Task: Assessing, Diagnosing, and Treating Musculoskeletal and Neurologic Issues
Take into account the instance of Sue from the case research in Chapter 13 of your textbook:
Sue is a 68-year-old wholesome lady with no important medical historical past. She is within the workplace as we speak with criticism of intractable nausea and vomiting for the previous 5 weeks with an 11-pound weight reduction. On assessment of programs she additionally has famous a boring, persistent headache, issue with focus, and a few blurred imaginative and prescient.
(Kennedy-Malone et al., 2019, p. 359)
Picture Credit score: [Blend Images/Ariel Skelley]/[Blend Images]/Getty Photographs
Sue additionally has a notable household historical past of diabetes and coronary heart assault. How would you, as a sophisticated follow nurse, assess, diagnose, and deal with Sue? What particular issues associated to the older grownup inhabitants would it’s essential to think about? Maintain these ideas in thoughts as you study this week’s case research.
Reference:
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. G. (2019). Superior follow nursing within the care of older adults (2nd ed., p. 359). F. A. Davis.
To organize:
• Evaluate the case research supplied by your Teacher.
• Replicate on the affected person’s signs and features of issues which may be current.
• Take into account the way you would possibly assess, carry out diagnostic assessments, and suggest drugs to deal with sufferers presenting with the signs within the case.
• Entry the Targeted SOAP Observe Template on this week’s Assets.
The Task:
Full the Targeted SOAP Observe Template supplied for the affected person within the case research. Be sure you handle the next:
• Subjective: What was the affected person’s subjective criticism? What particulars did the affected person present relating to their historical past of current sickness and private and medical historical past? Embrace an inventory of prescription and over-the-counter medication the affected person is at present taking. Evaluate this listing to the American Geriatrics Society Beers Standards®, and think about various medication if acceptable. Present a assessment of programs.
• Goal: What observations did you be aware from the bodily Assessment? What have been the lab, imaging, or practical assessments outcomes?
• Assessment: Present a minimal of three differential diagnoses. Record them from prime precedence to least precedence. Evaluate the diagnostic standards for every, and clarify what guidelines every differential in or out. Clarify you crucial pondering course of that led you to the first prognosis you chose. Embrace pertinent positives and pertinent negatives for the particular affected person case.
• Plan: Present an in depth remedy plan for the affected person that addresses every prognosis, as relevant. Embrace documentation of diagnostic research that shall be obtained, referrals to different health-care suppliers, therapeutic interventions, training, disposition of the affected person, caregiver help, and any deliberate follow-up visits. Present a dialogue of well being promotion and illness prevention for the affected person, taking into account affected person components, previous medical historical past (PMH), and different danger components. Lastly, embody a mirrored image assertion on the case that describes insights or classes discovered.
• Present at the least three evidence-based peer-reviewed journal articles or evidenced-based pointers, which relate to this case to help your diagnostics and differentials diagnoses. Ensure they’re present (not more than 5 years outdated) and help the remedy plan in following present requirements of care. Comply with APA seventh version formatting.
By Day 7
Submit your Task.
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Targeted SOAP Observe
Pupil’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date
Affected person Data:
M, 66, M, Hispanic
S (subjective)
CC (chief criticism): History of uncontrolled hypertension.
HPI (historical past of current sickness): Mario is a 66-year-old Hispanic male who presents to the emergency room at his native hospital with acute aphasia, proper facial droop, and right-sided weak point. The sudden onset of signs occurred on the publish workplace the place he works half time. One of his co-workers referred to as 911. On the best way to the hospital, the superior squad crew evaluated Mario’s neurologic deficits and glucose ranges. The squad crew then notified the receiving hospital of a potential stroke affected person. Lucinda, his spouse, tells the nurse practitioner that Mario has a historical past of uncontrolled hypertension (and he was typically non-compliant along with his anti-hypertensive drugs). His current prognosis of diabetes additionally was famous, in addition to the oral hypoglycemic brokers he was taking.
Present Medicines:
Tenormin (atenolol) 25-50 mg/day PO to deal with hypertension
Sulfonylureas 2.5/250 mg twice each day with meals to deal with diabetes
Allergic reactions: No recognized meals and drug allergy symptoms.
PMHx: Hypertension and diabetes.
Soc and Substance Hx: Mario leads a sedentary life-style that had contributed to his extra weight. Mario is a smoker, normally smoking a couple of pack and a half every day. He takes alcohol sometimes.
Fam Hx: Mario’s dad and mom handed away from myocardial infarctions once they have been of their late 60s. His kids are wholesome with out important medical historical past. His two sisters endure from hypertension whereas his solely brother is diabetic.
Surgical Hx: Splenectomy at 38 years.
Psychological Hx: Mario has a historical past of melancholy after his retirement one yr in the past. He was handled efficiently. He has no historical past of suicidal ideation or self-harm tendencies.
Violence Hx: Mario lives peacefully with the neighbors with no incidences of sexual or bodily violence.
Reproductive Hx: Mario has two daughters. He’s sexually lively along with his spouse. No historical past of sexual dysfunction. He practices vaginal intercourse with out historical past of oral intercourse.
ROS (assessment of signs):
GENERAL: No unintentional fever, chills, fatigue, or physique weight modifications.
HEENT:
• Eyes: Issue in seeing. He makes use of eye glasses as a result of a historical past of shortsightedness.
• Ears, Nostril, Throat: No listening to issue, runny nostril, or sore throat.
SKIN: No pores and skin lesions or rashes.
