Advance health assessment and clinical diagnosis in primary care
Responses to classmates must consist of at least 350 words (not including the greeting and the references), do NOT repeat the same thing your classmate is saying, try to add something of value like a resource, educational information to give to patients, possible bad outcomes associated with the medicines discussed in the case, try to include a sample case you’ve seen at work and discuss how you feel about how that case was handled. Try to use supportive information such as current Tx guidelines, current research related to the treatment, anything that will enhance learning in the online classroom. Insomnia Sleep loss is one of the most underestimated cause of a decreased quality of life and humans need for sleep varies from person to person (Alhola & Polo-Kantola, 2007). The average sleep length is 7 to 8.5 hours. Sleep is important for body restitution, energy conservation, thermoregulation, and tissue recovery. Sleep is also essential for cognitive performance and memory consolidation. Sleep loss activates the sympathetic nervous system which can increase the blood pressure and cortisol secretion. Sleep loss is also associated with impaired immune function and metabolic changes such as insulin resistance, decline in cognitive performance and change in mood (Alhola & Polo-Kantola, 2007, Dains et al, 2016). The most common sleep disorder is insomnia. It is characterized by difficulty falling asleep, difficulty staying asleep, waking up too early or complaints of waking feeling unrefreshed. Acute insomnia refers to difficulty falling asleep or remaining asleep at least three nights a week for less than a month. Chronic insomnia are the same symptoms and a daytime complaint of for example fatigue, poor concentration, interference in social and family activities lasting for one month or longer (Lewis et al, 2014). Subjective data: Presenting 71-year-old JD a Caribbean immigrant. She reports an inability to sleep since the loss of her husband a week ago from a tragic accident. He was 73 years old. They were married for 45 years. He was her best friend. They have 2 adult children Karen 44 and Thomas 42 each live about 30 minutes away. Mr. JD worries about the funeral arrangements and life after the burial. Chief complaint- “I can’t sleep since my husband died a week ago”. OLCART- Onset a week ago after husbands’ death. Location not applicable. Characteristics- unable to fall asleep and stay asleep. Aggravating not applicable. Relieving nothing has made her sleep not even a warm glass of milk. Treatment did not take medicine for not sleeping. Past medical history. Diagnosed with hypertension 10 year ago takes metoprolol 25mg daily. Past surgical history: Had hysterectomy for fibroids 21 years ago. Family history Mother had hypertension and diabetes still alive at 93 lives with younger sibling. Dad died of a heart attack at age 65. Client denies smoking, using drugs or alcohol. A retired teacher with a doctorate in education. Attends the Catholic church. Is a very active member. Plays the piano. Takes Calcium and Vitamin D supplements. Allergies: none reported. Review of systems: Eyes-uses reading glasses. Ears nose and throat denies any change in hearing, no nasal congestion, no pain in throat. Cardiovascular: hypertension takes Metoprolol 25mg daily. Denies chest pain and shortness of breath. GI reports normal bowel movements, no change in wieght. Denies burning on micturition and incontinence. Musculoskeletal: denies pain in joints. Denies skin rash or other lesions Neurological: mild headache on and off. Did not take any meds for headache. Denies thoughts of hurting herself. Endocrine: denies thyroid problems and any other hormonal disorder. Objective data: Client sitting upright in chair. Appropriately dressed. Seemed distracted looking in the distance. Oriented to time place and person and situation. Head, ear, nose and throat remarkable. Eyes uses reading glasses. Neck no enlarged lymph nodes felt. Chest: symmetrical, vesicular breaths heard bilaterally. No adventitious sound heard. Cardiac sounds normal S1, S2, no murmur. GI: remarkable, Genitourinary remarkable, Skin remarkable. Diagnoses: Acute insomnia possibly related to grieving process. Treatment: Consider Melatonin 5 mg for 5 days 1 hour before bedtime. Avoid strenuous activity within 6 hours of sleep. Do not go to bed hungry. Review after one week. Consider Valium and psychiatric consultation (Lewis et al, 2014). Diagnostic test: The diagnosis of insomnia is made based on the patients report and clinical evaluation. The clinician may not symptoms of decreased attention and cognition as a result of loss of sleep. Other test can be done to evaluate organ functions and state of health include basic metabolic profile (BMP), complete blood count (CBC). Reference: Alhola, P., & Polo-Kantola, P. (2007). Sleep deprivation: Impact on cognitive performance. Neuropsychiatric disease and treatment, 3(5), 553–567. doi: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656292/ Dains, J.E., Baumann, L.C. & Scheibel, P. (2016) Advance health assessment and clinical diagnosis in primary care. (5th edition. Pp. 431-443). Mosby Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher. L., (2014) Medical-surgical nursing: Assessment and management of clinical problems (10th ed. PP 101-104). Elsevier
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