Clinical Case Studies for the Family Nurse Practitioner

Leslie Neal-Boylan

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9781118277850
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Clinical Case Studies for the Family Nurse Practitioner is a key resource for advanced practice nurses and graduate students seeking to test their skills in assessing, diagnosing, and managing cases in family and primary care. Composed of more than 70 cases ranging from common to unique, the book compiles years of experience from experts in the field. It is organized chronologically, presenting cases from neonatal to geriatric care in a standard approach built on the SOAP format. This includes differential diagnosis and a series of critical thinking questions ideal for self-assessment or classroom use.

Section 1: The Neonate

Case 1.1 Cardiovascular Screening Exam

By Mikki Meadows-Oliver, PhD, RN

Case 1.2 Pulmonary Screening Exam

By Mikki Meadows-Oliver, PhD, RN

Case 1.3 Skin Screening Exam

By Mikki Meadows-Oliver, PhD, RN

Case 1.4 Oxygenation

By Mikki Meadows-Oliver, PhD, RN

Case 1.5 Nutrition and Weight

By Mikki Meadows-Oliver, PhD, RN

Case 1.1 Cardiovascular Screening Exam

By Mikki Meadows - Oliver, PhD, RN

SUBJECTIVE

Joseph, a 10-day-old male, was brought into the primary care office for a weight check. He is accompanied by his parents. His mother is concerned about his feeding habits. She believes that he takes awhile to drink his formula – longer than his siblings did; and she also thinks that he sweats more than they did, even when he doesn’t feel warm.

Birth history: Significant for a 36-week gestation. His birth weight was 2600 grams. Because of his premature birth, Joseph was required be hospitalized for the first week of life in the Neonatal Intensive Care Unit (NICU). During his stay in the NICU, he was noted to feed without problems, maintain his temperature without assistance, and gain weight. His weight at discharge from the hospital 3 days ago was 2400 grams. Because of his premature birth status and his decreased weight, the family was told to follow up with the primary care provider in 3 days.

In the office today, his weight is 2490 grams. Further questioning about Joseph’s birth history reveals that the mother’s pregnancy was normal. She had no infections, falls, or known exposures to environmental hazards. She did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. During labor, she experienced a failure to progress, which resulted in her having a cesarean birth. The baby’s Apgar scores were 8 at 1 minute and 9 at 5 minutes.

Social history: Joseph was born to a single, 29-year-old mother. His father is involved but does not reside in the household. Joseph lives in an apartment with his mother and two other siblings (ages 2 and 4 years). The maternal grandmother (MGM) lives nearby and is able to help Joseph’s mother provide care. The family receives several governmental subsidies such as Women, Infants, and Children Supplemental Nutrition Program (WIC), Temporary Assistance for Needy Families (TANF), and Medicaid. Educationally, Joseph’s mother has a high school diploma. She works in a local retail store. Joseph’s father works in a manufacturing plant. The family has no pets. The MGM smokes but does not smoke in the home.

Diet: Breastfeeding ad lib with supplementation of a milk - based formula.

Elimination: 6 – 8 wet diapers daily with 3 – 4 yellow, seedy bowel movements.

Sleep: Sleeps between feedings.

Family medical history: PGF (age 54): diabetes mellitus, heart attack at age 50; PGM (age 53): healthy; MGF: deceased from stroke at age 47; MGM (age 54): asthma; mother (age 29): asthma; father (age 31): healthy; Sibling #1 (age 4): asthma; Sibling #2 (age 2): heart murmur.

Medications: Currently taking no prescription, herbal, or OTC medications.

Allergies: No known allergies to food, medications, or environment.

OBJECTIVE

Vital signs: Weight: 2490 grams; length: 44 centimeters; temperature: 37° C (rectal).

General: Alert, well-nourished, well-hydrated baby.

Skin: Clear with no lesions noted; no cyanosis of lips, nails, or skin; no diaphoresis noted; skin turgor with elastic recoil.

Head: Normocephalic; anterior fontanel open and flat (2 cm × 3 cm); posterior fontanel open and flat (1cm × 1cm).

Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted.

Ears: Pinnate normal; tympanic membranes gray bilaterally with positive light reflex.

