Unfolding Case Study C.B. is a 45-year-old Hispanic female with a…

Question Answered step-by-step Unfolding Case Study C.B. is a 45-year-old Hispanic female with a… Unfolding Case StudyC.B. is a 45-year-old Hispanic female with a history of type II diabetes who came to the emergency department (ED) triage window because she felt crummy; complaining of a headache. She describes the headache as Bilateral non-pulsatile pain lasting 12-24hrs. The headache preceded by tight feeling high in neck. She rates the headache as a 5 in a 0 to 10 scale. She took Tylenol but now it did not help. She states that light & noise make it worst. She reports having sinus headaches in the past, but not like this headache, the only thing that helped was going to bed. She denies weakness but states that she feels very anxious “like something back is going to happen” because she feels dizzy.What clinical data is RELEVANT and must be NOTICED as clinically significant by the nurse? What did you noticed?Medical Hx. She has been quite healthy except for recurrent sinus headaches. These headaches began approximately 15 years ago and at least initially, nearly always responded to antibiotics. The headaches were located over the forehead and cheeks. She rarely noted fevers or chills but would often have clear nasal discharge and nasal congestion. Her stomach was also upset, which she attributed to postnasal drainage. She also states that sometimes her jaw pops and is painful. She states that her sinus pain has been worse since she has a recent “flu” with nasal congestion.What additional clarifying questions do the triage nurse need to ask C.B. to determine if her cluster of physical symptoms is consistent with an acute event?Social Hx: C.B . has been under some stress at work recently. She was promoted one year ago and has had to work longer hours. The company has been downsizing and several colleagues have been laid off. While she doubts her job is in jeopardy it has been upsetting, and has increased everyone’s work load. She never married and is not involved with a sexual partner. C.B does not smoke, has a rare glass of wine (CAGE -) and never used drugs. She drinks three cups of coffee per day.FHx:Father – alive and wellMother, age 75, DMMaternal aunt died of a ruptured brain aneurysmThe patient’s concern, if asked, of a brain aneurysm. Her aunt died of a ruptured brain aneurysm.How will your answer the patients concern?What clinical data is RELEVANT and must be NOTICED as clinically significant by the nurse?You quickly do the vital signs.Results:B/P 140/90P. 102O2 sat: 98% on room airRR: 30T: 97.0What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse?Physical ExaminationWhat are the main physical examination skills you will need to provide safe care for this patient?What body system(s) will you assess most thoroughly performing a FOCUSED assessment based on the primary/priority problem? Identify correlating specific nursing assessments.How do you to establish the headache acuity using the physical assessment and why? (you must offer the rational. For example, I will cranial nerve examination to rule out stroke).What will be the Red Flags that will make you seek immediate referral for this patient?There is any other information that you will need to decide the level of acuity? Health Science Science Nursing NUR 3069 Share QuestionEmailCopy link Comments (0)