Patient Case Studies for Accurate Nursing Assessments

• Jon Teegardin

Performing accurate nursing assessments on patients establishes a baseline of information regarding a patient’s complaint and history of present illness. The patients represented in this paper are not real, instead they are created to allow for examples of basic nursing assessments. This paper will assess two patients, one with chronic lower back pain and one with psychiatric and substance abuse complaints.

Patient one

The first patient is a 45 year old female who presents to the emergency room after arriving by private vehicle with a complaint of lower back pain with radiation down the right leg to the foot.

My assessment of the patient begins when I go to the lobby and call the patients name. The patient ambulates with an even steady gait to the examination room. The patient does not require assistance ambulating. Once in the examination room, privacy is provided and an interview and full assessment are conducted.

After introducing myself, the patient is identified using two identifiers, name and birthdate. The information provided by the patient is verified against the chart and an identifying wristband is applied. The chief complaint is then verified using an open ended question: Can you tell me why you are visiting the emergency room today? The patient’s response is “Back in 20012 I injured my back when my boyfriend was drunk and he slammed me against a wall. The doctor told me I had several ruptured discs in my back and it hurts so bad tonight I can’t stand it. The pain started about three days ago and has gotten progressively worse. I reassure the patient that she will be treated as soon as we can get the doctor in the room (Jarvis, 2012). The patient then asks for an emesis bag and states “I’m hurting so bad I think I’m going to throw up”. An emesis bag is provided. The patient retches several times and spits into the bag. No vomitus is noted.

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I continue with my interview by asking about the patients’ health history (Jarvis, 2012). I ask the patient about medication allergies. The patient states she is allergic to penicillin’s. Next I ask the patient about any medications she currently takes. The patient reports she takes the following medications: Xanax, 1 milligram 3 times per day, Gabapentin, 400 milligrams 3 times per day, Vicodin 10mg-325mg every 4 hours for pain, Lisinopril 20 milligrams, every day, Simvastatin 40 milligrams every day, Cyclobenzaprine, 20 milligrams every 6 hours, Ultram, 50 milligrams every 8 hours as needed for pain. When asked for a primary care physician, the patient states “I have recently switched doctors and I have an appointment on Wednesday with my new doctor. The patient presents an appointment card for a local physician.

The patient is next asked about her medical history. The patient reports a history of hypertension, high cholesterol, anxiety, and ruptured discs in her lower back. The patient reports a surgical history of bilateral breast augmentation, bilateral tubal ligation, appendectomy, total hysterectomy, and tonsillectomy/adenoidectomy. When questioned about any surgical interventions for her back, the patient states “I don’t have insurance so I can’t afford to get any surgery on my back”. The patient reports a family history of hypertension, anxiety, and depression on her mother’s side. She also reports smoking 1 pack of cigarettes per day for 10 years but quit smoking 15 years ago.

With my initial interview complete, the physical assessment begins (Jarvis, 2012). The patient is placed in a hospital gown for the examination. Vital signs are obtained. The blood pressure is 168/109 in the left arm, 166/106 in the right arm, heart rate is 79, oral temperature is 98.5, respirations are 16 per minute, oxygen saturation is 97% on room air, and the patient rates her pain on a numeric scale as a 10 out of 10 in her lower back. She describes the pain as a sharp, constant pain that is aggravated with movement, and helped with medication. She also relates radiation of the pain to her right leg as a burning sensation. The patient has shoulder length hair that is clean and well groomed. She denies any hearing problems, visual problems, congestion or cough. No drainage is noted from her ears, the eyes are clear with no redness or conjunctiva. Pupils are equal and reactive to light. Nares are clear bilaterally without swelling. The patient has good dentition with evidence of dental intervention with fillings visible in three teeth. The lips, tongue, oral mucosa, and uvula are unremarkable. Facial symmetry is good with no drooping. The patient’s neck is supple with full range of motion and the trachea is midline. Respirations are clear and even bilaterally. The heart is auscultated and is strong and even at 78 beats per minute. Normal S1 and S2 are present. The patient denies any pain or mass in the breasts and reports that she self-examines monthly and her last mammogram was two years ago. Hand grips are strong and equal, radial pulses are strong and equal bilaterally. The abdomen is soft and non-tender to palpation. Bowel sounds are present in all four quadrants. A healed surgical scar is noted in the lower right quadrant. The patient denies any incontinence of bladder or bowel, and reports nausea and vomiting related to her back pain. The back is grossly unremarkable, and is tender to palpation in the area from L1 to L5. The patient denies any burning or pain on urination, and denies flank pain. The patient reports a burning sensation down the right leg to the foot. Foot strength equal bilaterally, with strong bilateral pedal pulses. A scar is noted on the anterior right lower extremity distal to the patella. The patient reports that she accidently cut herself there as a child and required stitches to close the laceration. The patient’s mood and affect are appropriate for her age and the current situation. Her speech is clear. The patient is reassured that the physician will see her and the bed is verified to be in its lowest position with the wheels locked. The call light button is explained to the patient and placed within easy reach. The patient is reminded to request assistance prior to ambulating.

Summary of findings

My summary of finding is that the patient appears to be suffering from chronic back pain related to a traumatic injury in her past, and has uncontrolled hypertension related to noncompliance with her medication regimen.

SOAP note

S: Patient reports excruciating back pain radiating to the right leg, with nausea and vomiting prior to arrival. She also reports being out of her prescription medications which include a blood pressure medication.

