Jenny G., a 48-year-old recovering IV drug abuser, presents with general malaise, anorexia, abdominal pain, and slight jaundice. She is currently staying in a women’s shelter and looking for a job. She is divorced, with two grown children whom she hasn’t been in contact with for years.
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CC: “When I was on drugs, I felt fine. Now that I’m clean, I feel crappy.” Lab results: Elevated ALT, Hepatitis C antibody positive, Hepatitis A antibody positive.
Answers to Questions
What additional subjective data do you think the patient will share?
The patient is expected to share her general lifestyle habits, including dietary issues. Besides, she might speak more about her children and her desire to get in touch with them. Moreover, she could dwell upon her possible job.
What additional objective data will you be assessing for?
It is necessary to access her general health, skin, hair, nails, head, eyes, ears, nose, mouth, throat, neurologic system, endocrine system, breast, respiratory system, respiratory system, peripheral vascular system, hematologic system, musculoskeletal system, urinary system, genital system. This information is obtained from the patient’s words. Besides, it is important to discuss her sexual health (Gordon, 2014).
What National Guidelines are appropriate to consider?
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It is appropriate to consider National Guidelines for hepatitis C. It includes clinical management, tests, and treatment. Besides, it focuses on its prevention and avoidance of transmission.
What tests will you order?
The following tests are necessary: a biochemical blood test, urine test, blood test for virus hepatitis markers, lipidic profile, and protein metabolism test. These tests are critical to consider the diagnosis. It is not possible to diagnose the patient with certain diseases without the results (Ackley, Ladwig, & Makic, 2016).
Will you be looking for a consult?
A consult appears to be necessary. It is reasonable to discuss the situation with a medical specialist. Besides, it might be wise to address a psychotherapist.
What are the medical and nursing diagnoses?
Medical diagnoses might be hepatitis A, hepatitis C, and anorexia. However, it is possible to state the diagnoses only after the tests are ready. Nursing diagnoses are malaise, abdominal pain, slight jaundice, and poor nutrition (Ackley et al., 2016).
Are there any legal/ethical considerations?
There are some ethical considerations. It is obvious that the patient is suffering from an emotional disorder. Thus, it is important to gently suggest addressing a psychotherapist.
What is your plan of care?
As for a medical plan of care, it is necessary to examine the patient, evaluate the test results, and prescribe either additional tests or treatment. As for a nursing plan of care, it is necessary to make an assessment and to prescribe necessary tests. Complementary therapy is a special diet. In the case of hepatitis, it implies a normal consumption of carbohydrates and proteins, with a certain limit of fats. It is necessary to exclude food that contains purine, extractive substances, cholesterol, ether oils, sorrel acid, and fat products. It is important to add food that is rich in cellulose, pectins, and lipotropic elements, as well as liquids (Urden, Stacy, & Lough, 2017).
Are there any Healthy People 2020 objectives that you should consider?
As for Healthy People 2020 objectives, it is necessary to consider the programs of nutrition and weight status and of health-related quality of life and wellbeing. Since the patient does not abuse drugs anymore, the program of substance abuse is not applicable. Besides, the program of sexually transmitted diseases does not take into account any types of hepatitis.
Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting her and the family involved in the care to reach optimal health?
Based on the Circle of Caring, in order to reach optimal health, a psychotherapist should get involved in the situation. Since the patient has some emotional problems, the assistance of a mental specialist is critical. Besides, it might be important to try to unite the patient with her children, who are supposed to take care of her. Thus, it might be reasonable to look for the patient’s children and organize a set of meetings with the patient and the specialist. It is important to persuade the children that their mother needs them.
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What is additional patient teaching needed?
The patient should be taught how to cope with the disease. She should know what medicine to take when to take it, what to eat, and what physical activities to undertake. Besides, it is critical to be aware of how to avoid transmitting the disease to other people and how to live a full life with such a diagnosis.
What billing codes would you recommend?
As for the billing code, it might be recommended to use Current Procedural Terminology (CPT). It states the diagnosis and describes procedures. Besides, it can be accepted when it comes to payment by third parties.
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2016). Nursing diagnosis handbook: An evidence-based guide to planning care. Maryland, MO: Elsevier.
Gordon, M. (2014). Manual of nursing diagnosis. Boston, MA: Jones & Bartlett Learning.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2017). Critical nursing care: Diagnosis and management. Maryland, MO: Elsevier.