7.7 Learning Activities

Case Study

Kinsey Valdez, age 26 years, is brought into the urgent care clinic today by her roommate, Sara, who reports a recent change in Kinsey’s behavior and difficulty concentrating. Kinsey states she let her roommate bring her to the outpatient clinic because she was not feeling well, and “I just do not know what’s wrong.” During the initial visit with Kinsey, the nurse notes that Kinsey turns away, does not make eye contact, and speaks quietly.

Sarah reports that Kinsey has had a lack of energy for several weeks. She says that Kinsey frequently talks about her life being “hopeless,” doesn’t get out of bed in the morning, and has no interest in sleeping or eating.

Sarah further explains that when Kinsey was 16, her best friend died in a car accident and she experienced severe depression at that time. She received family support but did not take any medication and was not involved in traditional counseling services. Additionally, Kinsey recently discovered that she is HIV positive and this occurred roughly on the anniversary of her best friend’s passing.

Kinsey has been living with Sarah for 3 years in an apartment and they also work together as nurses on the night shift in the Med-Tele unit at a local hospital. Kinsey’s closest family member, her younger brother, lives 3 hours away and they rarely speak. Kinsey admits that she has few friends and states, “I’m usually not much fun to hang out with, but I’m okay with that.” She has also been picking up many extra shifts at work due to short staffing in recent weeks. Kinsey states,  “I’m worried that this positive HIV test will cause me to no longer be able to work as a nurse.”

Kinsey is instructed to go to the nearest Emergency Department (ED) for further assessment and follow-up. Sara takes her to the ED. The nurse from the urgent care clinic called the ED nurse with brief report. When Kinsey and Sarah arrive, they are placed in a private ED room immediately upon arrival.

Reflective Questions:

1. What CUES do you recognize as relevant in planning and providing care for Kinsey?
2. What is Kinsey’s priority nursing problem?
3. What are your first steps in caring for Kinsey?

ASSESSMENT

The ED nurse performs an assessment and collects the following data.

Vital signs: BP 110/64, P 48, T 35.8, O2 sat 97% on room air, R 16

Pain (PQRST): Pain location: knees and ankles bilaterally. Provocation (P): “Always there, does feel a bit better after sleeping for a while.” Quality (Q): “Achy.” Radiation (R): None, Severity (S): 3/10. Timing (T): Started about 3 weeks ago after falling on the ice at work when leaving after a night shift.

Focused Assessment Findings

Neuro: Reports a history of migraine headaches but has had none in recent years. Wears contacts most of the time, sometimes wears glasses. Denies dizziness, changes in vision, or any numbness in limbs.
Respiratory: Breathing is unlabored and regular, but occcasionally shallow when resting.
Cardiac: Denies any complaints.
GI: Weight: 52.3 kg, a 3 kg decrease from previous visit to the hospital 1 year ago.
Eating 1 meal daily but only eats if roommate makes food and brings it to her in bed. “I’m just too tired to eat most of the time.” Nibbles on snacks and drinks Gatorade and protein shakes at work. Last BM yesterday, pattern is regular. Denies nausea or vomiting.
GU: Denies any complaints.
Skin: Three small scratches are present on her left forearm that are evenly spaced and superficial. No redness, tenderness, or warmth noted. Face is pale. Small rash across chest that is non-raised, light pink, not warm or itching.

Psychosocial Assessment Findings
General appearance and behavior: Wearing pajamas, hair is in loose bun, no makeup. Apprehensive and detached, avoiding eye contact. Slouched in chair, with feet up in a modified fetal position. Cooperative, but passive.
Affect and mood: Sad facial expression, blunted affect, slow movements, and quiet monotone voice
Speech pattern: Slow, minimal speech. Quiet, logical sentences.
Thought content: Depressive thought content, without evidence of delusions or hallucinations.
Cognition: Alert and oriented x 3. Has Bachelor’s degree in Nursing and an RN license and is articulate and intelligent.
Judgment: No evidence of changes in judgment.

Labs Results
Results are unremarkable, negative for ETOH and cannabis. CD4 is 641 u/L

Additional Reflective Questions
4. What additional CUES are relevant for planning Kinsey’s care based on the nurse assessment?
5. What is your hypothesis for Kinsey after analyzing the nursing assessment data?
6. Write a SMART goal for Kinsey’s care based on priority nursing problem(s).
7. What priority nursing interventions are important to implement when caring for Kinsey?