O: the patients’ blood pressure is elevated at 168/109, the lower back is tender to palpation. The patient ambulates without assistance but appears to be in mild distress.

A: Nontoxic appearing white female that appears consistent with her stated age of 45 years old. EENT within normal limits. PERRLA at 3mm. Facial symmetry equal with no facial droop noted. The neck is supple and trachea is midline. Regular apical rate with S1 and S2. No S3 or S4 noted. Hand grips strong and equal bilaterally. Radial pulses strong and equal bilaterally. Respirations are even and unlabored. Lungs clear to auscultation bilaterally. The abdomen is soft and non-tender. Bowel sounds present in all four quadrants. Tender in the lower back region from L1 to L5 with radiation of pain to the right leg. No vomiting noted during assessment. Denies diarrhea. Denies urinary symptoms. Leg strength strong and equal bilaterally. Ambulates without difficulty or assistance. Pedal pulses present with no edema noted in lower extremities.

P: Patient placed on non-invasive blood pressure monitoring and positioned for comfort. Expect MD orders for oral anti-hypertensive to reduce blood pressure and intramuscular injection of narcotic pain medication with antiemetic to control nausea and vomiting. Prepare patient for X-ray of lumbar spine region, and possible CT of the same area. A urine pregnancy test is contraindicated because of history of hysterectomy. Potential for admission to hospital for consult with orthopedist and surgical intervention.

Patient two

The second patient is a 62 year old female who has a chief complaint of alcohol dependence, benzodiazepine dependence, and depression.

This patient is called from the lobby and ambulates to the exam room with an even, steady gait. Once in the examination room, privacy is provided and an interview and full assessment are conducted. I identify myself and the patient is identified using two identifiers and an identification band is placed on her wrist.

I begin by obtaining a social history of the patient (Jarvis, 2012). She states she has never seen a psychiatrist and has been treated for depression by her primary healthcare provider. The patient is currently employed as a nurse practitioner/midwife with a county health department. She thoroughly enjoys her job and is fearful of losing her position due to chronic absenteeism related to her alcohol abuse. She reports consuming approximately one half gallon of liquor daily and has smoked one pack of cigarettes per day for twenty years. In her spare time she says that she enjoys sewing and gardening. The patient describes childhood as “normal”, had a “great relationship” with her father, but states “my mother loved my brother more than me, and nothing I did was good enough for her, even though I got straight a grades in school, and was active in church and band”. She further states “my mother used to beat me for waking up in the morning, because she said that I would eventually get into some kind of trouble”. ”My brother is gay, but very successful working in Atlanta. I don’t see him enough, and I don’t hold what my mother did against him. I wish we saw more of each other. I got divorced over my drinking, so that was that, I could deal with all of it, up until my daughter died. Any other night I would have watched TV with her, but I was so tired that night. I went straight to bed and she decided to drive down to her brothers, 2 miles away. She made it about halfway, and was killed when she went off the road and hit a culvert, causing her car to roll several times. She died instantly”.

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Having obtained a social history, I begin obtaining medical history from the patient. The patient reports that she is allergic to codeine, Demerol, sulfa drugs, and Zithromax. She reports having a hysterectomy, cholecystectomy, and left foot ORIF. She is currently taking clonazepam, Lexapro, singular, and Xanax. She reports her mother and father had a history of alcohol abuse and are both deceased.

My next assessment is a mental status examination. Having built a therapeutic relationship with the patient, I ask the patient if she has considered harming herself or had any command hallucinations (Jarvis, 2012). The patient denies any suicidal ideation or any hallucinations of any sort. The patient is well dressed, clean, pleasant, and cooperative. Her thought process is coherent with no ambivalence. The patients affect is calm and her appropriateness of mood to thought is normal. There is no depersonalization. The patient does not appear to be delusional, obsessive, or display ideas of reference. She is oriented to person, place, time, and situation. Vital signs are obtained and are all within normal limits. The patient denies any pain.

Summary of finding

My summary of finding is that this patient is suffering from depression, related to her divorce and the death of her daughter. Her needs include counseling, detox, and peer support. The patient’s education is an asset to her treatment. She has the support system of two sons. Stressors include her divorce due to her alcoholism and the sudden death of her daughter. Her coping methods include alcohol abuse, benzodiazepine abuse, and social isolation.

SOAP note

S: The patient reports feeling depressed and abusing alcohol and benzodiazepines. She denies suicidal ideation.

O: The patient is well dressed, clean, pleasant, and cooperative. Her thought process is coherent with no ambivalence. The patients affect is calm and her appropriateness of mood to thought is normal. There is no depersonalization. The patient does not appear to be delusional, obsessive, or display ideas of reference. She is oriented to person, place, time, and situation. Vital signs are obtained and are all within normal limits. The patient denies any pain.

A: The patient is suffering from depression related to her divorce and the death of her daughter. She could benefit from an inpatient rehab program.

P: Prepare patient for lab draws to obtain baseline values, presence of drugs of abuse, and medical clearance. A call to the Georgia Crisis Access Line is anticipated for placement of the patient in an inpatient detoxification/rehabilitation program. Referral to grief counselor is also a possibility.

References

Jarvis, C. (2012). Physical Examination and Health Assessment [VitalSouce bookshelf version]. Retrieved from http://digitalbookshelf.southuniversity.edu/books/978-1-4377-0151-7/outline/5