Individual Case Study

Database
Patient Profile D.K. is 78 year old female who is quite pleasant. D.K. was admitted into Healthsouth on November 3, 2008. D.K.’s admitting diagnoses are Debility, Rheumatoid Arthritis, Triple Arthrodesis on the right hind foot, GERD, Constipation, Hypertension, and Osteoporosis. I was the student nurse assigned to care for D.K. on clinical day November 10, 2008.
Communication
D.K.’s primary language is English, her speech is within normal limits and she had no difficulty communicating. The therapeutic communication techniques I used in communicating with the client were touch, eye contact, and open ended questions. The touch communication technique was very effective because it showed the client compassion towards the vulnerability the client was experiencing in the hospital. The client had excoriated skin located on her pubis, the primary nurse wanted the client to leave her undergarments off in order to let the skin to heal through air. The client was extremely vulnerable and a simple touch to the client’s hand gave the client a sense of compassion. I also used eye contact, maintaining eye-contact during conversation shows respect and willingness to listen. (Potter, P.A. & Perry, A.G., 2009, p. 345). This technique gave the client a feeling of comfort that someone was listening to her which prompted the to client open up and spoke to me about her life and her family. Using eye-contact with the client gave her a sense of trust in sharing her personal life with someone in such a vulnerable situation. Last but not least, I used open-ended questions to give the client room to express herself and also to get a better understanding of the client. In the very beginning of the visit, the client was very tired and gave me short answers during the assessment. Using open-ended questions helped the client open up and answered my questions with more detail.
Psychological/Lifespan
According to Erikson’s eight stages of development, D.K. is identified as “integrity vs. despair (old age)” which creates physical and social losses through retirement or illness. (Potter, P.A. & Perry, A.G., 2009, p. 140). I classified D.K. in this stage due to the fact that she is a widow after 48 years of marriage, which has left her with role strain. D.K. has been a wife and mother, now that she is living alone it is hard for her to see where she fits in yet she is very happy with her accomplishments in life. Now that D.K. has limited mobility, it makes the role strain a little harder to cope with due to the fact that she has to rely on others to care for her which she is not used to. This external struggle is also another cause leading her to the integrity vs. despair stage. The client’s current stressors involve the immobility of her right foot. D.K. was completely independent prior to her admission into the hospital. The client was living on her own, driving, and performing activities of daily living. The clients rheumatoid arthritis gave the client some complications day to day, but other than that the client was able to manage on her own. D.K.’s mobility limitations will cause the client some inconveniences when the client goes back home because she is currently living alone. Despite the client’s physical limitations, the client is emotionally strong. The client looks to her inner strength to get through her physical tribulations everyday. The client shares that she copes with her problems whether physical or emotional through her emotional strength and independence. The clients marital status is widowed. D.K. was married for 48 years until her husband past away eight years ago in the year 2000. The client’s support systems are her only daughter and her friends within her housing community Sun City Anthem. D.K.’s neighbors are also her best friends which has been very helpful during her struggles with her rheumatoid arthritis.
Cultural/Spiritual
The client D.K. was born and raised Catholic. The stated that her religion and beliefs are very important to her and help her cope with her trials and tribulations. The client also states “I love my Catholic religion, but it’s hard for me to go to church every Sunday because I become very emotional.”, during this statement the clients eyes welled up with tears which showed her passion towards her religion. The client manifests her beliefs by praying and never doubting her Lord. Catholicism has given D.K. a brighter outlook in life. The client shares that she doesn’t get stressed out or upset when things went wrong because there is a higher purpose for everything.
Nursing History The client D.K. was discharged from St. Rose Hospital after having a triple arthrodesis performed on her right hind foot. D.K. was admitted to the rehabilitation hospital Healthsouth in order to nurse back and rehabilitate her physical limitations back to health. The client complained of ankle pain upon admission to Healthsouth. D.K. also had hypoactive bowel sounds in all four quadrants and experienced constipation. The client stated that her last bowel movement was on October 30, 2008 prior to her admission to the sub-acute facility. The client also had excoriated skin located on her pubis, DK stated that she suffered from UTI due to the catheter that was placed during her stint in St. Rose Hospital. Other than that, the client was very pleasant and her assessment had no irregularities aside from her medical diagnoses. The client’s main admission diagnosis is Debility. Debility is defined as feebleness, weakness, or loss of strength (Mosby 2006, pg. 515). Signs and symptoms that support this diagnosis are fatigue, limited mobility, dyspnea, and activity intolerance.
Current Surgeries Related to Admission Diagnosis The client had a triple arthrodesis performed on her right hind foot. This recent surgery is the cause for the client’s current admission diagnosis.
Client’s Past Medical History The clients past medical history involves a medical diagnosis of Rheumatoid arthritis, Hypertension, GERD, and Osteoporosis. The client’s medication intended to relieve complications of her rheumatoid arthritis has helped relieved pain and regain the function of her hands. Although the arthritis that developed in her right ankle worsened and disabled the client. The client stated that she realized the severity of the arthritis in her ankle when one day she felt a tremendous amount of pain stepping on the brake while driving. The client understood the danger and was admitted to the hospital for surgery, this diagnosis contributed to her admission into the sub-acute facility. The surgery has given the client limited mobility and during her hospital stint the client developed other complications that has also contributed to her admission.
Diagnoses developed since admission The client developed excoriated skin on her pubis due to the girdle the client wears daily in the sub-acute facility. The clients’ bed mobility enabled this problem because
Narrative Systems Assessment
Neurological
The client is awake, alert and oriented to person, place, time. PERRLA. The client is very pleasant and cooperative. The client’s speech is within normal limits. The client is able to make general movements, obtains balance and coordination. The client’s vision and hearing are within normal limits.
Cardiac
The clients’ apical pulse is 61 and strong with a regular rhythm. Heart sounds are strong with no adventitious sounds. The client’s capillary refill is 2 seconds and within normal limits. The client obtained uniformly fair, warm, and dry skin. The client had no signs of edema on her lower extremities. The client had no homans present during assessment. The clients radial pulses are palpable bilaterally with a rate of 63 beats per minute, strong and regular rhythm. The clients’ left posterior tibialis and dorsalis pedis pulses were strong with a regular rhythm and palpable with a pulse rate of 63 beats per minute. The right leg is contained in a cast but the client toes are pink and able to move toes without difficulty.
Respiratory
The client’s lungs are clear bilaterally to auscultation with a rate of 18 breaths per minute with regular depth and a symmetrical chest. The client’s breathing pattern is non-labored and regular.
Gastrointestinal
The clients abdomen is rounded with no signs of distension, and The client’s abdomen is soft to palpation with no rebound tenderness. Bowel sounds are present in all four quadrants. The client’s bowel movement pattern is within normal limits once or twice a day with characteristics of soft, formed, brown stool. The clients last bowel movement was clinical day 11/10/2008 in the morning.
Nutrition/Metabolic
The client is placed on a low fat, low sodium diet. The client has an intake of 80% of her meals and fluids. The client has no complaints of dysphasia. Genitourinary/Renal The client is continent with complications of excoriation on her vaginal surface. The client has no bladder distension.
Musculoskeletal
The client’s motor grips are symmetrical with a strength of 4+/5. The client is able to perform active ROM with unaffected extremities. The clients transports via wheelchair due to the surgery.
Integumentary
The client obtains intact, uniformly fair, warm, and dry skin with a elastic turgor.
Pain Assessment The client is suffering from acute pain in her right ankle with a grade of 1 on a 1 to 10 scale. The client stated that the pain is dull and not bothersome.

