Situation: The patient, Danielle Young Bear, came to the clinic

Situation: The patient, Danielle Young Bear, came to the clinic today with complaints of a persistent cough and fatigue that have lasted for 2 weeks. It started as a common cold, but she was concerned that it was something more serious since the cough and fatigue have not resolved yet. The signs and symptoms are consistent with the aftermath of a common cold. However, she is taking several different prescription drugs, and is also self-medicating with OTC medication and using herbal therapies. Background: Ms. Young Bear is a 32-year-old female. She is not one of our regular patients, but her usual provider is on vacation, so she was referred to our clinic. She has a history of low back pain acquired at her job as a construction worker, and she is also being medicated for depression. The low back injury occurred approximately 1 year ago. At the time of injury, Ms. Young Bear was seen in the Emergency Department and a lumbar spine x-ray was performed. The report noted possible mild degenerative disc changes in the lumbar spine, negative for fractures. A follow-up CT scan and orthopedic consultation was recommended. Ms. Young Bear was given a referral to outpatient physical therapy and a plan for pain treatment with prescription medication was set up. Assessment: Ms. Young Bear is alert and oriented. I have performed an initial assessment and found her lung sounds to be clear and equal. She has mild posterior pharyngeal redness, but her throat is otherwise benign. She has full range of motion in the lumbar spine and demonstrates no edema, redness, or ecchymosis in the area of her lower back pain. Medication reconciliation still remains to be done. Recommendation: I would like you to take vital signs and do a focused pain assessment. Please also make sure to go through her medications, including prescription medication, OTC medications, and herbal therapies, and perform medication reconciliation. Please notify me with your findings when you are done. 1. *In a single paragraph, briefly provide the name using initials, age and history of this client’s illness *Why the client is being seen in the health care setting *What treatments, if any, the client has experienced so far. 2. *Use the National Center for Complementary and Integrative Health web site. Be sure to cite the source. *What is willow bark”? *How is it used’? *Summarize the evidence about its effectiveness. Are there other options that clients might consider? 3. *Describe medication reconciliation. When is it used? *Why is medication reconciliation used? 4. *As the nurse, identify at least 2 priority problems for this client. *Explain WHY each of these problems are a concern or issue (These problems do not have to be written as nursing diagnoses.) 5.*Consider Danielle’s priority problems and think about the medication regimen. What are potential concerns when reflecting on these issues. 6. *What specific education should the nurse provide Danielle about care NOT RELATED to medications. Identify at least 2 areas. Explain what the educational need is. * Why are each of these needs important? 7. Construct a medication table/chart/template or study guide that analyzes all the client’s pharmacologic treatments, taking into consideration the client’s unique characteristics, situational factors, functional level, etc. Includes all forms of pharmacology including OTC, alternative substances, IVs and oxygen as appropriate. • Generic name and drug class …………………… • Mechanism of action • Indication of use specific to THIS CLIENT • Pertinent side effects & drug-drug interactions specific to this client. If none are pertinent, then identify those that the nurse should be aware of for all clients. • Nursing considerations or implications including necessary monitoring based on client specific characteristics (at least 2. Do not include client education here) • Key client education points about each medication Citation for information for each drug and reference on reference page MEDICATIONS prescription medication :cyclobenzaprine 5 mg 3 times a day, duloxetine 60 mg once a day, tramadol 50 mg 4-6 times a day, and a tablet with hydrocodone 5 mg and acetaminophen 325 mg 4 times a day. over-the-counter or herbal medication Nyquil 3 tablespoons a day for cold, acetaminophen 500 mg 4 times a day, ibuprofen 600 mg 3 times a day, and sometimes drink 1 cup of willow bark tea for the pain.’

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