Case
Study: Mr. James Anderson
Background:
Mr.
James Anderson is a 78-year-old retired African American male with a primary
diagnosis of Urinary Incontinence and Dehydration with intermittent
exacerbations. He also experiences poor sleep quality. Mr. Anderson has a past
medical history of benign prostatic hyperplasia (BPH), hypertension, and mild
cognitive impairment. He recently had a urinary tract infection (UTI) and was
hospitalized for dehydration secondary to poor fluid intake. His current
problems include urinary urgency and frequency, occasional urinary leakage,
fatigue, confusion, and difficulty falling asleep.
Current
Medications:
Tamsulosin
0.4mg PO qd for BPH, Lisinopril 10mg PO qd for hypertension, Amlodipine 5mg PO
qd for hypertension, Oxybutynin 5mg PO bid for urinary urgency, Melatonin 3mg
PO qhs for sleep.
Social
History:
Widowed
for 5 years with two adult children who live out of state. Mr. Anderson lives
alone in a senior apartment complex. He used to be active in his local
community center but has withdrawn due to his health issues. He enjoys
gardening but has difficulty managing it due to his urinary symptoms and
fatigue. Mr. Anderson relies on a caregiver who visits him twice a week for
assistance with activities of daily living.
Current
Orders:
Home
health nurse visits three times per week for fluid intake monitoring, bladder
training, and assessment of urinary symptoms. Urology follow-up for evaluation
of urinary incontinence and BPH management. Fluid restriction education and
dietary consultation for managing dehydration. Cognitive assessment and
referral to a neurologist for further evaluation of cognitive impairment. Sleep
hygiene education and referral to a sleep specialist for evaluation of sleep
disturbances.
Rubric
Criteria
Points
Pertinent, Focused Physical and/or Psychosocial Assessments
5
– Assessment techniques and rationale
– Explanation of how assessments inform care
Patient and Caretaker Education
5
– Clarity and relevance of education provided
– Explanation of importance to patient and caregiver
Anticipated Labs
5
– Selection of relevant labs and rationale
– Explanation of how labs aid in patient management
NANDA Nursing Diagnoses and Interventions
5
– Selection of appropriate nursing diagnoses
– Relevance and feasibility of interventions
SMART Goals
5
– Specificity and measurability of goals
– Feasibility and relevance to patient’s needs
Medication Reconciliation
5
– Accuracy and completeness of reconciliation
– Explanation of medication-related risks and benefits
1.
What 3 pertinent,
focused physical and/or psychosocial assessments would you perform? What
techniques/inventories/assessment scales would you use? Explain why.
2.
What would you educate
the patient and caretakers about? Explain why.
3.
What labs would you
anticipate checking, if applicable? Explain why.
4.
List 5 NANDA nursing
diagnoses with 3 interventions for each NANDA diagnosis. At least two
problem-based dx and the rest of the three dxs can be any you’d like. Please
refer to your nursing dx book.
5.
What goals would you set
for Ms. Bernstein? Please list at least three; ensure they are SMART goals.
SMART = Specific, Measurable, Attainable, Realistic, and Time-Bound
6.
Perform a medication
reconciliation, indicating the indication, side effects (common), adverse
effects (serious and/or life-threatening), and drug interactions of each of her
medications.
Please include a cover page, a reference page, and in-text
citations if you’re citing a nursing/medication reference, using APA
format.
Rubric
Case Study Rubric (4)
Case Study Rubric (4)
Criteria
Ratings
Pts
This criterion is linked
to a Learning OutcomePhysical Assessment
Accurately chooses
appropriate focused assessments to perform on this patient given data in the
case study. Accurately chooses appropriate RN questions to assess the patient
given patient data.
5 pts
This criterion is linked
to a Learning OutcomeNursing Education
Accurately chooses
appropriate education topics to discuss with the patient.
5 pts
This criterion is linked
to a Learning OutcomeNANDA Dxs
Lists 5
appropriate nursing diagnoses for this patient. At least two problem-focused,
at least two at-risk, and one can be your choice.
Write 3 RN interventions per dx.
5 pts
This criterion is linked
to a Learning OutcomeMedications
For each
medication, list the indication (as it relates to this specific pt), SEs/AEs,
and drug interactions.
5 pts
This criterion is linked
to a Learning OutcomeSMART Goals
3 goals required.
5 pts
This criterion is linked
to a Learning OutcomeAPA Format
APA format is used
(in-text citations, cover page, headers).
5 pts
Total Points: 30
