CASE STUDY #2 – MRS. JONES
STUDENT NAMES (STUDENT IDs):
CLINICAL INSTRUCTOR(S):
Mrs. Jones is a 60-year-old female patient who is coming in the emergency department by ambulance
due to complaints of severe back pain that started today. The patient reports the pain is in her back.
The patient also has had nausea and vomiting and has not been able to keep any medications down due
to the nausea and vomiting. The paramedic that responded to the call gave a report to you that it looked
like Mrs. Jones was living in poor conditions and that a lot of medication bottles were empty. Mrs. Jones
lives at home alone and her only family is her daughter that lives about two hours away from her.
Recent Medical History: The patient is a type I diabetic with poor blood sugar control. Her insulin
regimen has recently been adjusted by her endocrinologist in order to lower her high blood sugars. She
has a past medical history of kidney failure, chronic pain, heart murmur, anemia, substance abuse and
depression.
Physical assessment: Students will complete the physical assessment.
1. What is your course of action when meeting this patient? Explain step by step how you would
care for her and prioritize your interventions for the first 10 minutes of meeting her before
calling the physician.
I would assess the patient for any airway, breathing or circulation problems, this includes taking
vital signs. Assessing if there is any bleeding present, skin damage and patients LOC. I would look
into the chart for any allergies and current medications along with PMH. Administer pain
medication and reassess pain level.
It's always the assessment phase that matters and that steers how a nurse would be
treating the patient and referring any significant data to the primary physician. The nurse
must focus on the chief complaint and work around it until the nurse develops a clinical
picture of what the patient is presenting. Questions like: "Where is the pain located and for
how long have you had this?" "Have you eaten anything that might have caused your
This study source was downloaded by 100000829943187 from CourseHero.com on 05-21-2022 17:21:26 GMT -05:00
https://www.coursehero.com/file/77168558/NURS-481L-DAY-2-CASE-STUDY-1-1docx/
, CASE STUDY #2 – MRS. JONES
vomiting?" "What is the content of vomitus?" "Does the pain radiate to any other part of the
body?" "Is this the first instance that this happened?" "Have you done anything you think
that might have caused this?" "Did you take any medication before and/or after you noticed
this?" "Do you have any significant conditions you'd like to tell me which could help point out
the origin of your complaint?" while communicating with the patient the nurse should be
able to get the vital signs and at least do physical assessment to help grasp the situation
further and once all this is done, the nurse requests the physician to order a pain medication
to help alleviate the pain the patient is feeling.
2. What kind of assessment would you complete on this patient and why? (Full head to toe or a
focused assessment). Describe step by step your physical assessment.
I would do a full head to toe assessment on this patient
Typical findings on a diabetic patient with CKD would most likely note the following: central
obesity that is noted by a BMI that is above normal, hypertension with history that is known
to go beyond 160mmhg systole, extremities seem noticeably rigid but still moveable due to
poor vascularity of blood vessels and nerves also poor neuro-muscular responses notices in
extremities that may appear darker in skin tone than the rest of the body again due to poor
vascularity, possible neurologic deficits may be noted by poor touch and temperature
senses, probable loss of tendon reflexes might also be present, muscle atrophy in
extremities that may also appear to be clawing, skin ulcers may be visible with possibility of
gangrene, possible faulty vision due to presence of cataracts or glaucoma, and fatigue
might be evident. Other assessment would be to order a lumbo-sacral x-ray that might help
determine the cause of the back of the patient along with the chest x-ray because the
patient is known to have a heart disease with murmur heard during auscultation to help rule
out extent of cardiomegaly. Blood exams should be ordered like: CBC, Na, K+, Mg,
Creatinine, BUN, Urinalysis, CKMB, Troponin I quantitative, ESR, FBS and Lipid profile (if
already fasting), HBA1C, RBS/CBG, ABG, NT PRO BNP, 2D echo with color flow doppler,
ECG 12 leads with long lead II, CT scan of the kidneys and etc.
3. Please write the SBAR that you would give the physician after assessing this patient for the first
time? What are the priorities in treating this patient?
SBAR: S: Mrs. Jones is presenting flank pain accompanied by nausea and vomiting and her
complaints have just started today. She hasn't been able to keep down medications orally
due to her condition. B: According to the paramedic that got the patient, he saw a few empty
bottles of medication in Mrs. Jones' house. She is known to have a history of CKD, is a
known diabetic with blood glucose levels poorly managed at home, and per ausculatation,
heart murmurs were present. A: I think the patient is manifesting either drug-induced UTI or
a possible kidney attack. R: I recommend to give the patient an IV dose of Paracetamol
since Tramadol couldn't be given because she's vomiting and an imaging study of the
kidney should be checked
This study source was downloaded by 100000829943187 from CourseHero.com on 05-21-2022 17:21:26 GMT -05:00
https://www.coursehero.com/file/77168558/NURS-481L-DAY-2-CASE-STUDY-1-1docx/
STUDENT NAMES (STUDENT IDs):
CLINICAL INSTRUCTOR(S):
Mrs. Jones is a 60-year-old female patient who is coming in the emergency department by ambulance
due to complaints of severe back pain that started today. The patient reports the pain is in her back.
