Assessment Task:
Karen Case Study Nursing Assessment Answer

Learning Outcomes

A. Complete a detailed biomedical and holistic analysis of the case

B. Develop clinically relevant therapeutic goals, and treatment strategy including patient prescription

C. By reviewing the evidence compose clinically relevant resource material including therapeutic summaries

 

Prepare:

  • Following the defined critical case analysis process, assess the case provided below.
  • Refer to class practice, notes, module readings, subject textbooks and associated peer-reviewed journal articles to obtain the appropriate information for a thorough case analyses
  • Nutrition and Western Herbal Medicine Students are not required to include iridology assessment or analysis.

Structure:

Following the steps outlined case critical analysis process:

  •  Construct a holistic/naturopathic schematic (mind-map) outlining case facts, practitioner theories, and mechanisms of action connecting the critical case understanding (no word count attributed to this attachment). 
  • Provide a detailed yet concise section introducing and substantiating the holistic understanding of the case as reflected in the mind map
  • Construct a detailed yet concise biomedicalization of the pathophysiology, aetiology, diagnosis and conventional medical treatment of the condition.
  •  Provide a differential diagnosis for this case
  • Analyse the diet and nutritional status of the patient and provide a summary within the report. Add formal dietary analysis as an attachment (no word count attributed to this attachment)
  • Provide a concise referenced table analysing observations, anthropometrics and signs (no word count attributed to this table)

Provide clearly constructed and prioritised treatment aims which align and reflect your critical understanding of the case as defined in the above sections. Provide four short terms and one long term treatment aim. Ensure to formulate your aims using the appropriate structure:
o What are you (as the clinician) trying to achieve?
o Where are you trying to achieve this? (body system, area)
o How? What is the mechanism of action (physiology) that you are seeking to modify?
o Actions
o Modalities(be specific)

  • Outline an evidenced-based prescription addressing your critical understanding of the case as reflected in the above sections, specifically your treatment aims need to be covered here, actions. Substantiate your prescription choices with evidence for the
  • therapeutic mechanism of action as reflected in your aims and therapeutic dose. From there you can recommend a product &/or herbal combination (tea, tincture, tablet).
  • Note in this section you provide a rational evidence-based and therapeutic dose for your individual selected nutrients &/or herbs – not for a product or combination e.g., justify the use of Magnesium in your case not MagOptiCell; justify Hypericum, not Nervatone.
     

Case Details

Karen is a 51-year-old woman who has come to you for help with her hot flushes. She is experiencing 5-6 hot flushes during the day in which she will suddenly feel the heat rising from her feet to the top of her head – she becomes red in the face and sometimes on her neck and chest, and this is sometimes accompanied by sweating. At night, she has been waking up 3-4 times per night bathed in sweat and has trouble getting back to sleep. She needs to change her nightclothes a couple of times per night. These symptoms have been gradually worsening over the last 2-3 months. Karen also reports vaginal dryness and discomfort in recent months. 

Menstrual History

Karen underwent menarche at age 12. Her periods have been regular throughout her life – every 28 – 30 days. She has occasionally experienced some bloating in a couple of days prior to her period, and occasional lower abdominal cramping – but comments that these have been fairly minor symptoms and not required any treatment or painkillers. She bled for 5-6 days and described her flow as “average”. Karen’s last menstrual period was about 6 months ago, and in the year prior to that was a little irregular, with her skipping a couple of periods. Her mother underwent menopause at around 50 years of age.

Nervous system

Karen describes herself as a bit of a “stressed” as she tends to worry about issues at work or at home. When she is stressed, she tends to have trouble sleeping and wakes often. At the moment she rates her stress levels as 9/10 and attributes most of this stress to her hot flushes. Her energy levels are low at the moment – usually, she describes herself as an 8/10 but at the moment is about 4-5/10. Karen also reports that her libido is “not great” at the moment and that her husband would love you to treat this.

Medical History

Karen is married with three children aged 15, 18 and 20 years old – all children live at home, with the eldest at university, and the younger children at secondary school. Karen works as a medical administrator in a private hospital. Her husband is a secondary school teacher. Karen is not currently taking any prescribed or over the counter medication, and generally tries to avoid medication. She has self-prescribed:

Swiss women’s multi – 1 mane for “energy” but not sure if it’s helping

Blackmores Fish Oil – 1 mane because it is “good for you”

Blackmores Vitamin C – 1 per day if she feels she is getting a cold.

Karen describes her general immunity as “good”. She experiences one or two colds per year, but these usually resolve in about a week. She sometimes gets a “bit of hayfever” in Spring with a runny nose and itchy eyes. She occasionally takes a “couple of Zyrtec”, but usually manages it with Garlic & Horseradish tablets. With the recent onset of Spring and changeable weather, Karen has taken Zyrtec 3-4 times in the past fortnight.

 

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  • Uploaded By : Mitchell Lee
  • Posted on : November 18th, 2018

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