History and physical:
George Mayfield is a 68-year-old Black male with a past history of hypertension. He reports that he has not taken his meds the past year because it was “too much bother” and he “felt fine.” He is seen at the Olympia Free Clinic for healthcare. George came to the clinic because of a headache that has been persistent the past week and blurred vision.
Past medical history
• Hypertension
• Unknown immunization history
Social and family history
George is veteran. He has struggled with alcohol abuse in the past but denies ETOH use in the past year. He has been homeless since he lost his job as a mechanic ten years ago and currently lives in his car. He has never married and has no close friends or relatives with whom he stays in contact. He smokes one pack of cigarettes per day.
Allergies
NKA/NKDA
VS
Current VS PQRST Pain
Temp: 97.8F/36.4C Provoking/Palliative Nothing/nothing
Pulse: 90, regular Quality Dull ache
Resp: 18, regular Region/radiation. Head
BP: 188/96 Severity 7/10
O2 Sat: 93% Room air Timing Constant
Physical examination:
General Clothing soiled, hair and beard unkept. Foul body odor, feet with callouses. Teeth are yellow stained and many are missing with poor dentition
Resp. Breath sounds diminished bilaterally with an occasional strong, dry cough
Cardiac Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
Neuro Alert & oriented to person, place, time, and situation (x4)
GI Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU Voiding without difficulty, urine clear/yellow. Voids three times during the night
Skin Dirt on hands and under fingernails, fungal toenails present on both feet, feet persistently itch, are swollen, macerated and moist with peeling of the skin layers between toes on both feet.
Patient case study questions
1. What objective assessment data is relevant and must be interpreted as clinically significant by the nurse? At least 5 data points must be reviewed. There may be more.
Relevant data Clinical significance
2. George is at risk for several barriers to healthcare. Identify three of these barriers. At least 3 barriers must be reviewed. There may be more.
Barrier 1.
Barrier 2.
Barrier 3.
3. Considering the nursing roles of education, advocacy, management of care, collaboration, and leadership, create a list of three nursing interventions at each level of primary, secondary, and tertiary level of care for George. Examples provided do not count towards your three nursing interventions.
Primary Prevention: Keep disease or injury from occurring (AKA Educate)
Ex: Provide resources for personal hygiene such as community shower locations
1.
2.
3.
Secondary prevention: Detect or treat existing disease or injuries (Screen and treat)
Ex. Schedule dentist appointment at free clinic to treat severely diseased teeth
1.
2.
3.
Tertiary prevention: Reduce injury or disease to minimize disability (Rehabilitation)
Ex. Provide education on warning signs of worsening hypertension
1.
2.
3.
