Clinical II – SIM 4 – Case Studies
*to be done early in the semester
Case Study 1
Scenario
P.M., 24-year-old house painter, too ill to work the past 3 days. Arrived at your outpatient clinic with his girlfriend, he seems alert but acutely ill, with an average build & a deep tan over the exposed areas of skin. He reports headaches, joint pain, a low-grade fever, cough, anorexia, & nausea and vomiting (N/V), especially after eating any fatty food.
P.M. describes vague abdominal pain that started about the same time as the other problems. He states that he has been using “a lot of Tylenol” for his pain. His past medical history reveals he has no health problems, is a nonsmoker, & drinks “a few” beers each evening to relax.
Vital signs are 128/84, 88, 26, 100.6 ° F (38.1 ° C); awake, alert, & oriented × 3; moves all extremities well with complaints of aching pain in his muscles; very slight scleral jaundice present; heart & lung sound clear & without adventitious sounds; bowel sounds clear throughout abdomen & pelvis; & abdomen soft & palpable without distinct masses. You note moderate hepatomegaly measured at the midclavicular line; liver edge is easily palpated & tender to palpation. P.M. mentions that his urine has been getting darker over the past 2 days.
1. Your institution uses electronic charting. Based on the health history and assessment described in the scenario, which of the following systems would you mark as “abnormal” as you document your findings? Mark abnormal findings with an X and provide a brief narrative.
X Abnormal
☐ Neurologic:
☐ Respiratory:
☐ Cardiovascular:
☐ Gastrointestinal:
☐ Genitourinary:
☐ Musculoskeletal:
☐ Skin:
☐ Pain:
Case Study Progress
P.M. is manifesting key signs of hepatitis. Laboratory work is requested for identification of his precise problem.
2. Which key diagnostic tests will determine exactly what type of hepatitis is present?
Laboratory Test Results
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Sodium Potassium Chloride CO2 BUN Creatinine Platelets Indirect bilirubin Total bilirubin Albumin Total protein ALT AST LDH ALP PT/INR aPTT Urine urobilinogen Anti-HAV IgM HBsAg |
140 mEq/L 3.9 mEq/L 102 mEq/L 26 mEq/L 10 mg/dL 1.3mg/dL 210,000/mm3 1.6 mg/dL 2.3 mg/dL 3.8 g/dL 6.5 g/dL 66 units/L 52 units/L 245 units/L 176 units/L 12 sec/1.06 32 sec 1.6 IU/L Negative Negative Positive |
3. Which of P.M.’s laboratory results specifically indicate liver disease?
4. What is the difference between the hepatitis B surface antigen (HbsAg) and the hepatitis B surface antibody (HbsAb)?
5. What factors in his history could have compounded the increased ALT levels?
6. Considering the basic pathology of hepatitis, what type of diet will you strongly encourage P.M. to follow?
7. For each characteristic below, identify whether it describes hepatitis A (A) or hepatitis B (B).
______a. Fecal-oral transmission.
______ b. Transmitted by sharing needles.
______ c. Transmitted by blood transfusions.
______ d. Vaccination is a three-shot series.
______ e. Illness is usually mild, similar to a flulike infection.
______ f. Symptoms include anorexia, nausea, vomiting, fever, fatigue, and jaundice.
8. In P.M.’s case, the HbsAg is positive. This result indicates that P.M. is infected with hepatitis B and is in the acute period of the disease. Is this disease contagious? What precautions would you take while he is in the hospital?
9. Pruritus is usually associated with jaundice. What will you do to ease this problem for P.M.? Name five interventions.
10. How will you explain to P.M. the likely progression of his disease?
11. P.M. is living at home with his parents and four younger siblings. The youngest is 4 years old. His parents ask how to prevent the rest of the family from getting hepatitis. What specific instructions will you give?
12. How will you know that these instructions are understood?
13. Given P.M.’s lifestyle, what specific patient teaching points must you emphasize?
Case Study Progress
P.M. is ready for discharge in a few days, & he confides to you that he feels so “guilty” about having hepatitis and endangering his girlfriend and family. He tells you he was at a party and did not think the one-time needle use could hurt him. He has lost his job because he is not able to go back to work & he hopes his family is not too afraid to have him return home.
14. What action will you take?
Case Study 2
As a senior student you are assigned to work with a preceptor in the emergency department. It is a remarkably busy day, & it seems as if every patient, regardless of chief complaint, has an issue with fluid, electrolyte, and or acid-base balance.
The first patient you see is a thirty-seven-year-old landscaper who is brought to the ED after collapsing on a job at the local country club. He is slightly confused but can tell you he feels dizzy & weak. His skin is flushed, dry, and with poor turgor. He has dry, sticky mucous membranes. The nurse identifies a nursing diagnosis of deficient fluid volume.
1. Describe how each of the following would change and the rationale for the change in the presence of deficient fluid volume
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Expected Change |
Rationale |
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Heart rate
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Blood pressure
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Serum hematocrit
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Urinary output
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Urine specific gravity
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Weight
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2. What is usually the first indicator that an individual needs more fluids?
3. The ED physician orders IV fluids for this patient. What types of fluids are indicated for a fluid volume deficit due to dehydration?
The preceptor tells you to go ahead & initiate an IV site and start the fluids. The fluid order is to start 1000 mL of fluid as ordered at 150 mL/hr. The infusion tubing has a drop factor of 15 gtt/mL.
4. This infusion will run by gravity rather than an infusion pump. How many drops per minute should you time the infusion at to ensure the correct hourly rate? (See Chapter 22 in “Calculate with Confidence)
5. The patient has a “full sleeve” tattoo on both arms. Discuss the implications of this finding and how you will initiate the intravenous site.
6. You have difficulty finding a vein in the presence of the deficient fluid volume. What strategies can you employ to help make a vein more visible/palpable?
7. After 30 minutes of the infusion, the patient states, “My arm where the needle is feels funny.” What should you do first? What further data do you need from the patient?
Several hours later the patient is feeling better & is now oriented x 3. The ED physician wants the patient to be drinking oral fluids without difficulty prior to being discharged from the ED.
8. Discuss the strategies to increase fluid intake that are most appropriate to this setting.
9 The patient is discharged after adequate hydration. Discharge teaching includes ways to prevent this from happening again on the job. What key points should the nurse include in the teaching applicable to the job site?
*Turn in to SIM4 Case Study Folder in D2L Dropbox