Describe the assessment of a patient, detailing the signs and symptoms
Clinical Experience Week 2Did you face any challenges, any success? If so, what were they?The second week in the clinical center was also uneventful and I did not experience any challenges in my practice. I successfully managed to carry out the duties that were assigned to me without any problems as well as successfully offer care to the patients that I encountered. The nursing staff also offered me more autonomy and tasks in the practice after experiencing my competence from the first week. My confidence in the clinical practice was also more elevated compared to the first week which also enhanced my efficiency and lessened any doubt I had about my capabilities. Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales. One of the patients that I assessed was a 54-year-old female farmer whose main complaint was “chronic back pains, especially during the colder seasons.” The patient says that the pain started as a mild case that has progressively been growing over the past one month resulting in unbearable pain, especially after her farming activities. The pain is mainly localized in her lower back area and is usually extreme if she spends her day on the farm in another bent or upright position. Prolonged sitting has also caused some degree of pain but it is not as severe compared to when she is from her farm. Colder days have also seen her experience elevated levels of pain which also incapacitate her from working on her farm. She also disclosed that she had tried using some over-the-counter pain killers but they had not provided any assistance to her pain which led to her seeking medical attention. Subjective Data I collected the subjective data by questioning the patient on past and possible related issues that may have also affected her skeletal system. The patient identifies that she has never suffered from any back-related injury and neither has she fallen in such a way as to hurt her back in any recent time. She also acknowledges spending most of her farming while either standing or bent since she does not have a large enough farm to necessitate the need for a tractor to farm. I also gathered that she works harder than normal to provide for her family since she was a widow with two of her children in university that still depended on her efforts.Objective Data The objective data was collected from an examination aimed to test her skeletal system. All her other systems were observed to be normal with normal blood pressure and heart rates which shows that she was relatively healthy. Her activity as a farmer had also ensured that she had a relatively healthy body weight; she also discounted the possible existence of hypertensive illnesses. A physical exam on her back indicated stiffness and inflexibility in her spinal cord. No injuries were identified on her back and palpation along the spinal cord area revealed that she experienced a slight pain in her lower back as well. However, an x-ray on her back indicated the presence of cartilage loss, erosion, and small fractures with reduced vertebra spaces.Assessment Based on the results from the exam on the skeletal system, the primary diagnosis was established to be lumbar arthritis with differential diagnoses being spinal stenosis and spondylolisthesis.Lumbar Arthritis Lumbar arthritis is a form of arthritis that develops in the lower back of the spinal cord and leads to the generation of stiffness and chronic pain. Yoon et al. (2020) acknowledge that lumbar arthritis is an uncommon but severe condition of the spine. The main reason for the selection of this diagnosis came from the results in the x-ray as well as the stiffness that was identified in the spinal cord. The patient’s age and nature of work is also a risk factor for the development of arthritis within the body.Spinal stenosisSpinal stenosis is also a major cause of symptoms or lower back pain within the body. Lee et al. (2020) identifies that spinal stenosis is a result of the narrowing of the spinal canal due to degenerative changes in the spinal joints which then results in chronic pain. Spinal stenosis causes chronic pain in the lower back similar to lumbar arthritis but the x-ray results did not indicate the narrowing of the spinal canal to make Spinal stenosis a primary diagnosis.SpondylolisthesisSpondylolisthesis is developed when a spinal disk moves out of its normal place as a result of injury or overstressing on the lower back. Austevoll et al. (2021) acknowledge that Spondylolisthesis is when one of the spinal cord vertebrae slips from its normal position and moves forwards which is usually found in older populations. However, the x-ray results did not indicate any moved spinal vertebra along the spinal cord.Plan of CareA prescription of ibuprofen 800 mg three times a day will be the main prescription for the patient which will assist in the management of the pain that is being experienced by the patient. Peck et al. (2021) identify that ibuprofen is an NSAID-based mediation that has been proven to offer quicker and more effective relief, especially in lumbosacral pain in the lower back. The mediation will assist in proper pain management with stronger medication being suggested to offer better pain relief.Mention the health promotion intervention for this patient.I recommend that the patient adopt a better