go to the emergency room and was admitted to the telemetry unit.

In the given scenario, I am a family nurse practitioner in a busy emergency room. Early in the evening hours, I am presented with a concerned mother who is seeking medical attention for Paige, her six-year-old daughter. The mother reports the patient has been displaying cold symptoms for a few days with a cough that continues to worsen. The issue that the patient faces is limited access to healthcare providers in the area who accept Medicaid, which is Paige’s health insurance provider. After discovering Paige’s physician’s office does not have any appointments available for three days, the concerned mother decides to seek care for her daughter at the emergency department. Considering the patient’s condition is considered non-urgent, and our

Patient Amy Ford has come into the office complaining of abdominal pain, increasing amounts of diarrhea and has been dehydrated. Amy is a very active 30-year-old with no children and travels all over the United States and stays at camp grounds in her RV. Amy has said that she previously bathed in a nearby lake at her camp site and has poor hand hygiene. Amy also enjoys hiking and traveling to different State land marks. Her overall health has been very good until approximately a month ago when the symptoms started. Her family history has no signs of heart disease or canner. She has come to the doctors because she thinks that something is wrong with her stomach or intestines.

The patient is 65-year-old gentleman who presented to the emergency room with fever, urinary urgency, lower abdominal pain, no nausea no vomiting. The wife also reported that the patient had a leak from the Foley catheter. The patient this has a history of hypertension, dementia and enlarged prostate. He is been followed by urologist at St. Hackensack University Hospital and currently has a urinary retention with indwelling Foley catheter. He presents to our ED with a temp of 102.3, white count of 24.6 which goes up to 25.5 and the left shift. Urinalysis reveals him to be dehydrated with specific gravity greater than 1030, positive nitrates, positive large, leukoesterase, a large amount of blood and his cultures immediately grew Escherichia

The patient is a 43-year-old healthy female on birth control who tells me last night at about 10 o'clock, she started having urinary symptoms, including burning with urination, frequency, suprapubic pressure. She denies any flank pain, no fevers. She does tell me she suffered throughout the night with these symptoms, but then by this morning, she got AZO and did take that. This did relieve the symptoms. She feels quite comfortable throughout the day today. She does get normal periods on her birth control tablets. She states her last period ended this past Sunday. She did note that yesterday, she had some vaginal discharge that seems like dried blood. She has not had any itching or other vaginal discharge and no further

Occupational profile: Mary is a 43-year-old female who was diagnosed with MS 6 years ago and is currently admitted into the hospital with an acute exacerbation of MS symptoms. Mary and her 16-year-old daughter reside in a second level apartment. The apartment complex only offers stairs for means of ascending to upward levels. Mary’s daughter assists with home management tasks. Prior to the hospitalization, Mary was not employed and was on disability. She was functional in her ADL’s and IADL’s prior to this exacerbation. Mary is exhibiting frustration with her condition. Her goal is to return home.

An understanding in nursing sensitive indicators in this case could have solved a couple problems that arrived during this patient’s stay. One of the issues was that the patient’s back was reddened due to restraints being placed and the patient not being turned properly to prevent pressure ulcers. If this would have been recognized when the restraints were applied, the patient would have been turned every two hours by placing a pillow under the sides of the patient so that he would not be on his back constantly. Due to him being confused, he may have been moving around a lot and pushed the pillows out, but there is also the case he should be getting rounded on hourly at the minimum. If this understanding would have been understood and the nurse knew what could have happened, she would have been turning the patient to ultimately decrease the hospital stay.

The patient has a history of slightly elevated fasting blood sugar of 106 in 2012.

Patient reports urinary burning, urgency, and frequency for 2 days. He admits that he had similar symptoms 2 months ago, but he did not seek treatment because he was on vacation. States that he passes one kidney stone 1 week ago. Denies fever, chills, flank pain, and hematuria.

Mary was seen today following a repeat chest x-ray, which reassuringly shows almost complete resolution of the effusion with just some mild pleural thickening seen in the right base, which is a reaction to the parapneumonic effusion.

Two pt verifier name/dob confirmed. Pt states that she was diagnosis with a UTI and began antibiotic therapy on Tuesday evening. Pt states , this am she note that he urine was brown in color. Pt denies fever, chill, lower back pain, increase pressure to the lower abdomen. Encourage pt to drink plenty of water and continue taking her antibiotics as directed. If her symptoms worsen please go to ER and f/u with PCM. Pt agrees and verbalized understanding.

On admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings. J.P. was positive for dyspnea and a productive cough. She also