CASE STUDY??? Anyone interested in an interactice one??

UnchainedFever · Sep 25, 2008

May do all over the above, chemistries, UA and C&S... Taking a through history of home care may help as well. Are daughters competent to deal with care? Hydration? ADL's?

Daytonite, BSN, RN · Sep 25, 2008

let's show everyone what critical thinking and professional nursing is all about. for those who don't know me, i have been answering care plan questions on the student forums for a couple of years. i constantly tell students that this can be done by applying the nursing process. i think there should be a whole new forum for this since a fair number of students ask to see examples of a case study. it's been on my to do list to put one together for them and post it as an attachment. the problem has been (1) time, and (2) a choice of subject (don't want to give them something they are going to be doing in school so they can plagiarize it.)

anyway, my answer is yes.

GQRN · Sep 25, 2008

How about some acetaminohpen for the 100.6 and some Crystalloids for the 104/64 and hr 104 (what are her basline vitals?)

Check a FSBS (feeling bad), and assess for any diabetic ulcers leading to infections (temp 100.4)

Monitor for a few hours and dc if all is normal.

From the info, nothing really indicates a need for all the labs or ekg.

All she really has is a low grade temp, slight tachy and maybe a low bp but she IS on htn meds so I would want to kno her baseline.

luv2runRNnow · Sep 25, 2008

I'm a student with absolutely no ER experience at all so hopefully I'm not way off base! From the info we have, it doesn't seem like her vitals or disorientation (because it's her baseline) are indicating an acute emergency so I would want to take the time to find out a little more about her psych/social history. Does she have a primary care doc? Because she's made 4 visits this week to the ER without a hospital admission, is she using the ER as a primary care facility? If so, why? What did she and her family find as problems with the other 3 ERs (could give you an idea of their values to better help you meet them where they are). I'd want to know if her visit today was for the same symptoms as the other visits this week or is it an entirely different CC. Her vital signs show that there is something physiological happening but I think we need to get a bigger picture of this patient and her family to help determine what the next step is because something, whether psychological or physiological, is going on to have 4 ER visits in the course of the week. I realize I might be wearing my rose-colored glasses and in real life there might not be the luxury of having adequate time to try to figure out the 'story behind the story'!

Debilpn23 · Sep 25, 2008

Hi

I think this a great idea can't really think of anything else to add at the moment

Jolie, BSN · Sep 25, 2008

How about the OP (or another participant) returning to the thread sometime soon, summarizing what we've got so far and suggesting a direction to the next round of posts?

BradleyRN · Sep 25, 2008

Get a UA/C&S to r/o UTI (though i dont see how she could have made it through three other ER's without one.)

Find out if the sx are constant or occurring at certain times.

Also, get a Hgb A1C to r/o frequent hypoglycemia.

Look for abdominal distention and do a rectal check to r/o impaction (the pt is confused and the info provided by the daughters may be inaccurate since this is their fourth visit this week).

Medic2RN, BSN, RN, EMT-P · Sep 25, 2008

From the info, nothing really indicates a need for all the labs or ekg.

I would think based on her history and presently vague symptoms that we would need the labs & 12 lead. She has a history of MI - she meets all three criteria of the population that typically experiences atypical symptoms of MI: the elderly, females and diabetics.

With a history of GI bleed and temperature, I would want to see her H&H and WBC.

I would also ask the daughters if the patient takes her medications as prescribed by her doctor. Sometimes the patients are prescribed the meds, but don't always take them.

Medic/Nurse, BSN, RN · Sep 26, 2008

GREAT RESPONSES!

And I'll promise to get always get back. I hope that this will be a good thing.

HonestRN - great place to start.

starcandy- yes, we will need those labs

dragonflyRN - add those blood cx - never know with fevers

medic2RN - I know you are "feeling it" - wanting more from the daughters

RNREMT-P - got it covered - I like Mike's too. (I sometimes even get brave enough to go at 'em)

love2run1205 - no limits, sounds like you are right on - Welcome :)

I'm going give you some more info -

LIVING/ADL's: Patient (and her husband) lives with one of the daughters - but, manages most ADL's without assistance except for her husband. Pt does not drive. Pt weight is about 50kg and appears frail for age and overall reported health. Pt dmits to not eating or drinking very much.

IMPRESSION: Patient seems a bit sleepy but will answer ?'s on further assessment. Daughters seem stressed and will answer questions rapidly.

