CAM311A - Clinical Studies 3 - Critical Case Analysis - Nursing Report Writing Assessment Answer

Assessment Task:

CAM311A: Clinical Studies 3 Nursing Report Writing Assessment Answer

Case Details
Karen is a 51 year old woman who has come to you for help with her hot flushes. She is experiencing 5-6 hot flushes during the day in which she will suddenly feel heat rising from her feet to the top of her head – she becomes red in the face and sometimes on her neck and chest, and this is sometimes accompanied by sweating. At night, she has been waking up 3-4 times per night bathed in sweat, and has trouble getting back to sleep. She needs to change her nightclothes a couple of times per night. These symptoms have been gradually worsening over the last 2-3 months. Karen also reports vaginal dryness and discomfort in recent months. Menstrual History

Karen underwent menarche at age 12. Her periods have been regular throughout her life – every 28 – 30 days. She has occasionally experienced some bloating in the couple of days prior to her period, and occasional lower abdominal cramping – but comments that these have been fairly minor symptoms and not required any treatment or painkillers. She bled for 5-6 days, and described her flow as “average”. Karen’s last menstrual period was about 6 months ago, and in the year prior to that were a little irregular, with her skipping a couple of periods. Her mother underwent menopause at around 50 years of age.

Nervous system
Karen describes herself as a bit of a “stresshead” as she tends to worry about issues at work or at home. When she is stressed, she tends to have trouble sleeping and wakes often. At the moment she rates her stress levels as 9/10 and attributes most of this stress to her hot flushes.

Her energy levels are low at the moment – usually she describes herself as a 8/10 but at the moment is about 4-5/10. Karen also reports that her libido is “not great” at the moment, and that her husband would love you to treat this. Medical History

Karen is married with three children aged 15, 18 and 20 years old – all children live at home, with the eldest at university, and the younger children at secondary school. Karen works as a medical administrator in a private hospital. Her husband is a secondary school teacher. Karen is not currently taking any prescribed or over the counter medication, and generally tries to avoid medication. She has self-prescribed:

•  Swisse women’s multi – 1 mane for “energy” but not sure if it’s helping
•  Blackmores Fish Oil – 1 mane because it is “good for you”
•  Blackmores Vitamin C – 1 per day if she feels she is getting a cold.

Karen describes her general immunity as “good”. She experiences one or two colds per year, but these usually resolve in about a week. She sometimes gets a “bit of hayfever” in Spring with a runny nose and itchy eyes. She occasionally takes a “couple of Zyrtec”, but usually manages it with Garlic & Horseradish tablets. With the recent onset of Spring and changeable weather, Karen has taken Zyrtec 3-4 times in the past fortnight.

Karen recently had blood tests results:

1.  LDL 3.1mmol/L
2.  HDL 1.49 mm/l
3.  Triglycerides 1.7
4.  Ferritin 10 mg/mL
5.  Fasting blood glucose 5.3mmol/L

Karen comments that she has had a twitchy eyelid on and off for the last few weeks. Her tongue is slightly scalloped along the edges, and has a slight quiver. Nails have vertical ridging and break easily No history of migraines. Has occasional headache (1/30) – better for Panadol. Attributes these to dehydration. Musculoskeletal system

Karen mentions, in passing, that she has had some pain in her right shoulder for a few weeks. It is affecting her ability to hang out the washing and to reach high cupboards. She does not remember injuring it, but cannot reach above her head. She has had occasional issues with her joints, but these tend to respond well to rest and Osteopathic treatment. She has not had any treatment for her shoulder as she is too tired to arrange

Diet
Karen describes her diet as “pretty good. I try to avoid fats and eat lite products wherever possible”.
Breakfast: 60grams Special K, Skinny Milk 100mls, banana 12 grams coffee and milk 50ml

Skinny Milk; 2 sugars (10gm, white)

Morning tea: Full fat milk coffee 250 MLS sweet biscuit Tim Tam 1 or similar Oreo/Wagon Wheel (pick one)
Lunch: Sourdough white 55 grams, Nuttelex 15 grams (or margarine ), salad 60 grams, 30 grams

lite (25% reduced-fat) cheese, coffee 50 MLS Skinny Milk
Afternoon tea fruit 1/2 mango 100 grams, Tim Tam, 50 grams almonds Dinner 100 grams beef, 100 grams sweet potato, 50 grams green beans, korma curry sauce 100 MLS, 150 grams basmati rice ( all cooked weight); take away once a week (pizza or chicken & chips)

Water

200 grams vanilla lite Jalna yoghurt, banana 120 grams, Lindt dark chocolate 50 grams, dried dates x 4, about 4-5 glasses per day 250 mls water per glass

Soft drinks

Alcohol

Nil – just mineral water with dinner
2-3 glasses on Friday & Saturday, occasional glass of wine on other nights
(2-3/5) alcohol equivalent to 200 mls per night sweet white wine
Snacks Chocolate – 2-4 squares of dark chocolate (50 grams dark chocolate)
Has a “sweet tooth” and will eat sweet biscuits or cakes esp if tired

Red meat 3-4/7
Chicken 3/7
Fish rarely – hard to buy
Legumes rarely – not sure how to cook them

Exercise
Karen enjoys walking – usually walks her dog for about 30 mins most days, but lately has been too tired to get up. Feels worse for lack of exercise.
Sleep

Usually in bed by about 10.00pm and awake at 6.30am – wakes most nights to go to the toilet, but goes back to sleep quickly. However, has been feeling exhausted for last month or so and is going to bed at about 8.30 – falls straight to sleep, but wakes about 12.30 due to heat and sweat. Has trouble getting back to sleep – awake for an hour or two, and feels like just dozes until alarm goes off. Exhausted on rising.

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