lifestyle in her life by ensuring that she steers clear of overworking her body and reduces the strain that she places on her back. She should also avoid staying in one posture for longer than necessary, especially in standing and bending positions while she is farming. More frequent breaks in between work will also elevate her condition and ensure that she experiences less pain. Physical therapy such as massages is also recommended to reduce the stiffness that is along her back. Better working tools that reduce the level of work required will also elevate her condition greatly.What did you learn from this week’s clinical experience that can be beneficial for you as an advanced practice nurse?The main lesson that I learned this week was the value of taking good care of my body and the importance of practicing rest in any line of work. Overworking will most likely lead to negative effects especially as we age and should be avoided even though it is for the greater cause.ReferencesAustevoll, I. M., Hermansen, E., Fagerland, M. W., Storheim, K., Brox, J. I., Solberg, T., … & Hellum, C. (2021). Decompression with or without fusion in degenerative lumbar spondylolisthesis. New England Journal of Medicine, 385(6), 526-538. https://doi.org/10.1056/NEJMoa2100990Lee, B. H., Moon, S. H., Suk, K. S., Kim, H. S., Yang, J. H., & Lee, H. M. (2020). Lumbar spinal stenosis: pathophysiology and treatment principle: a narrative review. Asian Spine Journal, 14(5), 682. https://dx.doi.org/10.31616%2Fasj.2020.0472Peck, J., Urits, I., Peoples, S., Foster, L., Malla, A., Berger, A. A., … & Viswanath, O. (2021). A comprehensive review of over-the-counter treatment for chronic low back pain. Pain and Therapy, 10(1), 69-80. https://doi.org/10.1007/s40122-020-00209-wYoon, J., Efendy, J., & Redmond, M. J. (2020). Septic arthritis of the lumbar facet joints. Case and literature review. Journal of Clinical Neuroscience, 71, 299-303. https://doi.org/10.1016/j.jocn.2019.11.007 ReplyReply to Comment
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Question 1: Describe your clinical experience for this week.
My second week of clinical as an np student was educational, this week I was definitely more interactive and involved in each client’s case. I was able to complete my assessments both focused on current clients and comprehensive assessments for new clients and start recognizing proper diagnostic and treatments. The NP was able to inform and educated me on policies, procedures for proper diagnosis, and treatments for an array of conditions, she also touched on the importance of thinking on a practitioner level which requires me to evolve from the nursing level I’ve been so used to practicing. Critical and imaginative thinking was evident and utilized.
Question 2: Did you face any challenges, any success? If so, what were they?
In my experience, my success was making more correlations between identified diagnostics and proper treatment modalities that the np was prescribing. The challenges during this week at clinical was again were getting more familiar with the documentation system used, the language barrier, and learning medical coding for medical billing, coding, and insurance.
Question 3: Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
Upon arrival, a 23-year-old Haitian-American male patient complains of excruciating abdominal pain, ongoing nausea, and vomiting as well as a low-grade fever of greater than 100. The patient assesses the pain as 6/10 this morning, but it was as high as 9/10 when it first started two days ago. Before going to the medical facility, the patient complained of having lost his appetite and described the symptoms as cramping. The ROS was as following: Pt reports fever of 101.2 two days ago current temperature afebrile, denies night sweats, no weight gain or loss, no exercise intolerance, slight chills two days ago but no chills currently, no malaise. Pt reports no dry eyes, no vision changes, no irritation or eye discomfort. He reports no difficulty hearing or ear pain, reports no nosebleeds or nose issues, no sinus problems. Pt reports no sore throat, bleeding gums, no snoring , or dry mouth, no sinusitis. Pt denies sob when lying down, walking or at rest, denies murmurs or swelling, Pt reports no coughing, wheezing or sputum. Pt denies any palpitations, no known heart issues. Pt reports slight abdominal pain, a decrease in appetite since going to a restaurant two days ago. pt reports vomiting, diarrhea and slight cramping. Pt denies muscle aches, denies neck pain, no osteoporosis or fractures. He denies any skin issues. pt denies hair or nail changes, He claims that he has not had any loss of consciousness, weakness, numbness, seizures, dizziness, migraines, headaches, tremor, or gait abnormalities. He says he doesn’t have any symptoms of depression, insomnia, feeling secure in a relationship, alcohol misuse, anxiety, hallucinations, suicidal thoughts, mood swings, memory loss, agitation, dementia, or delirium. He claims not to be tired. He reports no phlebitis, anemia, bruises, engorged bleeding, or enlarged glands. He reports no itching, no hives, no runny nose, sinus discomfort, or frequent sneezing. Assessment finding are as following: Vital Signs: Temp 97.6F; BP 119/71; RR 16; P 86; HT 5.6 ft.; WT 160lbs; Blood sugar 89, BMI 26.1
