Mr Daley has difficulty hearing and is partially blind. He does not appear to be very cooperative with the medical team. He refuses medication, and is not improving. Act out the scenario to help your peer with the assessment. Not all the subjective and objective (assessment of the abdomen) is found on the case. Allow your peer to examine you.

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Select one of the followings:

 

Older adult failure to thrive (Adapted from elderconsult.com)

 

Mr Robert Daley is an 80 year-old man with a history of avoiding doctors lived at home with a caregiver. He developed pneumonia and was admitted to Harborview Medical Center. After being discharged from the hospital, Mr Daley is transferred to a nursing facility at Kline Galland. After 6 months in the facility, Mr Daley is found to have iron deficiency anemia. He is able to state that perhaps the colon cancer may be the cause, but he is not able to answer when asked if he will agree to have a colonoscopy to confirm this diagnosis. Mr Daley subsequently stops eating. The resident physician prescribed iron tablets. Mr Daley refuses to take his medication because he insists that the medication irritates his stomach. He does not like doctors and refuses all blood tests. Left with no choice, the medical team offers him comfort food like ice cream diet and Ensure. His weight did not increase. He now weighs 99 lbs. Although Mr Daley does not like doctors, he is usually very amiable to the nurses in the nursing facility. The physician understands the importance of interdisciplinary care and approach the charge nurse for help with health history interview and physical assessment of the abdomen. Mr Daley is slightly hard of hearing and partially blind. The nurse recognizes the challenge of conducting an assessment.

 

Instruction for the mock patient:

  1. Mr Daley has difficulty hearing and is partially blind. He does not appear to be very cooperative with the medical team. He refuses medication, and is not improving. Act out the scenario to help your peer with the assessment. Not all the subjective and objective (assessment of the abdomen) is found on the case. Allow your peer to examine you.

 

Instruction for the nurse:

  1. What is it like to have the privilege and trust of a patient? Consider what techniques will help you obtain data from this client. How did you obtain information and plan your care on a client who is hard of hearing and partially blind? Consider your challenges and how you plan to work with this client.
  2. Complete the health history interview and physical assessment for Mr Daley.
  3. Use the regional write up in Jarvis workbook, page 195-196 to serve as a guide.
  4. Be creative with data collection. Added on missing data if deemed appropriate.
  5. Create a Word.Doc. Submit SOAP note on canvas.

Describe your objective findings. No need to include pictures in 196.

  1. Include at least 2 nursing diagnosis or nursing problems under Assessment
  2. Ensure your Plan (intervention, follow-up care, patient teaching) are relevant to each of the diagnosis identified.
  3. Add your reflection to the assignment.

 

Cancer of the Colon (adapted from Johns Hopkins Advanced Studies in Nursing)

 

Ms Martha Lee, a 35-year-old Chinese female is presented to UW Medical Center with complaints of weakness and fatigue, although she continues to go to work. She is a labor and delivery RN in the same facility. She attributes these changes to menopause; her menstrual periods have been irregular but occasionally heavy. She experiences recent weight loss of 10 lbs over the past 6 months not attributable to diet or exercise. Ms Lee reports of chronic constipation and hemorrhoids, and mild dyspnea on exertion. She has not been to a screening colonoscopy or sigmoidoscopy. She never thinks she will need one. Contrary to her profession as a nurse, she does not believe in going to a doctor. She considers herself as a traditional Asian women who strongly believes in complementary and alternative medicine for healing.  Her current medications include ibuprofen 400mg orally as needed. Her mother, aged 83 has type 2 DM (treated for 35 years), and her father died of cancer of the colon. On admission, Ms Lee appeared pale and thin. She is 5’6” tall and weighed 128 lbs. Vital signs were as follows: BP 132/66mmHg, PR, 86 bpm, RR 22 bpm, and temp 99°F (37.2°C). She reports that her last bowel movement is 2 days ago. Ms Lee is afraid that the diagnostic test will turn out positive for cancer of the colon. She verbalizes that she does not want to die early.

 

Instructions for the mock patient

  1. Read the storyline carefully. Ms Lee is a RN who does not seem to appreciate the importance of taking care of herself. She has not been to a health screening, does not believe in going to the doctors. She believes in complementary and alternative medicine. She also appears to be afraid to ‘know the truth’ and yet ‘does not want to die’. It is confusing. Create a story for your peer and allow your peer to examine your abdomen.

