Luciana Gonzalez Comprehensive Health Assessment

Luciana Gonzalez Comprehensive Health Assessment

Ihuman case studies help students to get to interview patients and get to the root cause of their health review. Below is an example of an Ihuman case study for Luciana Gonzalez

Situation:Luciana Gonzalez is a 32 y/o female admitted for a comprehensive health assessment.

She is 5'4 (163 cm) and weighs 185.0 lb (84.1 kg). BMI is 31.8.

Background:BP: 124/82 normal. Pulse: 56 bpm. Respirations 22 breaths per minute, normal effort. A&O x4. SpO2 98% on room air. Temperature 98.8° Fahrenheit. Patient stated she has difficulty urinating with pain and discomfort. She states the pain is 2/10. She has the sensation of needing to urinate more than usual but expels less urine at times. She has a weak stream, normal color urine, with no froth. Patient does not need assistance to ambulate to the bathroom or to urinate. No blood, pus, or kidney stones present in urine. Patient has been experiencing these symptoms for the past couple of days. Patient has a past medical history of dysuria and urinary

 

What 2 observations did you notice initially when caring for this patient?

Nevus flammeus, the patient is Hispanic

1. Report:  bacterial in urine, dysuria, pain peeing, more frequent, weak stream felt that 

bladder was not fully empty.

a. How did you decide what to report and to whom? The assessment finding that were 

abnormal.

Labs findings and pain assessment, PQRSTU. Reported to MD.

b. What was the urgency level?

Not very argent but need routine check on pain.

c. Was there an organized way you reported it? We Used SOAP note analysis.

2. Execute: We reported to the doctor, about the bacteria in urine level,

3. What immediate independent actions could you do to manage the situation? assess pain 

and give pain meds if needed. 

4. Prioritize:

a. Did this situation require immediate attention, or could it wait for routine assessment in 

reporting?   It Could wait for the doctor to prescribe pain meds and antibiotic

b.

5. Anticipate

a. What needs would you anticipate in this situation? pain meds, and antibiotic

b. What could you do or how would you prepare for those needs?  Ask the MD for 

medication order and administered as ordered.

c. How would you access resources? Interrelationship with provide.

6. Rationalize/reasoning

a. What was the rationale/reasoning behind your actions?

 To treat possible infection and pain

7. Evaluate:

a. What are the primary areas of focus as you continue to manage this patient?

Focus on infection prevention of UTI

8. Discuss:

a. After self-reflecting and debriefing, how would you manage this patient in the future?

Teach back on how to prevent UTI recurrence, proper hygiene

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