Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.Mention the health promotion intervention for this patient.What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
Patient: A 34-year-old female presenting with recurrent headaches
Signs and Symptoms (S&S): Patient reports experiencing 8/10 intensity, bilateral frontal headaches that develop over the course of 20 minutes and last for 3 to 4 hours. She also experiences nausea, photophobia, and phonophobia. No focal neurological deficits are noted on exam.
Assessment: Headache is a commonly reported symptom often seen in primary care settings; however, it can be caused by an underlying pathology or medical condition such as migraines or intracranial lesions. Given the patient’s presentation with frequent recurrence of severe headache along with associated symptoms of nausea, photophobia, and phonophobia this could suggest a diagnosis of migraine headaches secondary to cranial vascular dysfunction. The differential diagnoses should include meningitis/encephalitis due to headache being one of the common constitutional symptoms; hypothyroidism due to thyroid abnormalities potentially causing bouts of headache; temporal arteritis due to its association with recurrent unilateral jaw claudication and headache; as well as subarachnoid hemorrhage due to severe “worst ever” type headaches that can have abrupt onset followed by decreased level consciousness.
The organization evaluated is a non-profit hospital system in Northern Nevada serving both a rural and urban demographic. The author has experience in both a clinical supervisory role within this organization and as a community partner continuing to work with the organizations top managers on initiatives to serve the health care needs of the community. This organization is locally governed with no out of state owners or shareholders and has greater than 150 community members serving on the boards or in advisory capacities. The organization has three key initiatives. One of these key initiatives for this organization is to integrate care in an effort to better manage the health of the community. The goals of this initiative are to help the population served achieve better health through improved outcomes, manage or reduce their healthcare costs, and improve the patient experience. The second initiative is to build key relationships through community partnerships. The goal of this initiative is to increase partnerships with physicians, employees, and community organizations. An example of this is the creation of a shared governance model to make recommendations to the leadership team. The shared governance committee is made up of designated staff from each department. This creates a partnership between the employees and the leadership and gives staff an outlet for their concerns to be heard. The hospital has also partnered with the community to offer health education classes at some of the larger churches in the area and has sponsored community gardens at some of the city parks encouraging members of the community to grow their own vegetables and encourage healthier lifestyle choices.>
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