Module 5 Case Study for Basic Nursing Informatics Academic Year 2020 PDF

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module 5 case study for Basic Nursing Informatics Academic Year 2020...

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Case Study Olivia C. Nichols Kent State University College of Nursing

CASE STUDY

2 Case Study SBAR

Hello Dr. Thomas. This is Olivia Nichols calling on March 17th at 1500. I have Mrs. Christianson here, who I am visiting at her home, who is 72 years old and is complaining of increased shakiness and swelling in her ankles. She has diabetes mellitus type 2 and hypertension and states that she has been taking her medications as directed but she states that she forgets sometimes. Also, she states that she has been checking her blood sugars at home once per day in the morning before her breakfast and is normally within the range of 158-190. She is currently taking Glucophage 500 mg oral three times a day, Aspirin 81 mg oral daily, Lisinopril 20 mg oral daily, and Actos 30 mg oral daily which is a new medication for her. The patient does not have any known allergies and states that she does not use tobacco, drugs, or alcohol. Upon assessment, her blood pressure was 120/80, heart rate was 68, respirations were 20, and the temperature was 97.5 degrees Fahrenheit. Her skin is intact, her heart sounds were normal but distant, and her lung sounds had rhonchi in bilateral posterior bases and the patient states she has had a productive occasional cough with clear spit. She was not using accessory muscles. The abdomen is obese, round, with bowel sounds x 4 quadrants. She has +2 edema bilaterally in her lower extremities and her pedal pulses are present bilaterally. Her hemoglobin A1C is elevated at 8.5%. My concerns are that the patient might not be compliant with her medications and her blood sugar checks since the patient stated that checking her sugar is painful. I would like the patient to be put on a stronger blood thinner since her hemoglobin A1C was elevated while on aspirin 81 mg. I would recommend an order for regular blood tests until the patient’s hemoglobin A1C is within a normal range. I think it would be beneficial to have a visit or have the patient come into your office to discuss a further plan of care....