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Case Study: Roles of a Nurse

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Mikyla Davis

on 27 February 2013

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Transcript of Case Study: Roles of a Nurse

Mikyla Davis
NURS 4155 Case Study: Roles of a Nurse Evaluation Headaches different from her usual migraines
Symptoms started a few days following a tooth extraction
PCP gave her toradol IM and advised her to take a zofran suppository and drink plenty of fluids.
She still wasn't able to hold anything down
C/o pain above her right eye
Chronic low back pain now radiating down her legs
Drs. suspect meningitis (unsure if viral or bacterial) Nursing Diagnoses Therapeutic touch and communication
Pain management
Nausea management
Improve energy flow Plan Interventions Therapeutic nurse-patient relationship developed
Modifications were made to establish methods best to control pain, nausea and anxiety
Pts pain, nausea, and anxiety were controlled
Pt became more relaxed
Pt and family discussed concerns and assisted in developing goals, implementing interventions and modifying plan of care
Pt and family verbalized and demonstrated understanding of teaching The Patient C.F. a 57 yo female admitted for fever, headaches & n/v

HX of migraine headaches and cervical/lumbar scoliosis Recent Illness Assessment C/O pain and nausea
very poorly managed
interfering with sleep and ADL's
meds not covering well
Anxiety
multiple requests
nothing is going right
Negative energy Medical Treatment 1. 2. 3. Acyclovir - viral meningitis
Hydrocodone/acetaminophen - headache
Ondansetron - nausea Flagyl - fungal meningitis
Clonazepam - anxiety/nausea
Zolmitriptan - migraine
Ambien - sleep aid
Fiorecet- headaches Ceftriaxone - bacterial meningitis
Trazadone - headache
Valproic Acid - prevention of seizures and migraines NCLEX Question A client has an allergic reaction to a newly prescribed IV medication. The nurse places the highest priority on which action? A. Instruct the client to remain calm.
B. Communicate the allergic response to the physician and pharmacist.
C. Stop the medication immediately.
D. Provide oxygen supplementation 5L via nasal cannula. By the end of the night patient will... Report pain and nausea are relieved or controlled

Verbalize methods that that provide relief from pain and nausea

Verbalize sense of relaxation and well-being Involvement of healthcare providers Med team: diagnose, prescribe, and coordinate care
Nurses: assess, diagnose, implement interventions, evaluate, advocate
PT: improve balance and strength
Case management: research and set up resources for home
HCA's: vital signs, assist with ADL's
Pharmacist: manage medications, determine at home meds

**All must collaborate and communicate changes/improvements in pt status** Music as a Therapeutic Intervention NCLEX Question Which of the following is most important when assessing a client's pain? A. The physical location of the pain
B. The client's perception of the pain
C. The client's vital signs
D. The client appears uncomfortable 1. Pain secondary to infection as evidence by verbal report of pain, expressive behavior and sleep disturbance.

2. Nausea secondary to meningitis and pain as evidence by report of nausea and decreased appetite.

3. Disruption in flow of energy secondary to illness, immobility, pain, and anxiety as evidence by tone of voice, negative outlook and frustration. Preparing for Home Provide education about
Medications to continue/stop & new meds
Safety
Assistance at home
Home health w/ PT
Home Infusion
Care of IV site and dressing
Appointments
When to call Dr. or go to ED Determine concerns of pt
Assess pts perception of pain, nausea & anxiety & determine control goal
Perform pain assessment, assess for nausea, anxiety & effectiveness of tx's
Determine factors in pts lifestyle
Use CAPA pain scale to monitor changes in pain
Collaborate in tx of underlying condition & proactive mngmt of pain, nausea, anxiety
Promote non-pharmacological measures (comfort, relaxation, diversion)
Administer medications on time
Utilize therapeutic touch/communication and establish trust
Discuss & provide education about plan of care and medication regimen
Manage environment
Deep breathing System/Organization aspects that impacted care CAPA pain assessment tool

Dogs allowed in hospital References Diagnostics To r/o specific meningitis types
Lumbar puncture -- +PMN's
CT -- no intracranial issues
CBC -- slightly elevated WBC count Discuss
Limitations of music therapy
Benefits of music therapy
Why nurses should or shouldn't implement non-pharmacological interventions Phipps, M.A., Carroll, D.L. & Tsiantoulas, A. (2010). Music as a therapeutic intervention on an inpatient neuroscience unit. Complementary Therapies in Clinical Practice, 16, 138-142. doi:doi:10.1016/j.ctcp.2009.12.001 Doenges, M.E., Moorhouse, M.F. & Murr, A.C. (2010). Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (ed 3). In K. DePaul & T. Baber (Eds.), pp 299-302, 532-536, 576-581. Philadelphia, PA: F.A. Davis Company.

Pearson Education. (2010). NCLEX RN review. Retrieved from: http://wps.prenhall.com/chet_adams_pharmacology_2/63/16214/4150804.cw/content/index.html & http://wps.prenhall.com/chet_kozier_fundamentals_8/61/15680/4014163.cw/content/index.html

Phipps, M.A., Carroll, D.L. & Tsiantoulas, A. (2010). Music as a therapeutic intervention on an inpatient neuroscience unit. Complementary Therapies in Clinical Practice, 16, 138-142. doi: 10.1016/j.ctcp.2009.12.001 Health Literacy
Questions
Verbalization
Demonstration Health Disparities
High SES
Insurance coverage
Access to quality care
College degree
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