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Clinical Scenario: Jennifer P, 37-year-old female, and her 37-year-old husband, David, present with the complaint of a possible fertility problem. The couple has been married for 2 years. The patient has a 4-year-old daughter from a previous relationship. The patient used birth control pills until one-and-a- half-years-ago. The couple has been trying to conceive since then and report a high degree of stress related to their lack of success. Jennifer reports good health and no problems in conceiving her previous pregnancy or in the vaginal delivery of her daughter. She reports that her periods were regular on the birth control pill, but have been irregular since she discontinued taking them. She reports having periods every 5-7 weeks. Past history is remarkable only for mild depression. Imipramine 150 mg qhs for the last 8 months is her only medication. Jennifer works as a cashier, runs 12-24 miles each week for the last 2 years, and has no history of STDs, abnormal Paps, smoking, alcohol or other drugs. She has had no surgery.

David also reports good health and reports no problems with erection, ejaculation or pain with intercourse. He has had no prior urogenital infections or exposure to STDs. He has had unprotected sex prior to his current relationship, but has not knowingly conceived. He has no medical problems or past surgery. David works as a long-distance truck driver and is on the road 2-3 weeks each month. He smokes a pack of cigarettes a day since age 18 and drinks 2-3 cans of beer 3-4 times a week when he’s not driving. He occasionally uses amphetamines to stay awake while driving at night. The couple has vaginal intercourse 3-5 times per week when he is at home.

 

What is the definition of infertility?

 

 

What are some etiologies of infertility?

3.      Complete the menstrual cycle process, filling in the correct endocrine glands and the target tissues – estrogen/progesterone, hypothalamus, ovary, pituitary, and uterus.

 

 

Noticing:

4.      Evaluation of client’s medical history: Describe any abnormal findings/potential issues related to Jennifer/David’s infertility etiology and describe your thoughts about these findings.

 

Interpreting: What is the initial work-up for infertile couples and what tests would you add for this couple?

Patient

Partner

 

 

Interpreting:

6.      What contraindications should healthcare personnel screen for prior to the use of clomiphene?

Clinical Scenario Progression: It has been found that Jennifer has primary ovarian insufficiency. She is prescribed clomiphene 50 mg PO every day for five days, starting on day 3 of menstrual period.

Interpret:

7.      When discussing administration of clomiphene with the couple, what information should be included?

 

Responding:

8.      When starting fertility treatment with clomiphene, it is important to discuss possible adverse reactions with Jennifer and David. Complete the following chart with information related to interventions and which reactions should be reported to the provider.

Adverse drug reactions to clomiphene

Patient and/or Nursing interventions

Report to provider

(yes/no)

Breast engorgement

Nausea, abdominal discomfort

 

Vasomotor instability

(hot flashes)

Ovarian hyperstimulation

 

Multiple gestation

 

Blurred vision, flashes of light, dizzyness

 

Reflecting:

9.      Couples who are experiencing infertility issues often require other specific interventions and/or nursing considerations. In relation to Jennifer and David’s situation, what particular nursing care topics should be addressed?

Problem Based Scenario – BPH

Client’s Chief Complaint:

“It is getting more and more difficult to urinate. When I do urinate it seems like I can’t empty my bladder and it gets painful. I am always waking up at night to urinate too.”

Clinical Scenario: 

Mr. B.H. is a 52 year old white male who was referred to the urology clinic by his primary care physician after complaining of his inability to urinate, painful urination and incomplete bladder emptying. Mr. B.H. symptoms have been getting increasingly worse over the past 3 months. Most recently Mr. B.H. has noticed an increase in pain and unequal stream flow of urine while urinating. He indicates that his problems seem to be worse at night and that the pain is greater during urination after waking from sleep.

Past Medical History:

Hernia operation at birth
Left forearm break, age 14
Right knee ACL repair, age 19
Right shoulder rotator cuff repair, age 20
Hypertension diagnosis, age 41
UTI x 2, age 50 and 52

Pertinent Family History:

Father alive, age 76 years, Smoker, CAD, HTN, COPD, BPH, prostate CA
Mother alive, age 76 years, Smoker, CAD, HTN, MI with cardiac stents at age 64
Brother alive, age 46, HTN
Sister alive and well at age 39 years
Father diagnosed with BPH at age of 57

Pertinent Social History:

Marine Corps Veteran with 2 tours in Iraq, 1991-1998
Has worked full-time as a real-estate agent for 15 years
Hobbies include woodwork, weight lifting, surfing and boating
Frequently spends time in the Pacific Ocean surfing, at least 3 times a week
Smoker x 20 years
Drinks approximately 3 beers 2-3 times a week
Diet high in cholesterol

Allergies:

NKA

Current Medications:

Atenolol 25 mg PO BID

 

Focused Physical Assessment:

           

Vital Signs:

T:  (oral) 98.2˚F

P:  (regular) 82 /min

R:  (regular) 18 /min

BP: 155/88 (sitting)

02 sat: 98% (room air)

Abdomen/Scrotum/Rectum

Bladder distended
Abdomen tender to palpation at lower quadrants
Digital rectal examination reveals enlarged, asymmetrical prostate gland; no tenderness; no masses; no nodules

Testing/Lab Results:

Basic Metabolic Panel (BMP)

Result

Complete Blood Count (CBC)

Result

Sodium (135-145 mEq/L)