Pt is Alert and oriented x4, makes good eye contact, and speech and responses are appropriate. No deficits were noted, Pt has good posture, appears to be in good health with proper hygiene and dressed appropriately, Mobility and Movements are smooth, and its overall composition is symmetrical and appropriate. Pts head is symmetrical, Hair is well distributed, no masses, lesions, or abnormal findings. The eyes do not show any signs of visual loss, hazy vision, double vision, or even yellow sclera. Hearing impairment or loss is not reported. Nose intact. Throat: patient denies having a sore throat or experiencing throat discomfort. There are no lesions and no urticarial. Skin turgor is unaffected. Skin hair is evenly spread. Visual acuity is intact with 20/20 vision. Visual fields and ocular movements are intact. Corneal Light Reflects normal. Hearing impairment or loss is not reported. The nose is intact, with no lesions or masses upon inspection, the smell is intact, clear normal discharge and pink moist mucosa upon inspection of the nasal cavity, no deviation, obstruction, or abnormal discharge present. The pts mouth is pink and slightly dry. Throat: patient denies having a sore throat or experiencing throat discomfort. His skin tone is appropriate for his race and age. Pt has a scar on the right knee from an injury during childhood. The neck shows no lesions, or abnormal masses, thyroid palpable and in good size, Full ROM, and proper swallowing noted. Chest is symmetrical and intact, no lesions, masses thrills or abnormal findings. PMI was present during inspection, palpation, and auscultation with normal findings. Regular heart rate and rhythm were observed. S1 and S2 are audible, and no abnormal sounds were noted. There were no whispers, scampers, or friction burns. Posterior and anterior chest is intact upon inspection. Inspiration and expiration are even and symmetrical. Thoracic expansion symmetrical, no abnormal findings during palpation and percussion, tactile fremitus normal, diaphragmatic excursion within normal range 4cm. Respiration was clear and free of adventitious sounds upon auscultation. Regular and unlabored RR. Asymmetrical chest wall Lungs are audible in all areas. Abdomen is symmetrical, flat, no lesions, abnormal movements, and skin is intact. Bowel sounds were present in all four quadrants, vascular sounds auscultated, and no thrills were noted in all vessels. Slight discomfort was detected, along with minor pain on palpation. . There is no mass or lesion. Murphys, Mcburney signs negative, rebound negative. Liver palpable and borders noted during percussion. Spleen non-palpable, negative for enlargement. Wave test negative.
Pt has full ROM noted, reflexes intact. CNII-XII is primarily complete. No disorientation or trouble was swallowing. There is no history of anemia, bleeding, or bruising. All pulses present, plus 2. There are no palpable lymph nodes and no history of splenectomy. Pts shows no signs of psychiatric conditions. Possible diagnoses are Bacterial gastroenteritis, Acute diarrhea, and Irritable bowel syndrome. Plan of care is completing a stool sample test, CBC, urine sample, possible abdominal xray, medication would be to rehydrate and provide electrolyte replacement to the pt po, Bismuth Subsalicylate 30ml PRN every 1hr for 24hrs for nausea and diarrhea, zofran 4 po PRN every 6hrs for vomiting, and Tylenol 500mg po PRN every 6hrs for pain.
Question 3: Mention the health promotion intervention for this patient.
Health Promotion includes educating the patient that he needs to practice hand cleaning to reduce spreading (De Marco et al, 2018). Get a good amount of rest. Adequate cleanliness and food preparations are essential for preventing subsequent illnesses (De Marco et al, 2018). Food should be stored correctly in a clean atmosphere.
Eat at a clean restaurants and wash vegetables and fruits before eating them to avoid consuming infected ones (De Marco et al, 2018).
Question 4: What did you learn from this week’s clinical experience that can be beneficial for you as an advanced practice nurse?
What I learned this week from clinical that will benefit my own practice is accurate documentation that rationalizes my diagnoses and treatment plans initiated for my clients. This is imperative in practice to not only accurately assess and treat patients for there medical concerns but it is of value for history taking and recall so that we have a complete recording of a clients case over time, its extremely useful for communication between providers and facilities, it also support and ensures that the insurance companies requirements are met for coverage on the medical and billing aspect of care.
References:
Buttaro, T., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2021). PRIMARY CARE: Interprofessional collaborative practice. (6th ed.). Elsevier – Health Science. https://www.elsevier.com/books/primary-care/978-0-323-55630-9 (Links to an external site.)
Cash, J. C., Glass, C. A., & Mullen, J. (2020). Family practice guidelines (5th ed.). Springer Publishing Company. https://www.amazon.com/Family-Practice-Guidelines-Fifth-FNP-BC/dp/0826135838 (Links to an external site.)
De Marco, R., Shankar, S., Rosenbaum, J., & Efron, D. (2018). A Case of the Stomach Flu. Journal of Paediatrics and Child Health, 54(2), 214–214. https://doi.org/10.1111/jpc.13828 (Links to an external site.)
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