 

Instructions for the nurse

  1. The client is a RN Ms Lee is a RN who does not seem to appreciate the importance of taking care of herself. She has not been to a health screening, does not believe in going to the doctors. She believes in complementary and alternative medicine. She also appears to be afraid to ‘know the truth’ and yet ‘does not want to die’. It is confusing.
  2. Complete the health history interview and physical assessment for Ms Lee.
  3. Use the regional write up in Jarvis workbook, page 195-196 to serve as a guide.
  4. Be creative with data collection. Added on missing data if deemed appropriate.
  5. Create a Word.Doc. Submit regional write-up and SOAP note on canvas.

Describe your objective findings. No need to include pictures in 196.

  1. Include at least 2 nursing diagnosis or nursing problems under Assessment
  2. Ensure your Plan (intervention, follow-up care, patient teaching) are relevant to each of the diagnosis identified.
  3. Include a reflection section. What is frustrating about this client? What kind of health teaching or health reinforcement is needed to help her understand? What is your struggle with health history interview that was difficult, especially with a difficult client?

SOAP Note #1

S:

MF is a 45 yo female with chief complaint of “stomach pain.” The sharp epigastric pain began 3 days ago, has been continuous, and does not radiate. She reports 9/10 pain severity. This is the first occurrence. Admits diarrhea, vomiting, anorexia. Denies fever, chills, weakness, nausea, shortness of breath, dyspepsia, hematemesis, hematochezia, melena, dysuria. LMP 1/5/19. Tried Pepto-Bismol with no relief. Last BM this AM.

PMH: Left Ovarian Cyst, Appendicitis, Gallstones, Irregular Menses, Scoliosis

PSH: Appendectomy, Cholecystectomy

Allergies: NKDA

Medications: Acetaminophen (Tylenol) 325mg 1-2 tabs PO q4-6h prn for back pain

FHx: Unknown

SHx: Denies EtOH, Tobacco Use

O:

T 99.0°F | BP 126/80mmHg | P 84 BPM, regular | RR 12 breaths/min, unlabored | SpO2 96% RA

H 67in | W 150 lb. | BMI 23.5

Gen: Slender female, neatly groomed, looks her stated age of 45 years. Alert and cooperative. Holding abdomen. Some distress.

Skin: Warm and moist. Good turgor. Nonicteric.

HEENT: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera are white and nonicteric. Conjunctiva and cornea clear.

Mouth/Pharynx: Oral mucosa pink, well-hydrated. No masses, lesions.

CV: RRR. S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs.

Pulm: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.

Abd: Flat, symmetrical. No scars, striae, caput medusa. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. Tympanic to percussion throughout. Tender to light and deep palpation of epigastric region. No guarding or rebound, CVAT, organomegaly.

A:

45 yo female with epigastric pain, diarrhea, vomiting, anorexia x 3 days. Likely gastroenteritis.

Differential Diagnosis:

  1. Ectopic Pregnancy
  2. Myocardial Infarction
  3. Gastroenteritis
  4. Choledocholithiasis
  5. Pancreatitis
  6. Hepatitis

P:

Labs:

  • Qualitative Beta-HCG with Reflex, R/O: Pregnancy
  • Troponin, R/O: MI
  • CBC, BMP, Lipase, LFTs, Bilirubin (total, direct, indirect)
  • U/A, Urine Culture

 

Imaging/Tests:

  • EKG, R/O: MI

Gastroenteritis:

  • Start 1L Normal Saline IV
  • Start Famotidine (Pepcid) 20mg PO qd
  • Start Calcium Carbonate (Maalox) 2 Tabs PO prn; Max 12 tabs/24h
  • Start Ondansetron (Zofran) 8mg PO q8h prn

Left Ovarian Cyst

  • Surgical removal scheduled for Friday per patient

Irregular Menses

  • Follow up with Dr. Chu (Patient’s OB/GYN)

Scoliosis

  • Follow up with PMD
  • Continue Acetaminophen (Tylenol) 325mg 1-2 tabs PO q4-6h prn for back pain

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

 

Adjusted DDx After H&P:

Ectopic Pregnancy

Myocardial Infarction

Gastroenteritis

Choledocholithiasis

Pancreatitis

Hepatitis

 

Initial DDx Based on CC:

Gastritis

Gastroenteritis

GERD

PUD

Pancreatitis

Appendicitis

Cholecystitis

Cholelithiasis, Choledocholithiasis

Cholangitis

Hepatitis

Acute Splenomegaly

Nephrolithiasis

Pyelonephritis

Irritable Bowel Syndrome

Irritable Bowel Disease

Diverticulitis

Endometriosis

Ruptured Ovarian Cyst

Ectopic Pregnancy

Cystitis

Salpingitis/PID

Myocardial Infarction

Aortic Aneurysm

 

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