CARDIOVASCULAR: The affected person has a historical past of chest pains and stress.
RESPIRATORY: Contracted Covid-19 final yr June. Since his discharged he has no incidence of shortness of breath or cough.
GASTROINTESTINAL: No historical past of diarrhea, vomiting, or nausea. Has regular bowel motion and no ache.
GENITOURINARY: No historical past of burning on urination.
NEUROLOGICAL: The affected person feels dizzy, loss of steadiness, and experiences numbness and delicate headache. No change in bowel motion. He has a drooping face and slurred speech.
MUSCULOSKELETAL: No ache or malfunction of the muscular tissues or joint.
HEMATOLOGIC: No historical past of bleeding or anemia.
LYMPHATICS: Splenectomy at 38 years.
PSYCHIATRIC: The affected person has a historical past of melancholy after retirement.
ENDOCRINOLOGIC: No historical past of sweating since recovering from Covid-19.
REPRODUCTIVE: He’s sexually lively however previous the child-bearing age.
ALLERGIES: No recognized meals or chilly allergy symptoms.
O (goal)
Bodily examination:
Very important indicators: 97.eight F, 124/89 mmHg, 18, 72/100, 5’5” inches, 255 kilos, BMI 42.43
Common: A&O *three NAD. Dressed appropriately for the clinic appointment.
HEENT: Diffuse involvement of his scalp and plaque. Facial drop.
Chest/Lungs: Chest ache and dyspnea.
Coronary heart/Peripheral Vascular: Leg weak point and numbness, and chilly ft.
Stomach: No organomegaly or rebound.
Genital/Rectal: Deferred.
Musculoskeletal: Symmetric muscle improvement however complains of weak point.
Neurological: headache, nausea, and seizures.
Pores and skin: No hemorrhage.
Assessment
Irregular coronary heart rhythm
Elevated Systolic values
Chest ache
Nausea
Diagnostic Assessments:
CT scan to examine for mind injury or bleeding.
MRI to diagnose stroke and examine for damages within the mind or tissues.
ECG to find out coronary heart illness triggering stroke similar to Atrial Fibrillation or MI.
CBC and coagulation profile to evaluate for thrombocytopenia earlier than recommending antithrombotic remedy.
Diagnostic Outcomes
CT scan exhibits a prognosis of stroke. No bleeding or ischemia.
A (Assessment)
Differential diagnoses:
Stroke
Stroke or cerebrovascular accident or CVA includes a loss of blood provide in a single half of the mind inflicting large injury (Campbell et al., 2019). It’s a medical emergency that’s characterised by issue in strolling, slurred speech, numbness, and dizziness (Campbell et al., 2019). Therapy similar to clot buster is efficient in decreasing mind injury.
Mind Tumor
Mind tumor includes the expansion of irregular cells within the mind. Some of the chance components embody genetic mutations or publicity to radiation (Seetha & Raja, 2018). A mind tumor can reduce brief the availability of blood within the mind. People might slowly develop signs associated to speech over months similar to slurred speech.
Hypertensive Encephalopathy
The situation happens as a result of mind dysfunction as a result of comparatively hypertension (Miller et al., 2018). Some of the signs might embody headache, vomiting, confusion, and hassle balancing.
Traumatic Mind Damage (Epidural/Subdural Hemorrhage)
The situation includes a sudden harm that causes injury to the mind (Campbell et al., 2019). It happens when the cranium is below impression from a blunt object or as a result of a fall.
P (plan)
The affected person and the spouse must be educated about stroke, the chance components, diagnostic assessments, and acceptable remedy. The dialogue with the spouse ought to embody the symptom and the chance components (Morin et al., 2021). For example, mind tumor or impression on the cranium. Different danger components embody hypertension, diabetes, smoking, and a sedentary life-style.
It is suggested that the affected person ought to change life-style and begin exercising and decreasing the load. The affected person must be thoughtful of the food regimen by decreasing the quantity of salt and fat within the meals.
The affected person would require medicine to cut back the extent of mind injury. A clot buster is important to cut back the injury. A referral to a bodily therapist, occupational therapist, and speech therapist is important to revive the functioning of the physique components (Morin et al., 2021). Failure of therapeutic interventions can undermine the mobility of a affected person.
Reflection
The case research exhibits that non-adherence to hypertension medicine can enhance the chance of stroke. Educating sufferers about adherence is important for restoration. Practitioners ought to comply with up to make sure acceptable adherence. Speedy response is important to cut back the extent of the injury.
The affected person is in danger of stroke as a result of contributing components similar to hypertension, diabetes, smoking, and a sedentary life-style. The affected person ought to assessment the life-style to advertise restoration and cut back reoccurrence.
References
Campbell, B. C., De Silva, D. A., Macleod, M. R., Coutts, S. B., Schwamm, L. H., Davis, S. M., & Donnan, G. A. (2019). Ischaemic stroke. Nature Opinions Illness Primers, 5(1), 1-22.
Miller, J. B., Suchdev, Okay., Jayaprakash, N., Hrabec, D., Sood, A., Sharma, S., & Levy, P. D. (2018). New developments in hypertensive encephalopathy. Present hypertension reviews, 20(2), 1-7.
Morin, D., Rémillard, S., Salerno, A., & Michel, P. (2021). Stroke affected person training: scientific proof, sensible utility. Therapeutische Umschau. Revue Therapeutique, 78(6), 249-258.
Seetha, J., & Raja, S. S. (2018). Mind tumor classification utilizing convolutional neural networks. Biomedical & Pharmacology Journal, 11(three), 1457.
