NR 602 Kayla Well Women Case Study

NR 602 Kayla Well Women Case Study

NR 602 Kayla Well Women Case Study

1. F., 37-year-old Female

S.

1. Well Women Exam

HPI: Kayla reports that she is healthy and takes no medication. She has no symptoms that she can think of other than she is currently having trouble falling and staying asleep, but associates this with stress and with sleeping in the same room with her two younger children. She is a 15-year smoker of 1PPD up until 18 months ago when she quit with the pregnancy of Riley. She is concerned about finances today and reports ongoing fatigue. She has not and menses since the birth of her last child. She is not currently sexually active with men, women, or both and has been abstinent for the last 6 months.

 

PMH: Kayla denies any past medical history other than four pregnancies, three births, one pre-term, and two C-sections with the last two births. She had one miscarriage at 10 weeks when she was 16. She also reports that she had PCOS as a teenager and has always had irregular menses. She had gestational diabetes with the last birth and preeclampsia causing the early delivery of Riley.

NR 602 Kayla Well Women Case Study

Current Medications: She is currently taking Advil PM every night to sleep

Surgeries: Denies any surgeries except two C-sections.

Allergies: She has no allergies.

Vaccine History: Unknown

Social History: She is a 15-year smoker of 1PPD up until 18 months ago. Drinks a glass of wine at night. She does not routinely exercise. She often skips breakfast and lunch and eats whatever the children eat for dinner, which is often processed, or quick food.

Family History: Kayla’s mother has a history of hyperlipidemia, Type 2 DM, glaucoma, breast cancer at age 50 treated with lumpectomy, and Hypertension. She is Latin American in descent, emigrating from Cuba in the 1970s. Kayla’s father has a history of hypertension, hyperlipidemia, and an MI with stenting 5 years ago.  The mother has two siblings; a younger brother in the U.S. Navy, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history.

ROS:

Constitutional- reports ongoing fatigue, trouble falling and staying asleep

HEENT- Not reported

Skin- Not reported

Respiratory- Reports former smoker; quit 18 months ago

Gastrointestinal-  Not reported

Genitourinary- Not reported

Neurological- Not reported

Musculoskeletal- Not reported

Hematological- Not reported

Lymphatics- Not reported

Psychiatric- Not reported

O.

V/S: Height: 155cm, Weight: 65.5 kg. B/P: 130/76, HR: 82, T: 98.7, Resp: 16, SpO2: 97%, BMI- 27.3 (Overweight)

General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam; skin: warm, dry, intact; HEENT: head normocephalic; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck supple w/o lymphadenopathy.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored.

Breast Exam: Breasts of normal development bil. Areola unremarkable. Nipples without discharge or tenderness. No masses or tenderness upon palpation

Abdomen: abdomen, soft, with normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg., equal.

External Genitalia: Mons intact with normal hair distribution, labia majora, minora, clitoris intact, Bartholin’s and Skene’s glands. Intact. No piercings. No hymen.

Vagina: Pink, moist, with rugae, no odor, tone good. No rectocele, cystocele, or discharge.

Cervix: pink with multi-parous patent os, no lesions, sl. anterior and freely mobile without tenderness.

Uterus: retrograde, small firm, midline, smooth, mobile, non-tender uterus., size, consistency, mobility. Adnexae: present, smooth, non-tender.

Diagnostic tests– Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, negative WBCs, nitrites, and leukoesterase, RBCs, glucose, and ketones.

NR 602 Kayla Well Women Case Study

Primary Diagnosis:

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Medication Education: Escitalopram is a medication in the class of selective serotonin reuptake inhibitors that helps decrease depression by inhibiting serotonin reuptake.  (Kane, Ouslander, Abrass & Resnick, 2013).  Take one tablet by mouth daily.  If you notice it makes you a bit sleepy, then take in the evening which will also help with your sleep disturbances and adjustment insomnia. Side effects include nausea, headache, insomnia, diarrhea, fatigue, and worsening depression (Kane, Ouslander, Abrass & Resnick, 2013).

Other Education: Increase your fluid intake and sustain from any carbonated or caffeinated beverages.  Wear cotton underwear, practice good hygiene to prevent urinary tract infections. (Fenstermacher & Hudson, 2016).

Go to the emergency room if you are having any thoughts of hurting yourself or others. A counselor is encouraged for therapy; this is a third-party person you can talk to about the stresses in your life. The counselor can also assist you with referrals and community services you may need (Fenstermacher & Hudson, 2016).