The patient also has had nausea and vomiting and has not been able to keep any medications down due
to the nausea and vomiting. The paramedic that responded to the call gave a report to you that it looked
like Mrs. Jones was living in poor conditions and that a lot of medication bottles were empty. Mrs. Jones
lives at home alone and her only family is her daughter that lives about two hours away from her.
Recent Medical History: The patient is a type I diabetic with poor blood sugar control. Her insulin
regimen has recently been adjusted by her endocrinologist in order to lower her high blood sugars. She
has a past medical history of kidney failure, chronic pain, heart murmur, anemia, substance abuse and
depression.
Physical assessment: Students will complete the physical assessment.
1. What is your course of action when meeting this patient? Explain step by step how you would
care for her and prioritize your interventions for the first 10 minutes of meeting her before
calling the physician.
I would assess the patient for any airway, breathing or circulation problems, this includes taking
vital signs. Assessing if there is any bleeding present, skin damage and patients LOC. I would look
into the chart for any allergies and current medications along with PMH. Administer pain
medication and reassess pain level.
It's always the assessment phase that matters and that steers how a nurse would be
treating the patient and referring any significant data to the primary physician. The nurse
must focus on the chief complaint and work around it until the nurse develops a clinical
picture of what the patient is presenting. Questions like: "Where is the pain located and for
how long have you had this?" "Have you eaten anything that might have caused your
This study source was downloaded by 100000829943187 from CourseHero.com on 05-21-2022 17:21:26 GMT -05:00
https://www.coursehero.com/file/77168558/NURS-481L-DAY-2-CASE-STUDY-1-1docx/
, CASE STUDY #2 – MRS. JONES
vomiting?" "What is the content of vomitus?" "Does the pain radiate to any other part of the
body?" "Is this the first instance that this happened?" "Have you done anything you think
that might have caused this?" "Did you take any medication before and/or after you noticed
this?" "Do you have any significant conditions you'd like to tell me which could help point out
the origin of your complaint?" while communicating with the patient the nurse should be
able to get the vital signs and at least do physical assessment to help grasp the situation
further and once all this is done, the nurse requests the physician to order a pain medication
to help alleviate the pain the patient is feeling.
2. What kind of assessment would you complete on this patient and why? (Full head to toe or a
focused assessment). Describe step by step your physical assessment.
I would do a full head to toe assessment on this patient
Typical findings on a diabetic patient with CKD would most likely note the following: central
obesity that is noted by a BMI that is above normal, hypertension with history that is known
to go beyond 160mmhg systole, extremities seem noticeably rigid but still moveable due to
poor vascularity of blood vessels and nerves also poor neuro-muscular responses notices in
extremities that may appear darker in skin tone than the rest of the body again due to poor
vascularity, possible neurologic deficits may be noted by poor touch and temperature
senses, probable loss of tendon reflexes might also be present, muscle atrophy in
extremities that may also appear to be clawing, skin ulcers may be visible with possibility of
gangrene, possible faulty vision due to presence of cataracts or glaucoma, and fatigue
might be evident. Other assessment would be to order a lumbo-sacral x-ray that might help
determine the cause of the back of the patient along with the chest x-ray because the
patient is known to have a heart disease with murmur heard during auscultation to help rule
out extent of cardiomegaly. Blood exams should be ordered like: CBC, Na, K+, Mg,
Creatinine, BUN, Urinalysis, CKMB, Troponin I quantitative, ESR, FBS and Lipid profile (if
already fasting), HBA1C, RBS/CBG, ABG, NT PRO BNP, 2D echo with color flow doppler,
ECG 12 leads with long lead II, CT scan of the kidneys and etc.
3. Please write the SBAR that you would give the physician after assessing this patient for the first
time? What are the priorities in treating this patient?
SBAR: S: Mrs. Jones is presenting flank pain accompanied by nausea and vomiting and her
complaints have just started today. She hasn't been able to keep down medications orally
due to her condition. B: According to the paramedic that got the patient, he saw a few empty
bottles of medication in Mrs. Jones' house. She is known to have a history of CKD, is a
known diabetic with blood glucose levels poorly managed at home, and per ausculatation,
heart murmurs were present. A: I think the patient is manifesting either drug-induced UTI or
a possible kidney attack. R: I recommend to give the patient an IV dose of Paracetamol
since Tramadol couldn't be given because she's vomiting and an imaging study of the
kidney should be checked
This study source was downloaded by 100000829943187 from CourseHero.com on 05-21-2022 17:21:26 GMT -05:00
https://www.coursehero.com/file/77168558/NURS-481L-DAY-2-CASE-STUDY-1-1docx/
