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Sarah Feldman
NURS 501
Dr. Regina Phillips
9/27/21
D.Y is a 32-year-old female presenting in the clinic. She complains of a persistent cough and
fatigue for the past two weeks. D.Y. admits that she is concerned because the cough and fatigue
have not gone away. She is taking prescription drugs along with OTC medications and herbal
therapies. Potential drug interaction is the concern in D.Y.’s case.
Medical reconciliation is the way to identify a patients list of current medications including
prescription meds, nutritional supplements, herbals, and over the counter (OTC) drugs. This
process is done to avoid errors such as drug interactions, duplication of medication, dosing
errors, and the omission of drugs, (Barnsteiner J.H, n.d.). In D.Y.’s case, the medication
reconciliation shows the potential drug interactions and the concern of liver damage with the
amount of acetaminophen she is taking.
In regard to providing D.Y. care, the nurse was told to do a focused pain assessment and assess
neurological status. He inspected and palpated her back and asked her questions regarding time
and place. The nurse should have examined the legs for sensation, motion, strength, pulse, and
color, to complete his assessment. Close to the end of the assessment the nurse called D.Y.’s
pharmacist to be notified of any medication changes. He should have also called her provider to
guide him in further treatment of D.Y.
One nursing diagnosis for D.Y. would be chronic pain related to inflammation of the lumbar
spine as evidence by the patient’s pain rating of 6. Another nursing diagnosis would be risk for
poisoning as evidence by inadequate knowledge of pharmacological agents.
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