Make sure your diet contains a variety of foods, particularly whole grains, fruits, and vegetables. Food and drinks containing caffeine, saturated fats, trans-fatty acids and cholesterol should be limited. You should also partake in regular exercise, at least 30-60 minutes a day, 3-4 days a week. Studies revealed women that follow these guidelines have lower rates of morbidity and mortality from coronary artery disease and certain forms of cancer (Schuiling & Likis, 2013).

Referral: Case management consults to assist in community referrals for healthcare and financial assistance.

Follow up: In office in 2 weeks to follow up on depression. Call the office if you have any problems or concerns.

Jo., 5-year-old, Female

 

S.

 

CC- Well child visit

 

HPI- The mother denies any recent illnesses in either child and reports they are here for their check-up. She was a full-term gestation, born cesarean section, with no complications in pregnancy. Mother smoked 1 PPD during her pregnancy. There have been no hospitalizations; she eats three meals a day and two snacks. There is a great deal of juice, soda, and processed foods given in the house. The patient currently lives with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Jo will be starting kindergarten this fall in the community’s elementary school.

 

Current medications- Chewable children’s multivitamin with iron

 

Allergies- NKA

 

Immunizations- Hep B, 2 months – Hep B, DTaP, HIB (COMVAX), PCV13, IPV, 4 months – DTaP, HIB (COMVAX), PCV13, IPV, 6 months DTaP, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella, Hep A, PCV 13, 18 months – DtaP, Hep A

 

PMH- Full-tern gestation delivered C-section, birth weight= 7lb 4oz, no complications during pregnancy, mother smoked 1 PPD throughout pregnancy, no hospitalizations

 

Social history- Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Jo will be starting kindergarten this fall in the community’s elementary school. They eat three meals and two snacks a day. There is a great deal of juice, soda, and processed or quick foods given in the house. They do brush their teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at home.

 

Family history- Maternal and paternal parents are smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia.

 

ROS:

 

Constitutional- “waking frequently to ‘play’”

HEENT- Not reported

Skin- Not reported

Respiratory- Not reported

Gastrointestinal-  Not reported

Genitourinary- Not reported

Neurological- Not reported

Musculoskeletal- Not reported

Hematological- Not reported

Lymphatics- Not reported

Psychiatric- Not reported

 

NR 602 Kayla Well Women Case Study

98. V/S:  Height: 109 cm, Weight: 27 kg, B/P:102/60, T: 98.2, HR: 88 BMP/reg., Resp: 18, reg, non-labored, SpO2: 99%, BMI- 22.7

General: Cooperative, talkative, appropriate

HEENT: head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; fundoscopic exam unremarkable; vision by Snellen exam 20/50 in her left eye, 20/40 in her right, and 20/30 together; tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent, unremarkable bil; pharynx unremarkable tonsils 1/4 bil; primary tooth eruption to include first molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o lymphadenopathy; thyroid small, firm, equal bil.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored

Abdomen: sl. rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly

Peripheral pulses: reg., equal., intact bil radial and pedal;

GU: labia majora and minora intact, no erythema or discharge.

Musculoskeletal: MAE. Able to do deep knee bends; hop on one foot on right leg but not left with any balance, tries but tumbles; able to balance on each leg for 10 seconds.

Cognitive Development: Able to state name and age; can write her own name; able to recall three friend’s names; knows all colors and can count to 13; dresses herself and has control of bowels and bladder; verbal throughout exam; all of speech clear and recognizable.

A.

 

Primary Diagnosis:

 

…

Anticipatory Guidance for Jo:

 

Topic: Nutrition

NR 602 Kayla Well Women Case Study

Target Age Range: (Middle Childhood 5-10 years old)

 

According to the Bright Futures Guidelines for a 5-year-old Jo has several priorities for this first visit. They first recommend that the concerns of the parents be addressed first. Then, school readiness, mental health, nutrition and physical activity, oral health, and safety should all be addressed. (Strasburger, 2015).

 

Definition: As for Jo’s dietary intake it is good that she is eating three meals a day with two snacks, but the large quantity of juice, soda, and processed foods are not good. During this age group it is the perfect time to counsel them on making appropriate choices on what to eat and drink to promote nutritional health. Guidance should be provided, or a referral can be given if the family needs nutritional helps due to cultural, religious, or financial reasons. One of these guidance items that should be discussed heavily in Jo’s case is the limitation of high-fat and low-nutrient foods and drinks, such as candy, salty snacks, fast foods, and soda. (Strasburger, 2015).

