Week 3 Assignment

Write a 1,200-1,500 word analysis of “Case Study: Healing and Autonomy.” In light of the readings, be sure to address the following questions:

1. Under the Christian narrative and Christian vision, what sorts of      issues are most pressing in this case study?
2. Should the physician allow Mike to continue making decisions that seem      to him to be irrational and harmful to James?
3. According to the Christian narrative and the discussion of the issues      of treatment refusal, patient autonomy, and organ donation in the topic      readings, how might one analyze this case?
4. According to the topic readings and lecture, how ought the Christian      think about sickness and health? What should Mike as a Christian do? How      should he reason about trusting God and treating James?

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

DUE TUESDAY 01/10/2017 —> ADVANCE NURSING PRACTICE 1

 

Assignment 2: Case Study Analysis and Care Plan Creation

Click here (I COPIED AND PAST IT ON BELOW)  to download and analyze the case study for this week. Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

 

CASE STUDY

 

Week 2: Respiratory Clinical Case

 

Patient Setting:

 

65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily.  She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.

 

HPI

 

Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.

 

 

 

PMH

 

History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.

 

 

 

Past Surgical History

 

None

 

 

 

Family/Social History

 

Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF

 

Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.

 

 

 

Medication History

 

Theophylline SR Capsules 300 mg PO BID

 

Albuterol inhaler, PRN

 

Phenytoin SR capsules 300 mg PO QHS

 

HTCZ 50 mg PO BID

 

Enalapril 5 mg PO BID

 

Allergies

 

NKDA

 

ROS

 

Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.

 

Physical exam

 

BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”

 

VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18

 

Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact.

 

Laboratory and Diagnostic Testing

 

Na – 134

 

K – 4.9

 

Cl – 100

 

BUN – 21

 

Cr – 1.2

 

Glu – 110

 

ALT – 24

 

AST – 27

 

Total Chol – 190

 

CBC – WNL

 

Theophylline – 6.2

 

Phenytoin – 17

 

Chest Xray – Blunting of the right and left costophrenic angles

 

Peak Flow – 75/min; after albuterol – 102/min

 

FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%

 

 

Visit the South University Online Library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, and Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.

Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

Click here to access the codes.

https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?generalError=Thank+you+for+your+interest+in+the+Medicare+Coverage+Database.+You+may+only+view+the+page+you+attempted+to+access+via+normal+usage+of+the+Medicare+Coverage+Database.

 

 

I PUT IT AT THE END OF THIS POST

Click here to download the care plan template to help you design a holistic patient care plan. The care plan example provided here is meant only as a frame of reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.

Format

Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be 2 pages excluding the title page and references and in 12pt font.

Name your document: SU_NSG6001_W2_A2_LastName_FirstInitial.doc.

Submit your document to the W2 Assignment 2 Dropbox by Tuesday, January 10, 2017.

Assignment 2 Grading Criteria	Maximum Points
Subjective Data The submission included the patient’s interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.	15
Objective Data The submission included measurements and observations obtained by the nurse practitioner. It included head to toe physical examination as well as laboratory and diagnostic testing results and interpretation (especially those that pertain to the diagnosis).	15
Assessment The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.	15
Plan of Care Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.	20
APA Used APA standards consistently and accurately when citing in the SOAP note and reference page. Utilized proper format with coversheet and header.	10
Total	75

 

 

SAMPLE (OR TEMPLETE) FOR THE WORK

 

Title of Plan of Care

 

Name

 

South University Online

 

Faculty Name

 

NSG 6001

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Please delete this statement and anything in italics prior to submission to shorten the length of your paper.

 

Patient Initials ______

 

Subjective Data: (Information the patient tells you regarding themselves: Biased Information):

 

Chief Compliant: (In patient’s exact words)

 

History of Present Illness: (Analysis of current problems in chronologic order using symptom analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried]).

 

PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and history sexual history).

 

Significant Family History: (Includes family members and specific inheritable diseases).

 

Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security and family history of violence).

 

Review of Symptoms: (Review each body system –This section you should place POSITIVE for… information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes:  ; ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:; Neurological:; Endocrine:; Hematologic:; Psychologic: .

 

Objective Data:

 

Vital Signs:  BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .

 

Physical Assessment Findings: (Includes full head to toe review)  

 

HEENT:

 

Lymph Nodes:

 

Carotids:

 

Lungs:

 

Heart:

 

Abdomen:

 

Genital/Pelvic:

 

Rectum:

 

Extremities/Pulses:

 

Neurologic:

 

Laboratory and Diagnostic Test Results: (Include result and interpretation.)

 

 

 

Assessment: (Include at least 3 priority diagnosis with ICD-10 codes.  Please place in order of priority.)

 

Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).

References

 

*** 20 hours****

1) Minimum  2  full pages (Follow the 3 x 3 rule: minimum three paragraphs per part)

2)¨******APA norms

 All paragraphs must be narrative and cited in the text- each paragraph

         Bulleted responses are not accepted

         Don’t write in the first person 

         Don’t copy and paste the questions.

         Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks) 

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 3 references per part not older than 5 years  (Journals, books) (No websites) 

5) Identify your answer with the numbers, according to the question.

Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

__________________________________________________________________________________

 

Case:

56 y/o Caucasian male presents to the primary care clinic with complaints of dizziness and nausea x 4 days. The patient reports he has not been able to get out of bed since the symptoms started. The patient reports symptoms are worse when he tries to get out of bed to stand. He denies any headaches or blurry vision. He states he is urinating more over the last few days and he has noticed an increase in thirst. He reports he just drank a large sweet tea before he came into the clinic.

The patient reports that he is out of his Lantus and metformin because he cannot afford the refill until he gets his disability check. He is disabled after his second CVA that left him with generalized weakness. His medical history includes DM, HTN, CAD.

Upon arrival at the clinic, the patient’s vital signs are as follows- Blood sugar 405, B/P 190/101, HR 102, R-20, T- 98.5.

Using Evidence Based practice, answer the following questions thoroughly. Be sure to use APA

 

Questions:

1. What are the pertinent positive and negative findings in this patient assessment?

2. Create a list of differentials with rationales for this patient?

3. Discuss a medication regimen for this patient considering his financial status?

4. What is the priority concern for this patient?

5. How does this patient’s comorbid diagnosis impact his current symptoms?

6. Discuss how the patient’s health beliefs, culture and behaviors impact the potential outcomes for the patient.

Week 6 Discussion

For this assignment, you will review the latest evidence-based guidelines in the links provided below. Please make sure you are using scholarly references and they should not be older than 5 years. The posts/references must be in APA format. 

Apply the information from the Aquifer case study to answer the following questions: 

1: Which essential questions will you ask this pediatric patient or his/her caregiver during this well-child check? Why are these questions important? What lab tests or diagnostic studies will you order and why?

2: What diagnoses would you give the patient in this case? Include the findings that support the diagnoses.

3: What is your treatment recommendation and education for the patient and family? Why? Include anticipatory guidance.