Nose: Both nostrils patent; no discharge.

Oropharynx: Mucous membranes moist; no teeth present; no lesions.

Neck: Supple; no nodes.

Respiratory: RR = 28; clear in all lobes; no adventitious sounds noted; no retractions; no deformities of the thoracic cage noted.

Cardiac/Peripheral vascular: HR = 120; thrill noted in pulmonic area; continuous, systolic, grade 3 heart murmur noted on exam in the pulmonic area of the chest with both the bell and diaphragm; no radiation of the murmur to the back or axilla; brachial and femoral pulses present and 2+ bilaterally.

Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly Umbilical cord is in place with no signs and symptoms of infection.

Genitourinary: Normal male; testes descended bilaterally; circumcision healing well.

Back: Spine straight.

Extremities: Full range of motion of all extremities; warm and well perfused; capillary refill <2 seconds. Negative hip click.

Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, plantar, palmar, and Babinski reflexes.

CRITICAL THINKING

Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?

—Chest radiograph

—Echocardiogram

—Electrocardiogram

What is the most likely differential diagnosis and why?

—Patent ductus arteriosus

—Venous hum

—Atrioventricular malformation

What is the plan of treatment, and what should be the plan for follow - up care?

Are there any referrals needed?

Does this patient’s psychosocial history influence how you might treat the patient?

What if this baby was a baby girl?

What if this baby had been born full term?

What if this baby had been born at a higher altitude?

Are there any standardized guidelines that you should use to assess or treat this case?

RESOLUTION

Diagnostics tests: ECG results are normal. CXR is normal. Echocardiogram reveals a patent ductus arteriosus.

What is the most likely differential diagnosis and why? Patent ductus arteriosis (PDA):

PDA is the most common congenital heart defect seen in premature infants. Intravenous indomethacin (the drug of choice) often stimulates closure of the ductus arteriosus in premature infants. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may also be used to stimulate closure of the PDA. Prophylaxis for infective endocarditis is required until the PDA is closed. No long - term sequelae usually occur if the PDA is treated before pulmonary vascular disease develops.

What is the plan of treatment, and what should be the plan for follow - up care?

• Monitor weight and other growth parameters at subsequent visits.
• Provide emotional support. Allow the parents to verbalize their concerns about their baby’s health maintenance. Facilitate mother-infant attachment.
• Return to clinic in 4 days for 2-week, well-child check and weight check.
• Discuss signs and symptoms of increased work of breathing (increased respiratory rate; intercostals retractions; nasal flaring) with parents and when to call the office (decreased by - mouth intake; decreased urine output; increased work of breathing; increased temperature ≥100.4°F).

Are there any referrals needed?

• Refer to cardiology for consideration of medication or surgery to aid in the closure of the duct.
• Consider referral for genetic counseling regarding future conception.

Does the patient’s psychosocial history influence how you might treat the patient?

Since this mother is a single mother with two other children in the home, it is important for the health care provider to ensure that the family is referred to the appropriate social service agencies. The family should be referred to the Women, Infants, and Children (WIC) program for supplemental food and infant formula services. Mothers with a lower socioeconomic status have been found to be more at risk for postpartum depression, so it will be important for the health care provider to screen this mother for postpartum depression at subsequent visits throughout the baby’s first year of life.

What if this baby was a baby girl?

Girls have been noted to be affected by patent ductus arteriosus twice as often as boys.

What if this baby had been born full term?

Functional closure of the ductus occurs within 15 hours of birth in a normal full - term infant, but true closure with the inability to reopen takes about 3 weeks.

What if this baby had been born at a higher altitude?

Babies born at higher altitudes are at increased risk for a patent ductus arteriosus.

Are there any standardized guidelines that you should use to assess or treat this case?

There are no standardized guidelines located in the literature for the assessment and/or treatment of patent ductus arteriosus.

REFERENCES AND RESOURCES

Giliberti, P., De Leonibus, C., Giordano, L., & Giliberti, P. (2009). The physiopathology of the patent ductus arteriosus. The Journal of Maternal -Fetal & Neonatal Medicine, 22(Suppl. 3), 6–9.

