Case Study for Classroom: Emergency Contraception and IPV at College Health Clinic 4

Palisades River University Health Clinic

Role: Nurse (RN) at clinic

On Wednesday of the first full week of classes at Palisades River University, freshman Ashley Brown

and her friend Shelby Allen arrive at the college health clinic. Ashley is nervous and a little tearful;

Shelby is looking all around to take in the environment. In triage, Ashley tells the nurse that on the

first day she arrived for freshman orientation for resident students she met a great looking, funny

guy from another state named Colin. They’ve spent the past 10 days together. Everything was

going well until they went to a party last night. They each had a couple of beers over several hours. She wasn’t drunk when she decided to go back to his room with him. Ashley is speaking very low and tells the nurse the sex was really rough. She has a bruise on her left breast and is really sore “down there”. Ashley says she is also upset because they didn’t use a condom. Her previous boyfriend in high school always had the condoms. Now she’s really worried.

Nursing Assessment
Name: Ashley Brown / DOB: 06/22/1996 18 y/o / Date: Wednesday 09/03/2014 / Time: 0845
Allergies: No þ Yes ¨ / Immunizations: Up-to-Date þ HPV þ Tetanus No ¨ Yes þ 2011
Flu No þ Yes ¨ planned? No ¨ Yes þ
Chief Complaint: needs emergency contraception / Primary Language: English
Alcohol: No ¨ Yes þ Tobacco: No þ Yes ¨ Recreational substances: No þ Yes ¨
Sexually active: No ¨ Yes þ Female: LMP 8/18/2014 Gravida 0
Dx/Tx STI No þ Yes ¨
Children? No þ Yes ¨ / On campus housing
Off campus housing in town
With parents (or others) commuter / Meal Plan: No ¨ Yes þ
Food Pantry Needs? No þ Yes ¨
Past Medical History:
fx R ankle October 2013
hx of chronic bronchitis during K-5. / Family History:
Mother: Living, no medical hx
Father: Living, HTN; Siblings: sisters: 13 y/o, 16 y/o, no significant hx / Social History:
Active, “works out”, dance class, on girls’ soccer team in high school, and planning to play intramural in college
Medications:
Ibuprofen 200-800 mg PO prn for headaches, menstrual cramps, muscle soreness
Echinacea tablets prn “for colds”
Vital signs
Pain / Temp / HR / BP / RR / SpO2 / Ht / Wt
3 /10 / 98.3 F / 94 / 100/60 / 22 / 99% in RA / 5’6” / 113 lbs
Assessment / Findings
Neurological / A&O X4, articulate, PERRLA
Respiratory / Pale, resp even and unlabored, BS clear = bilaterally
Cardiac / Regular rate and rhythm, Cap refill +2, No edema
GI / Did not eat this morning, BS + X4Q, BM yesterday
GU / Voided without difficulty this morning
Musculoskeletal / Ambulating well without difficulty or assistance
Integumentary / Pale, Two dime size bruises right upper outer quadrant L breast, No lesions or skin breaks
Psychosocial / Appears afraid, Verbalizing: unsure about decision to come to clinic but worried about pregnancy

Probable Health Care Provider treatment plan:

Anticipated HCP requests:

Which Healthy People 2020 objectives apply to developing a plan of care for Ashley at this visit?

Search for the evidence to base nursing practice. Is there a clinical guideline that supports the HCP probable treatment plan?

Search library database and locate two peer-reviewed health-care journal articles which will support or complement treatment plan and nursing interventions.

Prioritized Nursing Diagnoses / Outcome Identification / Short term goal / Nursing interventions
1.
R/T
M/B
2.
R/T
M/B
3.
R/T
M/B
4.
R/T
M/B
5.
R/T
M/B

Integrate prioritized nursing Interventions guided by principles of patient-centered care.

Locate online resources for Ashley to facilitate her understanding of the treatment plan.

Investigate the One Love MyPlan app on the One Love Foundation website. Will the app facilitate Ashley’s knowledge about her relationship with Colin? Is discussing the app with Shelby a HIPAA violation? What should the nurse say/do to introduce Ashley and Shelby to the One Love MyPlan app?

Health Care Provider Orders

9/3/14
09:20 / 1. Ibuprofen 800 mg PO now
2. Urine HCG now
3. Cervical swab for Gonorrhea and Chlamydia now
4. Paragard IUD insertion
R. Johnston, MD # 54376

Identify the rationale and nursing interventions for the Health Care Provider’s orders.

Health Care Provider Notes

9/3/14
10:45 / S: 18 y/o female reports consensual, unprotected “rough” sex with new partner. Requesting emergency contraception. States discomfort in perineum, L breast. ETOH consumption prior. Denies anal penetration. Denies STIs
O: Afebrile, P94, R22, BP 100/60, No CP/SOB, Neck full ROM, Lungs clear, RRR, BS+. Small, flat bruises x2 left breast aligned as if fingertip placement; GYN: L labia majora edema, no lacerations, vaginal walls intact, no vaginal edema, cervix intact, small hematoma 1 cm anterior to anal opening.
A/P: nulliparous female with trauma to breast and perineum during unprotected vaginal intercourse
1. Care of hematoma. Follow up with PMD or RTC if pain continues or increases. Defer sexual intercourse until edema and hematoma resolved.
2. Emergency contraception – options explained.
3. Ibuprofen 800 mg PO administered. Urine HCG negative. Cervical swab for Gonorrhea and Chlamydia sent.
4. Paragard IUD inserted. Slight bleeding post procedure.
5. Warning symptoms of IUDs explained. Follow up with PMD or RTC if symptoms develop.
6. Refer STI testing (chlamydia, gonorrhea, hepatitis B, C, HIV, and syphilis) 4 weeks with PMD or Health Dept.
7. Schedule crisis intervention appointment with Peter Avenue Counseling Services.
R. Johnston, MD # 54376

Review the Health Care Provider’s notes.

Why is there a lengthy time lapse between orders written and notes?

Discharge Teaching:

Reflection/Evaluation:

Discuss the importance of expertise with information technology as a component in providing quality care.

Each member of the group:

1. Identify a QSEN prelicensure Knowledge, Skill, and Attitude for patient-centered care, evidence-based practice, and informatics, generated during the case study.

2. Discuss the selected KSAs with the group. Did each member of the group select the same one or a different one? Why?

3. Review the categories and subcategories of the NCLEX framework of client needs. Which subcategories of client needs are a primary or a secondary focus of the case study? Discuss.

4. Did everyone in the group participate in the case study equally? Why, Why Not?