case study
- The Patient
The subject of this case study is Mary Nelson. Mary Nelson is a 30 year old divorced female who lives in the suburbs with her 7 year old son, Robert and her 60 year old widowed mother. She is employed full-time as a legal secretary.
She was driving home from work one evening when a car crossed into her lane and hit her car head-on. Ms. Nelson was taken by helicopter to the nearest trauma center where she was stabilized and treated for multiple injuries. Her mother, Mrs. Richards, was listed as her emergency contact and was contacted. Mrs. Richards agreed to care for Ms. Nelson’s son until Ms. Nelson could do so herself.
- Injuries
Diagnostic tests confirmed multiple fractures, including her left ulna (arm) and left femur (Leg). Her jaw was severely fractured, she lost most of her teeth, and her left hand was crushed. She also experienced head injury and concussion.
III. Treatment history
Ms. Nelson received immediate trauma care to stabilize her. She was admitted to the hospital’s trauma unit. Ms. Nelson underwent multiple surgical procedures to repair her fractures. She has been in the trauma unit for several weeks. Her fractures are healing well, and her condition is stable. Her pain control is good on oral pain medication.
Your Patient today
Nutrition.
Ms. Nelson has lost weight since admission. Her jaw was wired shut to promote healing. She can only consume liquids and is prescribed high calorie liquid supplements but she does not like their taste. Her mother often brings milkshakes which she likes. She does not have much of an appetite. It is not yet known if her chewing, swallowing, or speech was affected.
Mobility
Mary Nelson has limited mobility due to her fractured femur. She also has difficulty moving her left arm and hand. Her severe hand injuries that limit her fine motor coordination and movement. The extent and permanency of these limitations are not yet known as she is still in the healing stage. She goes to OT and PT daily.
Communication
Ms. Nelson can’t speak because her jaw has been wired shut. Her ability to understand verbal communication is unaffected. She occasionally gets frustrated when people cannot understand her. She communicates verbally as best she can. She cannot write due to the injury to her left hand.
Psychosocial
Ms. Nelson exhibits hopefulness that she will be able to return to almost full functioning. She is able to participate in decision making about her care. She is worried about her ability to work after her recovery since she must support herself and her son. She is glad her mother is caring for her son but is worried about her son’s decline in school work. She feels powerless to help him and feels as if it is because of her. She is experiencing some shortness of temper and occasional mood swings since her accident and states she has no patience any more. She is generally pleasant toward staff and cooperative with her treatment. She expresses anger at the other driver who caused the accident and plans to file a lawsuit.
Ms. Nelson’s mother and son visit frequently. Ms. Nelson’s mother is taking care of Robert. She states this is working out well, although Robert is worried about his mother and his schoolwork is suffering. Ms. Nelson has several friends and co-workers who visit occasionally. She and Robert have no contact with her ex-husband.
Guidelines
Step II: Individual Work
- Focus on your selected role and your Standards of Practice in that role.
- Decide what patient needs you will focus on and be responsible for.
- Propose how you will meet those needs for/with the patient.
- Write at least 2 measurable goals for the patient.
- How will you help the patient to meet the goal? What is your Plan of Care?
- What coordination with other health professionals will be needed?
- How will you communicate with these other members of the healthcare team?
- What problems do you foresee, if any?
- How will you solve problems to provide the best care?
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