Get Answer: Clinical Scenario Nursing Question Guide
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Structure your response with introduction, analysis, and conclusion.
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Original Question
CLINICAL SCENARIO: NURSING HEALTH HISTORY A. Patient’s Profile Name: Maricel Gender: Female Age: 55 years old Birthdate: January 17, 1966 Birthplace: San Pedro, Laguna Civil Status: Married Address: Muntinlupa City Nationality: Filipino Religion: Roman Catholic Educational Attainment: College Graduate Date of Consultation: December 20, 2020 Time of Consultation: 10:00 AM Admitting Diagnosis: Vertigo – whirling sensation, tinnitus and nausea and vomiting Chief Complaint: Meniere’s Disease HISTORY OF PRESENT ILLNESS: This patient, a 55 year old female, was suffering from vertigo – whirling sensation, tinnitus and nausea and vomiting according to her husband. Few hours after, above symptoms are now associated with unilateral hearing loss (right side), diaphoresis and sometimes rolling of the eyeballs after being examined by the doctor and diagnosed with Meniere’s Disease. HISTORY OF PAST ILLNESS: In the previous 2 years, the patient reported recurrent episodes of rotational vertigo (about 1/month) lasting from a few minutes to 1-2 hours, often with a right ear fluctuating hearing loss. Migraine and vertigo never occurred together. FAMILY HISTORY: The patient’s family history has hypertension and DM in her mother side but there are no other medical illnesses indicated. No known history of HPN, DM, Cancer from the father side. Her family history was positive for migraine (mother and one of three sisters). SOCIAL AND PERSONAL HISTORY: The patient never drinks alcohol but does smoke 1 stick in a day if she feels stress. The patient reported the first attack of migraine at the age of 20 years, which more typically occurred before menstruation, at a frequency of 1-2/month. GENERAL SURVEY December 20, 2020 10:00 AM VITAL SIGNS INTERPRETATION FINDINGS Temperature 36.7 Normal Pulse Rate 76 bpm Normal Oxygen Saturation 99% Normal Respiratory Rate 18 cpm Normal Blood Pressure 110/ 70 mmHg Normal As a final result, her audiometric threshold showed a right sided low frequency sensorineural hearing loss ADMISSION ORDER: The patient was consulted on December 20, 2020 at 10:00 AM with the following order: DIET: Low salt diet VITAL SIGNS: Every 4 hours DIAGNOSTICS: CBC with platelet count, Na, K, Urinalysis, Caloric stimulation test MONITOR: Risk for Injury Therapeutics: Nursing and Medical Management 1. Assist patient during attack; stand in front; encourage to change position slowly, avoid bright light, support patient when ambulating, safety is priority, keep the patient in supine position during attack, keep the room dark when photophobia is present. 2. Administer medications as prescribed: Administer 40 mg of Prednisone 1 tablet/day for 7 days, promethazine ( Phenergen) 12.5 mg 1 tab in the morning before meals and at bedtime PO BID, meclizine (Antivert) 50 mg 1 tab OD PO one hour before travel, hydrochlorothiazide/triamterene (Dyaside) 25 mg 1 cap OD PO. 3. Prevent attacks of the disease: provide proper diet, encourage stop smoking, take medication as prescribed. 4. If the prescribed medications will not work and if vertigo attacks associated with Meniere’s disease are severe and debilitating and other treatments don’t help, surgery might be an option and advised to the client the Endolymphatic sac procedure. Course in the Clinic (This is just a pattern – hypothetically make your own course in the ward as you chart, record and report the daily care and activities done to the client) Day 1: Patient C.B.D was admitted at San Lazaro Hospital at 3:00 am, with a diagnosis of dengue. Patient exhibited fever, abdominal pain, join pain, and headache with a complaint of rashes; vital signs are BP: 100/80 mmHg, T- 38.4°C, PR- 81 bpm, RR- 24 cpm. Then, patient was hooked to Lactated Ringer’s at 125cc/hr while and order for complete blood count, rinalysis, clinical chemistry, chest x-ray, and dengue was done together with a diet as tolerated except dark colored foods with strict aspiration. Medications are given: Omeprazole 40mg TIV and ORS sachet in 250 ml water. Patient is strictly monitor for any signs of narrow pulse pressure; hypertension. At 6:00, patient was admitted into the female ward and in at 10 am complaint of skin itchiness related to rashes and was given Cetirizine HCL 10kg tab, PO, OD. The next day, patient is encouraged to increase fluid intake and order for repeat CBC. Question: 1. Make at least 2 priority nursing care plans to this patient? (nursing diagnosis, nursing intervation and rationale)
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