RECENT HISTORY: Reason for prior ED visits: Pt was having urinary burning and felt bad (fever, diarrhea) Daughters admitted patient had some urinary urgency and had vomited a few times since last ED discharge

TRIAGE ASSESSMENT: Does not appear in acute distess. Daughters however, appear to be very distressed. Pt denies any CP, SOA. Pt admits that her stomach hurts a little - but now denies any problems with urination or bowel movements. Oh yeah, we have these new medicines (from a prior ER visit) Levaquin, Klor-Con, Zofran ODT.

ADDITIONAL INFO from this weeks ER visits. Per the daughters - they said mom had a urinary tract infection and "gastric atitis" They said her potassium was low - they have her IV fluids and medicines and gave us the new medicines we showed you (noted above).

* Patient was "sent" over from her PMD's office. She had vomited x 1 this morning and the daughters rushed her to "her" doctor. The MD's office had not called to "prepare" us for the arrival - but, the daughters thought it best to get "mom here".

* Patient received an IM injection of 50mg of Phenergan 1 hour PTA at ER

CONSIDERATIONS:

Brief assessment: Alert, sleepy. Lungs - CTA, no increased work of breathing. Heart sounds - S1S2 - normal.

Triage standing orders:

* Give tylenol 1 gram - will have RN do it "PR" in patient room as patient "does not think she can keep it down.

* Establish IV saline lock and obtain CBC, CMP, Mg, Blood cultures x 2, Obtain urine specimen. May place foley cath if warranted.

No initial standing order for IV fluids, EKG, O2 for the patient age/presentation.

Who do you assign this patient to? - what room do you put her in? (we all know this can be important).

* May not be a "sick" patient at this point - but,

* Appears that the "daughters" will require some time/effort

Should this patient get your last monitored bed. You have 28 bed ED - and have 3 open rooms right now (1 monitor, 1 general and 1 gyn room). You have 16 monitored beds - 4 are ICU "holds" and the others are monitor necessary - does she get the last monitored bed??? Why? or why not? You have 6 RN's (and charge RN), 2 paramedics and 2 PCT's. Everyone is busy to some degree.

You have 4 others awaiting triage and have just spied a 50ish man walking in holding his chest. Hmmmm.......

Once I get a response or two - we will take over the case from the primary ER nurse POV.

UnchainedFever · Sep 26, 2008

I would put her in the general bed and pin her daughters down to ask/answer questions. Family seems to be overwhelmed with her car and only one daughter assisting. May be fatigue on that daughters part. May need skilled placement for a respite for family.

Babs0512 · Sep 26, 2008

I'm in. I'm really interested in finding out about her other ER visits.

Others have suggested most everything I'd want ordered, but I'd add a CXR, Is she having any pain?

In a women her age, the most common reasons for a fever are UTI, Pneumonia.

The OP needs to give us more information. What do her labs end up showing? Does she smoke? Any CP? Swelling in LE? What is her white count, normal, elevated or low?

Thanks

Sorry, didn't see your update. How did she get 50mg Phenergan IM before coming to the ER????

I'd put her in a monitored bed. Her K+ is likely to be off R/T vomiting, and the Klor con she probably isn't keeping down. Low K+ can cause weakness and cardiac arrhythmias. She is one of those patients that your dammed if you do, dammed if you don't. She absolutley has to be monitored with her cardiac hx.

getoverit, BSN, RN, EMT-P · Sep 26, 2008

Hmm...good questions. And naturally there has to be a guy walking in with apparent chest pain! Even though no orders for O2, that's a nursing intervention and I'd have her on at least 2 liters while I"m obtaining the hx.

I think it would be remiss to not obtain a 12 lead (or at least a 6 second strip, I'd like to see her t waves) because this lady is the classic example of atypical AMI. I'm betting an electrolyte imbalance and an acid-base derangement. If she doesn't have an order for an EKG, then I think she should get the general room...a crash cart can be brought in if we need it, even if it's just to run a strip.

She may be sleepy in part from the phenergan. I'm wondering if her denial of problems voiding and bms are her attempts to be cooperative and "not cause a problem". We'll give her a chance to produce UA but more than likely end up giving a Foley.

I also think we need to rapidly triage the guy holding his chest because he may have a problem that ends up distracting us from this lady. We'll know a lot more when the labs come back.