Theresa Samuels Case Study

Theresa Samuels Case Study

Theresa Samuels, a 72-year-old-retired African American woman, arrives to the community health center for her three-month follow-up appointment. T.S., has a medical history of diabetes, type 2, osteoporosis, secondary hypertension, and dyslipidemia. Due to the death of her only daughter from COVID-19, 4 months ago, T.S., has become the sole caregiver of her three teenage grandchildren. Troubled with unexpected finances, T.S., conveys to the nurse the immense pressure and stress she has been experiencing since the death of her daughter.

The patient had her bloodwork completed at LabCorp prior to her appointment. The nurse conducts a comprehensive assessment and notes the following objective and subjective data:

Objective data:

Blood pressure = 140/90

Heart rate = 92

Respiratory rate = 22

Pulse oximetry = 94% on room air

Present weight and height= 210 lb. (95.2 kg) / 5’5

 

Physical Assessment

· HEENT=Pupils equal, reactive, responsive to light and accommodation.

· Cards = Regular rate and rhythm; S1S2; Grade 1/6 systolic murmur; 2+ pitting edema bilateral lower extremities; +2 pedal pulses bilaterally; +2 radial pulse bilaterally; no carotid bruit auscultated.

· Resp = Respiratory rate 22 bpm; mild wheeze noted in bases bilaterally; all other lung fields clear to auscultation

· GI = Bowels normal; present in all 4 quadrants

· Skin = Skin is dry and intact; not rashes or skin lesion noted

· GU = Voids frequently; urine output is <30mL/hr; tea-color urine

· Neuro = Intact; oriented to person/place/time/situation (X4); motor and sensory function within normal limits

 

Labs

· Hemoglobin A1C = 7.5%

· Cortisol level = 35 mcg/dL

· Fasting blood glucose = 132mg/dL

· Erythrocyte sedimentation rate (ESR) = 45 mm/hr

 

Subjective data:

· Complains of muscle aches and pains with movement, and some tingling in the lower extremities

· She states that her vision is blurry at times

· Most of the time she is compliant with her medications but will sometimes avoid taking Hydrodiuril to keep from having to go to the bathroom so often

· Sleeping 3 – 4 hours a night

· Eats a candy bar if her blood glucose is less than 120 mg/dL

 

 

 

Medication Reconciliation

Crestor 40 mg Daily	Diltiazem 180 mg PO Daily
Lotensin 10 mg PO Daily	Metformin ER 500 PO Daily
Cholecalciferol 25 mcg PO Daily	Calcium 1000 mg PO Daily
Hydrodiuril 12.5 mg PO Daily	NPH 10 units BID

 

During the health assessment, the nurse offers T.S., the yearly influenza vaccine; but T.S., declines, stating, “The flu shot will cause me to get the flu and I just don’t have the time to be