Katakam, L., Cotton, C., Goldberg, R., Dang, C., & Smith, P. (2010). Safety and effectiveness of indomethacin versus ibuprofen for treatment of patent ductus arteriosus. American Journal of Perinatology, 27, 425–429.

Lin, Y., Huang, H., Lien, R., Yang, P., Su, W., Chung, H.,... Liu, W. (2010). Management of patent ductus arteriosus in term or near - term neonates with respiratory distress. Pediatrics & Neonatology, 51, 160–165.

Taggart, N., Cetta, F., O’Leary, P., Seward, J., & Eidem, B. (2010). Left atrial volume in children without heart disease and in those with ventricular septal defect or patent ductus arteriosus or hypertrophic cardiomyopathy. The American Journal of Cardiology, 106, 1500–1504.

Tavera, M., Bassareo, P., Biddau, R., Montis, S., Neroni, P., & Tumbarello, R. (2009). Role of echocardiography on the evaluation of patent ductus arteriosus in newborns. The Journal of Maternal-Fetal & Neonatal Medicine, 22(Suppl. 3), 10–13.

Case 1.2 Pulmonary Screening Exam

By Mikki Meadows - Oliver, PhD, RN

SUBJECTIVE

Caitlin, a 12-hour-old female, was born at home via planned home birth. She was brought into the office for an initial health maintenance visit. On initial examination, she was found to have rapid breathing when the office nurse weighed her. Caitlin is accompanied by both parents. There are no parental concerns.

Birth history: Caitlin is the product of a 40-week gestation. She was delivered vaginally at home by a certified nurse midwife. During the pregnancy, Caitlin’s mother had no falls, infections, or known exposures to environmental hazards. She did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. The total labor duration was 2 hours. Caitlin’s birth weight was 3380 g and her Apgars were 9 at 1 minute and 9 at 5 minutes.

Social history: Caitlin was born to a 37-year-old mother. Caitlin is the second child and has a 3-year-old sibling. She lives at home with both parents and her older sibling. The family employs an au pair who also resides in the home. Both parents are college educated. The mother works as a research assistant, and the father works as an accountant. There are no pets or smokers in the home.

Diet: Breastfeeding ad lib, but mother feels that Caitlin is having problems latching on. Colostrum is present. Milk has not come in yet.

Elimination: Urinated at birth, and has had 3 wet diapers since that time. Passed meconium at 10 hours of age.

Sleep: Sleeps between feedings.

Family medical history: PGF (age 67): sarcoidosis; PGM (age 63): healthy; MGF (age 64): Type 2 diabetes; MGM (age 64): history of MI at age 63; mother (age 37): healthy; father (age 42): healthy; Sibling #1 (age 3): healthy; history of bronchiolitis.

Medications: Currently taking no prescription, herbal, or over - the - counter medications.

Allergies: No known allergies to food, medications, or environment.

OBJECTIVE

Vital signs: Weight in the office today is 3360 g; length: 48 cm; temperature: 37.2° C (rectal); pulse oximeter reading: 95% on room air.

General: Alert, active baby.

Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; skin turgor intact.

Head: Molding present; anterior fontanel open and flat (2 cm × 2 cm); posterior fontanel open and flat (1cm × 1cm).

Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted.

Ears: Pinnae normal; Tympanic membranes gray bilaterally with positive light reflex.

Nose: Both nostrils patent; no discharge; mild nasal flaring.

Oropharynx: Mucous membranes moist; no teeth present; no lesions.

Neck: Supple; no nodes.

Respiratory: RR = 68; crackles present in lower lung fields bilaterally; mild intercostal retractions; no grunting. No deformities of the thoracic cage noted.

Cardiac/Peripheral vascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2 + bilaterally.

Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly Umbilical is cord in place with no signs and symptoms of infection.

Genitourinary: Normal female genitalia.

Back: Spine s...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Contributors
• Preface
• Acknowledgments
• Introduction
• Abbreviation
• Section 1: The Neonate
• Section 2: The Infant
• Section 3: The Toddler/Preschool Child
• Section 4: The School-Aged Child
• Section 5: The Adolescent
• Section 6 Women’s Health Cases
• Section 7: Men’s Health Cases
• Section 8: General Adult Health
• Section 9: The Older Adult
• Index