Nursing Grand Rounds Lauri Gallimore BS, RN Dartmouth College [Footer] Nursing Grand Rounds Lauri Gallimore BS, RN Dartmouth College June 2, 2018

[Footer] LEARNING OUTCOMES To examine systematically a specific patient’s episode of care by reviewing pathophysiology, labs, imaging, differential diagnoses and nursing care provided. Provide a take away message to support and strengthen nursing care practices. Provide opportunity for professional development.

CASE STUDY #1 DEMOGRAPHICS 19 year old female First year student [Footer] CASE STUDY #1 DEMOGRAPHICS 19 year old female First year student From Washington State Asian, Pacific Islander PAST MEDICAL HISTORY Hip injury in 2005 No PSH After hours visit 10/6/17, admitted . After hours visit 3/1/18, admitted After hours visit 3/12/18, admitted

10/6/2017 After hours Nurse Visit (2:15 AM) [Footer] 10/6/2017 After hours Nurse Visit (2:15 AM) Chief Complaint: Nausea, vomited x 3, passed out x2, denies diarrhea. Reports she just got her period for the first time in 6 months (has always been irregular), and that the nausea occurred during an exam she was taking that ended at 10:30PM. VS: Temp- 36.5 Resp- 16 Sitting: BP 121/72 HR 65 Standing (1 minute): 107/59 HR 87 Positive postural change Abdominal exam: non distended, normoactive bowel sounds in all quadrants, no guarding, no rebound tenderness. Pain is a 4/10 LLQ with palpation. Admitted to Inpatient Nursing Department (IPD) for monitoring and supportive care. Ondansetron 8mg at 8:50 AM VS show + postural change HR increases from 66 to 110 MD reviews (unable to examine: pt asleep) and recommends Ondansetron and PO hydration 14:50 c/o nausea & headache. Receives ondansetron 8mg & Tylenol 650mg. Tolerating fluids and crackers Requests to be discharged Pt does not respond to a “just checking” message (10/7) and does not seek any care until next after hours visit 3/1/18

3/1/2018 After hours Nurse Visit (9:25 PM) [Footer] 3/1/2018 After hours Nurse Visit (9:25 PM) Chief Complaint: Nausea & vomiting, denies diarrhea. VS: Temp=36.8 Resp=18 Lying BP=117/78 HR=79 Standing BP=119/80 HR=84 WNL Pt reports having a migraine for the past 4 days, dizzy, passed out 3 times (unwitnessed) nausea, vomiting , and abdominal pain. Abdominal Exam: Non distended, normoactive bowel sounds in all quadrants, no guarding, + pain left side of abdomen with palpation. Able to move head side to side, chin to chest, denies photophobia. Admit to IPD for monitoring & support. Ondansetron 8mg & Tylenol 650mg at 9:50PM. 3/2/18 9:00 AM MD evaluation: Reports consistent history to MD. Physical exam benign, all WNL, including abdominal exam. Reports poor sleep due to exams ASSESSMENT: Migraine & Nausea, ? Gastritis. PLAN: CBC, CMP, U/A, Toradol 30mg IM, Ranitidine 150mg 1 cap BID. Reports headache relief from Toradol, but continues to c/o abdominal discomfort (7/10) and nausea. Difficult blood draw, unable to obtain CMP

IPD admission 3/1/2018 cont’d [Footer] IPD admission 3/1/2018 cont’d LABS Specific gravity= 1.020 WBC= 7.9 H/H=12.6/39.4 PLT=219 Appetite is poor, but encouraged to drink. Reports to nurses that she is feeling better (3/2 8:00PM). She goes out to dinner with friends and returns at 9:30PM. Headache is a 5/10, states that abdominal pain is better. Sleeps all night with no complaints. Awakes 3/3, complaining only of a sore throat MD eval: Headache & abdominal pain improved, now c/o a sore throat. Throat is red, enlarged tonsils, no exudate, no lymphadenopathy. RST- negative. Pt is requesting discharge. MD encourages patient to get more sleep, increase hydration, discussed access and red flags. Patient left unit without alerting her nurse, resulting in her not receiving any discharge teaching/instructions.

ED visit 3/11/2018 8:00AM Morphine 4mg IV, IVF, Toradol15mg, [Footer] ED visit 3/11/2018 8:00AM Pt presents wit Abdominal pain, specifically left flank pain. Pt states that pain began last night, but she has had it intermittently since the Fall. Symptoms usually last 30 minutes, but currently has been all night. Episodes can occasionally coincide with exams. Associated symptoms include an episode of syncope, nausea, vomiting and gross hematuria. She noted irregular menses for several months, which do not seem to correlate with symptoms. PE is remarkable for LUQ, LLQ Abdominal tenderness, nausea & vomiting, flank pain & hematuria. Pt denies dysuria. Morphine 4mg IV, IVF, Toradol15mg, Renal ultrasound, CBC, CMP and UA, urine hcg Labs & U/S are WNL. Pt diagnosed with presumed stress reaction, with a low suspicion for other acute intra-abdominal pathology, requiring further imaging. Pt discharged with a prescription for Ondansetron 4mg ODT, and told to follow up with Dartmouth College Health Service.

3/12/2018 After Hours Nurse Visit (4:30 AM) [Footer] 3/12/2018 After Hours Nurse Visit (4:30 AM) Chief complaint: Abdominal pain for 24 hours, recently seen in ED, nausea, denies diarrhea. Pt reports hematuria and occasional dysuria Abdominal exam is remarkable for LLQ tenderness with palpation, guarding, no rigidity or rebound tenderness. + CVA tenderness. Ondansetron 8mg administered at 5:00 with good effect. Admit to IPD Nursing thoughts & concerns Nursing report to MD- Concern about abdominal exam & pain. MD exam 9:00AM: Afeb, VSS Pt reports consistent symptoms to MD. ED visit reviewed. 5/5 tenderness left side of abdomen, + guarding, + rebound, 4/5 CVAT on left side, no peritoneal signs. Poor appetite but drinking fine. Under a lot of stress related to finals. Reports a “bad cold” over the past few weeks. Symptoms have resolved, but cough lingers. Denies SOB, or chest pain, headache, ST.

Considerations Thoughts? [Footer] Considerations Thoughts? Patient as an accurate historian Patient health history When patients share different information with different providers Consistency in symptoms Cultural considerations Being aware of bias in medical diagnosis Do her visits offer any similarities? Differential diagnoses Next steps (labs/imaging) Pt reports history of migraines and irregular menses, yet not on health history

IPD admission # 3 continued 3/12/2018 [Footer] IPD admission # 3 continued 3/12/2018 CBC, CMP, Amylase, Urine for GC/CT and culture., CXR and Pelvic U/S CBC and CMP were WNL, urine for GC/CT- negative, urine culture- contaminated CXR- negative Pelvic ultrasound- Resolving hemorrhagic cyst on the left ovary, small amount of fluid and increased pain. Patient left the next day to fly home for Spring break, and reports feeling much better. She is managing her discomfort with Tylenol.

Nursing considerations, implications and take aways [Footer] Nursing considerations, implications and take aways Nurses often have the benefit of spending more time with patients, allowing them to obtain important information or observations that can be shared with the provider, aiding in the diagnostic process.

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