140

WBC (3.4-9.6 K/uL)

7.6

Potassium (3.5-5.0 mEq/L)

3.9

RBC (4.35-5.65 M/uL)

5.22

Chloride (95-105 mEq/L)

97

Hematocrit (38.3-48.6 %)

46.8

Glucose (70-110 mg/dL)

106

Hemoglobin (13.2-16.6 g/dL)

14.7

Calcium (8.4-10.2 mg/dL)

8.9

Platelets (135-317 K/uL)

290

BUN (7-25 mg/dL)

24

Creatinine (0.6-1.2 mg/dL)

1.0

Urinalysis

Result

Other Testing

Result

Color (yellow)

Yellow

Prostate Specific Antigen

5.2 ng/mL

Clarity (clear)

Clear

Void with post void residual u/s

350mL

Specific Gravity (1.015-1.030)

1.026

Protein (neg)

Neg

Glucose (neg)

Neg

Ketones (neg)

Neg

Bilirubin (neg)

Neg

Blood (neg)

Trace

Nitrite (neg)

Neg

Noticing:

10. When reviewing the client’s chief complaint, along with the history and physical, what are the most significant findings and why? Which lab and test results are most concerning and why?

·        Is there any other information (assessment data, testing, etc.) that would be helpful for determining the significance of the findings thus far?

Interpreting:

11. What is most likely occurring? What led you to this hypothesis?

12. What are the desired outcomes related to your hypothesis (give at least 2)?

13. What will happen if this condition is not treated?

Clinical Scenario Progression:  Mr. B.H. is diagnosed with benign prostatic hyperplasia. He is started on finasteride 5mg PO once a day. He is also started on doxazosin 1mg PO once a day. 

Responding:

14. What teaching should be provided to Mr. B.H. about his two new medications, finasteride and doxazosin? What are the major nursing considerations for each medication?

Drug Name

finasteride

doxazosin

Drug Classification

 

 

 

 

 

Pharmacologic Action

 

 

 

 

 

Adverse Effects

 

 

 

 

 

Administration

 

 

 

 

Nursing Considerations

 

 

 

 

Interactions

 

 

 

 

15. What other teaching should be included for the client about his condition?

Reflecting:

16. What findings would demonstrate that the pharmacologic therapy is working? What follow-up data is needed?

17. If the pharmacologic therapy is ineffective, describe (2) procedures or surgical interventions that could be offered to Mr. B.H. for his condition.

Problem Based Scenario – Menopause

Clinical Scenario: Zoila Lopez is a married, 55-year old woman living in suburban Los Angeles with her husband of 28 y+ears. She comes to the office today for her annual gyn/physical exam. Her LMP was 12 months ago. She smoked ½ pack of cigarettes daily from age 19-30 until she quit when she became pregnant with her first child. Her OB history is: G3 T2 P0 A1 L2. Her second and last child was born when Zoila was 35. She breastfed both of her children for one year each. Zoila’s past medical history is significant for arthroscopic knee surgery 10 years ago and migraines which she treats with good effect with ibuprofen 600 mg. Family history is significant for Pulmonary Embolism (father) at age 60 and hypertension (mother) and breast cancer (mother) at age 70. Her father is still living and her mother is deceased after a broken hip and pneumonia. No history available for siblings or grandparents. 

Zoila reports some friction within her relationship with her husband as her sex drive has diminished over the last year or so. She also reports an increase in anxiety and irritability.

What is the definition of menopause?

What are some of the health risks associated with menopause?

3.     Describe some of the clinical manifestations a woman may experience related to perimenopause/menopause.

Noticing:

4.     Evaluation of client’s medical history: Describe which of Zoila’s symptoms may be related to menopause.

5.     What are some other symptoms that you should ask Zoila about relating to menopause?

Interpreting:

6.     List the diagnostic tests that you would expect may be ordered related to determining perimenopause/menopause confirmation?

Clinical Scenario Progression: Diagnostic labs confirm that Zoila is menopausal.

Interpreting:

7.     What contraindications should healthcare personnel screen for prior to the use of (combined) medroxyprogesterone acetate and conjugated estrogen (Prempro)?

Interpreting:

 

     8.   When starting HRT treatment with medroxyprogesterone acetate for symptoms of menopause it is important to discuss possible adverse reactions with the client. Complete the following chart with information related to interventions and which reactions should be reported to the provider.

Adverse drug reactions to (combined) conjugated estrogen and medroxyprogesterone acetate

Patient and/or Nursing interventions

Report to provider

(yes/no)

Responding:

     9.   What are some of the benefits to beginning low-dose HRT soon after menopause?

Reflecting:

     10. Are there alternate options that may be offered to Zoila if she chooses to not use HRT that will help relieve her symptoms? List some of the symptoms she may be experiencing and options for alleviating these symptoms:

Menopausal symptoms Zoila would like to relieve

Alternative therapies

Reflecting:

     11. Zoila conveys to you that she feels that she is no longer attractive and that she has lost her femininity. What nursing interventions will you implement to help Zoila with this?

     12. What is your priority of care for the woman experiencing menopause who has low self-esteem?

     13. What health promotion interventions will be a priority for the patient entering menopause?

     14. What nutritional and exercise behaviors would you promote for the woman in menopause? Explain your answer.

SCIENCE
HEALTH SCIENCE
NURSING

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