Evidence Based Practice Case Study

Evidence-Based Clinical Practice Paper

J.D. is a 62 year old divorced Caucasian female. Patient is a reliable historian. She is allergic to Lisinopril. She currently has a desk job at a local call center. She went through menopause at age 50. She is on Lantus insulin 45 units every evening and Novolog sliding scale insulin with meals. She presents to the clinic today for a well woman exam with complaints of vaginal itching and burning.

Subjective Data

History of Present Illness

Vaginal itching and burning has been on and off x1 month with accompanying dysuria. She used a “generic Monistat” two weeks ago but did not have any relief, so went back and bought the name brand Monistat 1 this past Sunday. States symptoms have improved since then.

Review of Symptoms

General: denies fever, night sweats, significant weight gain or loss, exercise intolerance, depression, sleep disturbances, or fatigue

HEENT: denies dry eyes, irritation, vision changes, difficulty hearing, ear pain, sore throat, runny nose, or sinus pressure

Neck: denies swollen glands or stiff neck

Pulmonary: denies cough, wheezing, or shortness of breath

Cardiovascular: denies chest pain or palpitations

Gastrointestinal: denies abdominal pain, nausea, vomiting, diarrhea, constipation, acid reflux, or melena

Genitourinary: reports dysuria and vaginal itching, denies incontinence, hematuria, increased frequency, abnormal bleeding, or vaginal odor

Musculoskeletal: denies muscle aches, weakness, joint pain, back pain, or edema

Integumentary: denies any rashes, lesions, or change in hair

Neurological: denies numbness, headache, seizures, tingling or sensation changes

Endocrine: denies bruising, excessive sweating, thirst, hunger, heat or cold intolerance

Objective Data

Physical Exam

Vitals: blood pressure - 130/77, heart rate - 97, respiratory rate - 17, temperature – 97.9 , oxygen saturation –97% on room air, weight – 183 pounds, height – 5 feet 4 inches, body mass index –

In caring for this patient, Orem’s self-care deficit theory was used to direct treatment. The theory includes the three interrelated parts of theory of self-care, theory of self-care deficit, and the theory of nursing system. The theory of self-care focuses on the patient’s ability to perform activities to maintain well-being, life, and health by themself. The theory of self-care deficit recognizes when nursing interventions are needed, and the theory of nursing system defines how the patient's needs will be met by the patient, the nurse, or both (Petiprin, 2015). The factors of J.D.’s recent financial situation along with her history of diabetes were used to guide her treatment plan and education. Self-care activities to prevent reoccurrence of symptoms, as well as, when to contact provider or return to clinic were