Case 01: Focused Exam: Pain Management Results Turned In

Case 01: Focused Exam: Pain Management Results | Turned In Pharmacotherapeutics for Advanced Nursing Practice - Spring 2020, NGR 6172 Return to Assignment (/assignments/283572/)

Your Results

Lab Pass (/assignment_att

Experience Overview

Patient: Tanner Bailey Student Performance Index

56.5 out of 58

Proficiency Leve Beginning Developing P

Students rated as “proficient” demon advanced practice competencies a Digital Clinical Experience Score

100% comparable programs, the top 25% of a proficient practitioner.

Subjective Data Collection M 25 out of 25 9 Education and Empathy Pa This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs.Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score C m ou a rse y Her n o.c o om t on b

e 8-10 y -20 o 21 u

r

7:1

fi

6:4

n

a GM l T g -0 r 5 a

:00

de if your instructor chooses to include

additional components, such as documentation or time spent.

• out of 7 6.

Prescription Writing 10 out of 10

Time 149 minutes total spent in assign

Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Debrief Medication Selection Patient Teaching Prescription Writing

Interaction with patient 149 minutes Documentation / Electronic Health Record

Documentation: Provider Notes

Student Documentation Model Documentation

Subjective

Initial incident- picked up heavy box of sound equipment at work caused sudden back pain that has continued since (13 weeks ago).

Lifted with back instead of knees.

Describes pain as sharp and hot/burning with intermittent tingling primarily in lower back. Denies radiating pain.

Hasnt been able to work (directing plays), or do anything physical.Even walking is painful as well as lifting objects. Havent been able to do PT exercises (tried yoga) or followup with therapist recommended by hospital.

Changing position and rest helps improve pain. Patient is resorting to alcohol and opioids to relieve pain and combining them. States tried ibuprofen but didnt help.

Confirms only drank 1-2x a month prior to accident, but since then has increased number of drinks to 3 times a day.

Clarifies drinking a tumbler of whiskey (unspecified ounces) 3 times a day.

Resorted to alcohol instead of ibuprofen starting approx 11 weeks ago. Had first sip of wine as kid but started drinking alcohol in 20s (a drink or 2 a month).

Stopped drinking a week ago and started taking opioids for pain.

Started taking friend's hydrocodone prescibed after surgery (not own prescription).

Takes 1 pill (5mg hydrocodone and 325mg acetaminophen) 2x daily (1 in morning, 1 at night).

Denies tobacco/nicotine and recreational drug use.Pain rated 0-2 at its best, 7-10 at its worst.When taking ibuprofen, patient was taking 2 200mg pills every 4 (No Model Documentation Provided hours (400 mg Q4 hours). Didnt fill/take pescritpiton of ibuprofen given by hospital.

Was driven to the ER right after it happened by a friend, MRI was inconclusive per patient.

oBnpadf/ck pain has remained the same intensity since incident (patient appears emotionally distressed).

Documentation: Provider Notes

Pain starts upon wakening and improves some during day but always returns.

Affecting lifestyle and causing limitations.

Denies any other helath issues, disorders, or symptoms. Denies mental health disorders.

Father free of known health issues; Mother alcoholic with depression.

Patient denies addiction.

Takes testosterone- gender affirmation therapy (transgender). Injects in deltoif weekly for 2 years (100 mg total per week). Last had the testosterone injection yesterday.

Denies herbs/supplements.

No known allergies (meds, food, latex, seasonal, or environmental).Hasnt tried ice or heat for pain Taking something constantly for pain.

Social- makes $25,000 yearly. Full time job as theater director (unable to work for few months related to injury).

Identifies as male- use "he" and "him" Wears a binder for masculinity but denies aggravating back pain.Denies any risky behavior or intoxication.

Objective

Vitals stable.(No Model Documentation Provided Only current medication is testosterone 100mg once weekly (injections)

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