John C.: Older Man With an Injury

Ann S. Merrill, RN, MA, MS
Assistant Professor, College of Nursing
University of Oklahoma
Oklahoma City, Oklahoma

Information Obtained during the First Visit/Encounter:

John C., a 70-year-old man, lived alone in a low-income, one bedroom apartment for senior citizens that was on the city bus line. He had no family in the area. When he answered the door, he was hugging his right arm to his body and stated that he tripped over his cat and fell when going to the bathroom two nights ago.

John complained that the pain in his right arm had been constant for the last two days. His radial pulse was intact, and he was able to move all his fingers with adequate circulation to his hand. His forearm and elbow were bruised and swollen without disfigurement of the joint, and his skin was intact.

During the visit, John said that he was unable to use his right arm to complete personal care activities or to lift objects, and grimaced when he was asked to flex and extend his arm. He admitted that it was difficult to dress and cook for himself. He also said that the aspirin he took" really didn't do any good" and asked, "Why does it still hurt? Do you think I broke something?" The student nurse explained that swelling can stimulate pain and that x-rays were necessary to determine whether he had a broken bone. As they talked about tissue healing, the student nurse said that the swelling and bruising should decrease and that his range of motion should improve during the next few days, if he did not damage his bones, tendons or ligaments. John had not contacted his doctor, indicating that he did not want to bother anyone and did not have money to pay for care. The student nurse urged him to do so and explained that John’s Medicare benefits should cover his charges.

The student nurse suggested additional ways to help decrease pain, such as alternating heat and cold packs, using a sling for immobilization, and using distraction and relaxation by listening to some favorite music and petting his cat, Buddy. The student made a sling, applied it, and explained the symptoms of impaired circulation that would need immediate reporting.

John shared that he was afraid the apartment manager will find out about his pet and evict him, indicating that Buddy is "the best friend I ever had and I won't get rid of him”. The student asked John if he was lonely. He replied that he did not need more friends, and was “happier” than he used to be. They discussed ways to prevent similar accidents from happening. John said he could put the cat in a box at night; he did not want to leave a light on all night because it would increase his electric bill. They talked about pet carriers and nightlights. John said he could not afford a pet carrier, but would buy a nightlight next time he went to the store. The student nurse offered to find a pet carrier; John said he would use one at night if he had one. Before the student nurse left, John agreed to receive a follow-up telephone visit in two days.

Application of the Omaha System:

Domain: Environmental

Problem: Residence (high priority)

Problem Classification Scheme

Modifiers: Individual and Actual
Signs/Symptoms of Actual:

• unsafe storage of dangerous objects/substances
• inadequate safety devices
   

Intervention Scheme

Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information:

• safety (low-wattage night light, pet carrier)

Category: Case Management
Targets and Client-specific Information:

• other community resource (needed a free pet carrier)
   

Problem Rating Scale for Outcomes

Knowledge: 3-basic knowledge (identified some hazards and ways to increase safety)
Behavior: 3-inconsistently appropriate behavior (no night light or pet carrier; agreed to use them)
Status: 3-moderate signs/symptoms (risk of injury, especially during night; pet on premises violates lease agreement)

Domain: Psychosocial

Problem: Social contact (low priority: provide interventions and rate if John decides that he is interested in changing his lifestyle)

Problem Classification Scheme

Modifiers: Individual and Actual
Signs/Symptoms of Actual:

• limited social contact
• minimal outside stimulation/leisure time activities

Domain: Physiological

Problem: Pain (high priority)

Problem Classification Scheme

Modifiers: Individual and Actual
Signs/Symptoms of Actual:

• expresses discomfort/pain
• compensated movement/guarding
• facial grimaces
   

Intervention Scheme

Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information:

• anatomy/physiology (physiological basis of pain and factors that can increase amount of pain perceived)
• relaxation/breathing techniques (additional pain management techniques such as heat, cold, and distraction)

Category: Case Management
Targets and Client-specific Information:

• medical/dental care (urged to see provider)
   

Problem Rating Scale for Outcomes

Knowledge: 3-basic knowledge (limited knowledge about pain etiology)
Behavior: 3-inconsistently appropriate behavior (used aspirin and splinting during last 2 days)
Status: 3-moderate signs/symptoms (pain is unrelieved by aspirin and interferes with daily activities)

Domain: Physiological

Problem: Neuro-musculo-skeletal function (high priority)

Problem Classification Scheme

Modifiers: Individual and Actual
Signs/Symptoms of Actual:

• limited range of motion
• decreased muscle strength
   

Intervention Scheme

Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information:

• medical/dental care (symptoms require care; benefits should cover expenses)
• signs/symptoms-physical (physiological reasons for swelling and bruising, expected pattern of symptom improvement)

Category: Treatments and Procedures
Targets and Client-specific Information:

• cast care (applied sling to help immobilize elbow joint)

Category: Case Management
Targets and Client-specific Information:

• medical/dental care (urged to see provider)

Category: Surveillance
Targets and Client-specific Information:

• medical/dental care (scheduled phone call to ask if John saw provider)
   

Problem Rating Scale for Outcomes

Knowledge: 3-basic knowledge (limited knowledge about injuries/treatment)
Behavior: 3-inconsistently appropriate behavior (did not see provider/still reluctant)
Status: 3-moderate signs/symptoms: (symptoms need attention/interfere with daily activities)