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Client Scenario:Patient: J.R.Age: 66Gender: MaleHeight/Weight: 5'9"/ 200 pounds

 J.R. is a 66-year-old Caucasian male. He lives alone on a small rural farm. His wife died two months ago. His three children live out of state. J.R. spends his days working to keep his small farm running. J.R. was admitted for surgical repair for a torn rotator cuff of his right shoulder.

Allergies: NKDA (no known drug allergies)

Code status: Full Code

Privacy Code: none

Time: 0700

Attending Physician: Dr. Moss

Patient Chief Complaint: Right shoulder pain 6/10 (10 being the worst pain)

Current History: J.R.'s right shoulder had been causing him pain for a few days. He went to see is primary care doctor who referred him to a surgeon. He is a scheduled admission for surgery.

 

B/P                HR                  RR                 TEMP           SP02              PAIN

155/90            90                   16                 98.8               95%               6/10

History of skin cancer to nose which was removed by a dermatologist 3 years ago. Additional history includes hypertension, kidney stones, spontaneous pneumothorax, and sleep apnea. States he does not use his C-PAP machine for his sleep apnea because he "does not like the way it feels on his face". Last admission 8 years ago for hernia repair. Patient has smoked one pack a day since the age of 16. He reports that he now drinks 3-4 beers a day since his wife died. He wants to try to "stop his bad habits" but doesn't know they best way how.

 

HEENT Head normocephalic. 20/30 vision bilaterally. Slightly hard of hearing. Nares patent. Mucosa pink, with no lesions. Tonsils present.

RESPIRATORY Reports chronic, nonproductive cough.

CARDIOVASCULAR Denies chest pain, palpitations, or shortness of breath. No syncope or pre-syncope episodes.

NEUROLOGICAL Complains of weakness and pain to right arm. Denies numbness.

HEENT Slightly hard of hearing. Wears glasses when reading. No complaints of headaches, change in vision, nasal problems, or sore throat.

DIETARY HISTORY: Reports decreased appetite. Reports that his wife used to go grocery shopping and cook meals. Since her death he has mainly ordered in or has gotten fast food.

I & O No complaints of nausea, vomiting, or change in stool pattern, consistency, or color. Patient complains of occasional hesitancy with urination. Denies pyuria or hematuria.

INTEGUMENTARY Complains of dry, scaly skin. Worries about his increased risk of skin cancer since he is outside working on the farm. States he "uses sunscreen when he remembers to put it on".

LYMPHATIC: No palpable nodes. Denies problems with lymphatic.

ENDOCRINE Reports increase in fatigue over the past few months.

MUSCULOSKELETAL Patient complains of right shoulder pain that is stabbing and aching. He has been taking extra strength ibuprofen which helps bring his pain down to a 5/10. Gait is coordinated. Does not use any assistive devices.

PSYCHOLOGICAL/FAMILY - SUPPORT

Wife died two months ago. Lives alone on his farm. He is worried about he will be able to take care of his farm with his injury. Three adult children live out of state and patient only sees them on special occasions.

 

 

Care Plan

 

Subjective assessment data:

 

 

 

 

 

 

 

Objective assessment data:

 

 

 

 

 

 

 

Additional Assessment data:

 

 

 

 

 

 

 

 

1) Problem-Focused Nursing Diagnosis:

 

Related to (RT):

 

As evident by (AEB):

 

 

 

Planning/Expected Outcome:

Implementation/Nursing intervention(s):

Rationale

 

Evaluation/Patient Response

1)

 

 

2)

 

 

2) Risk for Nursing Diagnosis:

 

Related to (RT):

 

 

 

 

Planning/Expected Outcome:

Implementation/Nursing intervention(s):

Rationale:

Evaluation/Patient response:

1)

 

 

2)

 

 

3) Health Promotion Nursing Diagnosis:

 

Related to (RT):

 

 

 

Planning/Expected Outcome:

Implementation/Nursing intervention(s):

Rationale:

Evaluation/Patient Response:

1)

 

 

2)

 

 

 

  1. Which one of your nursing diagnoses would you consider your priority nursing diagnosis? Why?

 

 

  1. List four major risks to J.R.'s safety during this hospitalization.

 

It is now been 4 weeks, and J.R. is still having intermittent pain that forces him to lie down. He is concerned about getting back to work because he lives alone and is his own sole supporter. J.R. has been taking anti-inflammatory and pain medications, but they make him nauseated. He has made an appointment with Heather Montgomery, a nurse practitioner who focuses on the use of complementary and alternative (CAM) treatments.

 

  1. Heather uses the following types of treatments for pain. Which ones are CAM treatments? (Select all that apply.)
  2. Massage therapy
  3. B. Tai chi
  4. C. Guided imagery
  5. D. Chinese herbal therapy
  6. E. Narcotic administration

 

  1. Heather assesses that J.R. is very stressed about getting back to work as soon as possible and becomes tense and agitated when talking about it. What type of CAM treatment is the best treatment for J.R.?
  2. Relaxation therapy
  3. B. Biofeedback
  4. C. Acupuncture
  5. D. Gingko biloba

 

  1. Heather assesses the medications that J.R. is taking. Why would it be important to do that before recommending any herbal therapies?

 

 

 

Rubric


Case Study Assignment

Case Study Assignment

CriteriaRatingsPtsThis criterion is linked to a Learning Outcome

Assessment Data

Include subjective, objective, and any additional client assessment data.

5.0 pts

Full Marks

0.0 pts

No Marks

5.0 pts

This criterion is linked to a Learning Outcome

Nursing Diagnoses

Create one problem-focused, one risk, and one health promotion nursing diagnosis.

10.0 pts

Full Marks

0.0 pts

No Marks

10.0 pts

This criterion is linked to a Learning Outcome

Planning/Expected Outcomes

Create one expected outcome for each nursing diagnosis.

10.0 pts

Full Marks

0.0 pts

No Marks

10.0 pts

This criterion is linked to a Learning Outcome

Implementation/Interventions

Make least one intervention for every nursing diagnosis; include rationale for intervention and who the task can be delegated to.

10.0 pts

Full Marks

0.0 pts

No Marks

10.0 pts

This criterion is linked to a Learning Outcome

Evaluation of Outcomes

Discuss desired evaluation finding and/or how the intervention will be evaluated for each intervention selected.

5.0 pts

Full Marks

0.0 pts

No Marks

5.0 pts

This criterion is linked to a Learning Outcome

Questions

Answer the questions provided correctly. (2 points each)

10.0 pts

Full Marks

0.0 pts

No Marks

10.0 pts

Total Points: 50.0

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Client Scenario: is a 66-year-old Caucasian male. He lives alone on a small rural farm. His wife died two months ago. His three children live out of...
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