Educational points:

According to the CDC (2009) clinical growth charts, Jo’s BMI is 22.3 which are above the 95th percentile for body mass index for her age. Jo is considered obese for her age and needs help with healthy eating habits. The mother needs to be educated in being a healthy role model for Jo; children often mimic what they see from their parents. Jo should be fed more fruits, vegetable, nuts, seeds and whole grain foods. Jo should be getting at least 60 minutes of exercise a day and TV time should be limited to 2 hours a day. Foods high in fat and sugar should be limited to one treat a day (NIDDK, 2013).

The parents should be encouraged to support their children in being physically active and to be physically active together as a family. Parents of children with special health care needs should also be encouraged to allow their children to participate in regular physical activity or cardiovascular fitness within the limits of their medical conditions. (Strasburger, 2015)

As for Jo, she should be encouraged to be physically active for at least 60 minutes total every day. It doesn’t have to happen all at once, but can be split up into several periods of activity over the course of the day. (Strasburger, 2015)

The family should also limit the amount of time your child watches TV and plays video games or is on the computer to no more than 2 hours altogether each day. Any TVs from your child’s bedroom should be removed. (Strasburger, 2015)

Referral- Due to the results of Jo’s Snellen test she should be referred to an ophthalmologist for a further evaluation (Charbeck, 2015).

Follow up- Call the office with any problems or concerns. Return in 1 year for well child visit. (American Academy of Pediatrics, 2016)

 

References

American Academy of Pediatrics. (2015). Recommendations for Preventative Pediatric Health Care. Retrieved from https://www.aap.org/en-us/Documents/periodicity_schedule.pdf

Centers for Disease Control and Prevention. (CDC). (2016 S). Recommended Adult Immunization Schedule. Retrieved from http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.

Centers for Disease Control and Prevention (CDC). (2016) Retrieved October 26, 2017, from Clinical Growth Charts: http://www.cdc.gov/growthcharts/clinical_charts.htm

Charbeck, E. (2015) Pediatrics: Normal vital signs. Retrieved from: http://emedicine.medscape.com/article/2172054-overview.

Epocrates. (2017). Retrieved from MMRII: https://online.epocrates.com/rxmain

Epocrates. (2017). Retrieved from DTap: https://online.epocrates.com/rxmain

Epocrates. (2017). Retrieved from Escitalopram: https://online.epocrates.com/rxmain

Epocrates. (2017). Retrieved from Ipol: https://online.epocrates.com/rxmain

Epocrates. (2017). Retrieved from VAR: https://online.epocrates.com/rxmain

Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier.

Goroll, A. H. & Mulley, A. G. (2014). Primary Care Medicine (7th ed.). Wolters Kluwer Health.

Hollier, A. (2016). Clinical guidelines in primary care. Scott, LA.: Advanced Practice Education Associates

Kane, R., Ouslander, J., Abrass, I. & Resnick, B. (2013). Essentials of clinical geriatrics (7th ed.). China: McGraw Hill.

Maness, D. L., & Khan, M. (2015). Nonpharmacologic management of chronic insomnia. American Family Physician, 92(12), 1058-1064.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2013, June). Retrieved May 5, 2016, from Helping your overweight child: http://www.win.niddk.nih.gov

NR 602 Kayla Well Women Case Study

National Family Preservation Network (NFPN). (2015). The North Carolina Family Assessment Scales. Retrieved from http://www.nfpn.org/Portals/0/Documents/assessment_tools_overview.pdf

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2013). Helping your overweight child. Retrieved from http://www.win.niddk.nih.gov

Ramar, K., & Olson, E.J. (2013). Management of common sleep disorders. American Family Physician, 88(4), 231-238. Retrieved from http://www.aafp.org

Riley, M., Dobson, M., Jones, E., & Kirst, N. (2013). Health maintenance in women. American Family Physician, 87(1), 30-37. Retrieved from http://www.aafp.org

The American Congress of Obstetricians and Gynecologists. (ACOG). (2016). Well woman recommendations. Retrieved from http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations

Schuiling, K. & Likis, F. (2013). Women’s gynecologic health (Second ed.). Burlington, MA: Jones & Bartlett Learning, LLC.

 Strasburger, V. (2015). Anticipatory guidance. Retrieved from https://brightfutures.aap.org/Bright%20Futures%20Documents/17-Middle_Childhood.pdf.