The patient, Danielle Young Bear, came to the clinic today with complaints of a persistent cough and fatigue that

The patient, Danielle Young Bear, came to the clinic today with complaints of a persistent cough and fatigue that have lasted for 2 weeks. It started as a common cold, but she was concerned that it was something more serious since the cough and fatigue have not resolved yet. The signs and symptoms are consistent with the aftermath of a common cold, so this is not a big concern. However, she is taking several different prescription drugs and is also self-medicating with OTC medication and using herbal therapies.

Ms. Young Bear is a 32-year-old Native American female. She is not one of our regular patients, but her usual provider is on vacation, so she was referred to our clinic. She has a history of low back pain acquired at her job as a construction worker, and she is also being medicated for depression.

Ms. Young Bear is alert and oriented. The lung sounds are clear bilaterally and there is a bit of redness in the throat. There are no signs of serious injury.

Take vital signs, complete a focused pain assessment, and assess neurological status. Go through all her medications, including prescription medications, OTC medications, and herbal therapies, and perform a medication reconciliation.

Guided Questions:

• Document your initial nursing assessment findings, including orientation, level of consciousness, pain assessment (including indicators of chronic pain), and vital signs.
• In your simulation experience, you performed a medication reconciliation. Were there any drug-drug interactions? Explain.
• Discuss any education that was provided to the client, including adverse effects and excessive medication use.
• Are any referrals necessary? Explain.