Labs
Date Lab. Parameter Result Date Lab. Parameter Result
11/8
11/8
11/8
11/8
11/8

The clients urinalysis results included a positive result of protein and blood in urine. The urinalysis also revealed that the appearance of the urine was cloudy. The nurse must monitor urine output while caring for the client. D.K.’s albumin level is also low Protein losses may occur due to overall poor nutritional intake of calories and protein losses in the urine, stool, blood or in wounds. The nurse should carefully devise a healthy diet plan that can promote the clients’ nutritional health with a goal of raising albumin levels.

Nutrition The clients’ diet prior to admission was normal. The client ate and drank what she preferred daily. The client stated that she has no desire to cook and purchases microwaveable meals for their convenience. The client has orders for a low fat and low sodium diet due to her hypertension. The clients weight is 165 with a height of 6’3”, the clients BMI is 20.62. The client has a slightly low level of albumin which can which could indicate protein malnutrition, other situations may cause a low albumin levels including; stress, surgery, impaired liver function or over-hydration of body tissues.
In order to improve the albumin level, the client should consume both adequate calories and adequate protein.

Safety The client has a high risk for falls, due to the mobility limitations of her right leg. Safety interventions for this client would include: Placing the call light within reach, side rails up times 2. These interventions were very effective because the client is very pleasant and very cooperative.
Health Teaching The client is ready and very eager to learn client teaching because the client wants to go home and have a greater ability to perform activities of daily living. The client teaching topic I implemented is based on nutrition. The strategies I implemented was educating the client on the reason for her placement on a low fat low sodium diet. I helped the client understand the effects of foods high in sodium and fat. I also gave the client a variety of options that she can choose from to prepare and stay on this diet when discharged from the sub-acute facility. The client was very cooperative and interested in the information and asked questions on preparation of foods and where she can purchase food that will accommodate her lifestyle and diet.
Community Awareness and Discharge Needs The client denies usage of community resources in the past and present. After discharge, the client’s daughter will help care for the client from time to time. The client’s friends in her housing community will also assist DK in activities of daily living. The client obtains health insurance through Medicare. The client will be needing a toilet riser, bedside commode, wheelchair, and shower chair after being discharged from the sub-acute facility. The client’s community Sun City Anthem provides medical equipment to all community residents.
Personal Value of Nursing Case Study Preparing this paper is very valuable because this case study involves pertinent information on the clients status and propose interventions that will aid the client. The criteria for this paper is very detailed which provides helpful information to the student nurse that will prepare us to properly give individualized care for each patient encounter. I used critical thinking when helping comfort the client in her moment of vulnerability. The patient was instructed by the nurse to keep undergarments off, lift her gown and keep her pubis area out to open to air. This situation made the client feel extremely uncomfortable so I took the initiative to divert the client’s attention to help relieve her humiliation. This strategy worked for a fraction of the time, so I used the communication technique of touch to show the client compassion. The slight touch to her hand and shoulder showed the client empathy to the very embarrassing situation she was placed in.

Reference
Potter, P.A. & Perry, A.G. (2009). Fundamentals of nursing (7th ed.).

St. Louis, MO: Mosby, Inc.

Mosby’s Dictionary of Medicine, Nursing & Health Professions (7th ed.). (2006)

St. Louis, MO: Mosby, Inc.