Nursing Clinical 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.

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.

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

Patient states that she has had no head injuries, past or present. Patient states she has never suffered from vertigo or dizziness. BB states that she rarely suffers from generalized headaches. Patient avoids taking pain relievers of any kind when she does present with head pain.

My patient is a 58-year-old female, who presents with controlled type II diabetes, hypertension, and possibly thyroid tumors that have been there for a few years. She is under the care of a physician for her diabetes and associated controlled hypertension. I recommended several times that she see her physician after feeling the tumors around her neck and thyroid. Her medical history also indicates that she had rheumatic fever twelve to thirteen years ago, has arthritis in her knees, and occasional headaches. She is 5”3 and weighs 216 pounds. Her blood pressure was 126/80, pulse was 88 BPM, respirations were 20, and her temperature was 98.2 Fahrenheit. She doesn’t smoke and I made sure that she had eaten lunch and wasn’t hungry. She is currently on 100 mg Metformin for her diabetes, 120 mg. Lisinopril for hypertension, 40 mg. of Lovastatin to lower cholesterol, 80 mg. of Aspirin to prevent cardiovascular disease, and daily insulin. Reviewing her medical HX, I was informed that she usually checks her blood glucose daily, but had recently run out of strips, so it had been a

L.H. report no concurrent or severe headaches; There was no head trauma, syncope or vertigo. Patient wears corrective lens with no difficulty of vision or diplopia; absent of inflammation, discharge or lesion. Last eye exam was in September of 2016 with no history of glaucoma, cataracts. L.H. denies having any frequent colds, sinusitis, epistaxis and trauma. Patient reports having obstruction stating, “it happens when I am lying down” with an occasional postnasal drip.

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

She reports a history of back pain, ovarian cysts excision, and breast tumor. She denies chest pain, shortness of breath, or palpitations. Patient reports that her immunizations and preventive care are up to

He also had right more than left mastoid opacifications and states that he was recently treated for otitis media. He has hypertension, hyperlipidemia, coronary disease and had been noncompliant with his medications in the past. His exam was essentially normal except for the subjective vertigo. There was no nystagmus and no diplopia on the initial exam. On 06/19/2015, he gave a different history. He states that he had a strike to the left temporal on Tuesday 06/16/2015. This did not result in any vertigo or any other neurological symptoms at that time. It was two days later that he had the vertigo at work. The patient also claimed that he had been seeing double since the previous night and the morning of the 19th. However, his neurological exam at that time, failed to reveal any actual disconjugate gaze. The patient had an MRI MRA, which revealed old white matter ischemic disease and mild intracranial atherosclerosis, but no evidence for acute stroke or posterior circulation significant stenosis. His diagnosis was labyrinthitis, possibly due to his bilateral mastoiditis. He was treated with Augmentin for 10 days. His symptoms resolved prior to discharge on meclizine. On physical therapy on discharge, he had no

Present Illness- Miss B reports left ear pain for the past two day. She states that the pain started as a dull left sided ache that was a 2 on the 0 out of 10 verbal pain scale and has slowly progressed to a 7 at present. She relates the pain as an ache that is not aggravated or relieved by anything. Miss B reports that she was unable to attend school today due to ache and came in for treatment. She reports that she has taken an over the counter pain reliever, unknown name and dosage, with little relief. She denies fever, nausea, vomiting or diarrhea. Miss B does report that she has not been eating as much as it seems to hurt to chew but denies difficulty swallowing. She denies change in hearing, ear canal discharge and dizziness during the ache.

Childhood illnesses include measles, mumps, rubella, and chickenpox. She has fallen many times however, has never broken any bones. Serious traumas include three concussions. Has had many surgeries including tonsils removed, gastric bypass, right hip replacement, 2 bilateral knee surgeries, cataracts removed, back surgery and is waiting for shoulders to be replaced. Reports sinus infections in the spring and fall due to pollen and mold. These symptoms are similar to the ones she is experiencing now. Several years ago, she traveled around the world for 7 months and was in England for the Mad Cow Disease outbreak.

Patient is a 34-year-old left-handed white male who states that in January he was in a parking lot and was hit by a plow truck that was backing up. His back was turned and he did not know what was happening. He fell on his back and hit the back of his head on the tailgate. He denied any loss of consciousness. He did have a significant headache and neck pain, but no neurological symptoms. He did have some pain in his right hand and right ankle after this. He did present to the emergency room, where an unenhanced CAT scan was negative. Since then however, he has been having daily headaches. He has an almost constant, dull, mild bitemporal pressure sensation, but he also has significant

Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.

CHIEF COMPLAINT (CC): Patient complains of a history of chronic headaches with acute onset of double vision and right eyelid droopiness beginning 3 days ago.

Then she started noticing headaches at her menses. They start five days before her period and go through her period. Sometimes it can last beyond her period. She has otherwise, one to two headaches a week outside of her menses. These headaches again are pan cephalic. Sometimes it feels like she is wearing a helmet. They are knifelike and retrobulbar. They are worsened with exertion. She gets nausea, photophobia, and phonophobia with them. Last month, she had an episode of graying out of her vision and then zigzag lines, followed by dizziness and then after several minutes was followed by a headache. Last month, she had an episode of vertigo upon arising in the morning for 10 minutes, after that she had a headache. Otherwise, she has no neurological aura. There is no clear precipitant, except for stress. She has been on amitriptyline 10 mg for two months with no significant change in her headaches. Imitrex 100 mg sometimes helps. She recently took an over-the-counter medication with Tylenol and caffeine and