EXPERT_RESEARCHER


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

 

Assignment 2: Fact Examine Partition and Solicitude Project Creation

Click here (I COPIED AND PAST IT ON BELOW)  to download and stir the fact examine for this week. Create a holistic solicitude project for indisposition stoppage, bloom advancement, and quick solicitude of the enduring in the clinical fact. Your solicitude project should be established on prevalent attraction and nursing standards of solicitude.

 

CASE STUDY

 

Week 2: Respiratory Clinical Case

 

Patient Setting:

 

65 year old Caucasian feminine that was discharged from the hospital 10 weeks ago succeeding a motor transportation befittingty bestows to the clinic today. States she is having bitter wheezing, lack of exhalation and coughing at meanest uninterruptedly daily.  She can insufficiently get her say out extraneously prelude breaks to lay-hands-on her exhalation and avers she has charmed albuterol uninterruptedly today.

 

HPI

 

Frequent asthma attacks for the late 2 months (more than 4 times per week middle), earnest MVA 10 weeks ago; post traumatic rapine 2 weeks succeeding the befittingty; anticonvulsant phenytoin afloat – no rapine zeal spent rise of therapy.

 

 

 

PMH

 

History of interrupted asthma attacks spent bestow 20s; calm congestive disposition insufficiency diagnosed 3 years ago; attributed on sodium restraining regimen and hydrochlorothiazide; latest year attributed on enalapril due to worsening CHF; indications courteous-mannered-behaved-behaved inferior the latest year.

 

 

 

Past Surgical History

 

None

 

 

 

Family/Social History

 

Family: Father died age 59 of class insufficiency outcomeant to HTN; Mother died age 62 of CHF

 

Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 regimen 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 lack of exhalation, coughing, wheezing and application credulity. Denies dissipation, turgescence in the extremities and rapines.

 

Physical exam

 

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

 

VS succeeding Albuterol exhalationing composition - BP 134/79, HR 80, RR 18

 

Gen: Pale, courteous-mannered-behaved-behaved patent clear feminine unmistakable restless. HEENT: PERRLA, verbal contrivanceeness extraneously lesions, TM extraneously signs of inflammation, no nystagmus glorious. Cardio: Regular rebuke and rhythm natural S1 and S2. Chest: Bilateral expiratory wheezes. Abd: luxurious, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac denying. EXT: +1 ankle edema, on just, no bruising, natural pulses. NEURO: A&O X3, cranial nerves undented.

 

Laboratory and Sign 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 just and left costophrenic angles

 

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

 

FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%

 

 

Visit the South University Online Library and elaboration for prevalent knowing attraction (no older than 5 years) to acceleration your nursing actions. In union, weigh visiting government sites such as the CDC, WHO, AHRQ, and Healthy People 2020. Provide a detailed or-laws rationale justifying the inclusion of this attraction in your project.

Next detail the ICD-10 artificeation (diagnoses). The International Designation of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the functional method used in the United States to tabulate and specify codes to bloom provisions and allied conversance.

Click short to advent 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 solicitude project template to acceleration you artifice a holistic enduring solicitude project. The solicitude project in granted short is meant barely as a mould of allusion for you to construct your solicitude project. You are expected to enunciate a inclusive solicitude project established on your impost, individuality, and advanced nursing interventions. Reflect on what you entertain erudite about solicitude projects through dogged elaboration and fellow discussions and incorporebuke the conversance that you entertain gained into your enduring's solicitude project.

Format

Your solicitude project should be formatted as a Microluxurious Word muniment. Follow the prevalent APA edition epithet. Your Nursing Dissertation should be 2 pages still the epithet page and allusions and in 12pt font.

Name your muniment: SU_NSG6001_W2_A2_LastName_FirstInitial.doc.

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

Assignment 2 Grading Criteria
Maximum Points

Subjective Data

The meekness comprised the enduring's sense of prevalent medical amount. It comprised leading murmur, truth of bestow sickness, prevalent medications and infer prescribed, late medical truth, nobility truth, and reaim of methods.

15

Objective Data

The meekness comprised measurements and observations obtained by the value practitioner. It comprised top to toe visible demonstration as courteous-mannered-behaved-behaved as laboratory and sign testing outcomes and sense (in-particular those that pertain to the individuality).

15

Assessment

The meekness comprised at meanest three guidance diagnoses. Each individuality was accelerationed by munimentation in internal and concrete still n esss and permitted of imported omissions. All diagnoses were munimented using enlivening terminologies and prevalent ICD-10 codes.

15

Plan of Care

Plan comprised sign and sanative (pharmacologic and non-pharmacologic) address as courteous-mannered-behaved-behaved as advice and counseling granted. The project was accelerationed by attraction/guidelines, and the follow-up projects were glorious.

20

APA

Used APA standards conformably and accurately when citing in the SOAP still n ess and allusion page. Utilized befitting format delay coversheet and toper.

10
Total
75

 

 

SAMPLE (OR TEMPLETE) FOR THE WORK

 

Title of Project of Care

 

Name

 

South University Online

 

Faculty Name

 

NSG 6001

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Please delete this proposition and everything in italics antecedent to meekness to abridge the tediousness of your Nursing Dissertation.

 

Patient Initials ______

 

Subjective Data: (Information the enduring tells you touching themselves: Biased Information):

 

Chief Compliant: (In enduring’s straight say)

 

History of Bestow Illness: (Analysis of prevalent amounts in chronologic enjoin using indication partition [onset, colonization, number, attribute, amount, aggravating/alleviating factors, associated indications and compositions dressed]).

 

PMH/Medical/Surgical History: (Includes medications and why prelude, allergies, other senior medical amounts, immunizations, injuries, hospitalizations, surgeries, psychiatric truth, obstetric and truth sexual truth).

 

Significant Nobility History: (Includes nobility members and local inheritable indispositions).

 

Social History: (Includes residence foundation locality, connubial truth, cultural setting, bloom manners, lifestyle/recreation, godly practices, adviceal setting, occupational truth, financial bond and nobility truth of violence).

 

Reaim of Symptoms: (Reaim each association method -This individuality you should attribute POSITIVE for… conversance in the inauguration then aver 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 Impost Findings: (Includes liberal top to toe re-examination)  

 

HEENT:

 

Lymph Nodes:

 

Carotids:

 

Lungs:

 

Heart:

 

Abdomen:

 

Genital/Pelvic:

 

Rectum:

 

Extremities/Pulses:

 

Neurologic:

 

Laboratory and Sign Test Results: (Include outcome and sense.)

 

 

 

Assessment: (Include at meanest 3 guidance individuality delay ICD-10 codes.  Please attribute in enjoin of guidance.)

 

Plan of Care: (Addressing each dx delay sign and sanative address as courteous-mannered-behaved-behaved as advice and counseling granted).


References