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NURSING

Module 03 Content

1.

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Module 03 Content

 

It is nearly impossible to learn EVERYTHING about EVERY SINGLE drug we encounter. While it is important for us to look up select information about unfamiliar medications we administer, we can know the general indications and nursing interventions related to a drug if we learn key information about the drug classifications. For this assignment, you will be collecting information about different groups of drugs, or drug classifications, found in your Pharmacology textbook and creating a PowerPoint presentation (5-10 slides long).

Choose a drug classification (Examples: Typical or Atypical Antipsychotics, Anxiolytics, SSRI, Tricyclic Antidepressants, MAOI, mood stabilizers, opiates, NSAIDs, etc.) that is discussed in Unit Six or Unit Seven in Pharmacology: A Patient-Centered Nursing Process Approach textbook and then use your Davis’s Drug Guide or another SCHOLARLY source to provide the following information:

1. Summary of the Drug Classification (what different medical conditions are these drugs used to treat?) and list the names of 2-4 drugs in your chosen drug classification

2. Typical routes of administration

3. Common side effects and adverse effects common for the drug classification

4. Special considerations (caution with renal or liver insufficiency, harmful drug-drug interactions, etc.)

5. Common Nursing interventions and important client teaching

 

Please DO NOT just copy/paste your information from your textbook or drug guide–put the information into your own words. You DO NOT need to use APA formatting for your submission (because this is a PowerPoint), but please do include your references (in APA format) in the last slide. 

 


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nursing

Postpartum Hemorrhage Simulation Preparation/Pre-brief

Tina Nelson delivered a healthy male infant 6 hours ago. She had a midline episiotomy. This is her third pregnancy. She is now a G3P3003. She had an epidural block for her labor and delivery. She is now admitted to the postpartum unit.

1. What is important to note in the initial postpartum assessment? Include at least 5 assessments. Why is it important to assess for these things and what do the findings mean?

2. What are potential indications of a postpartum hemorrhage? List at least three indications.

3. What would you do if you found a boggy uterus?

4. What are the normal dose range and administration routes for oxytocin?

a. Induction/Stimulation of Labor:

b. Postpartum Hemorrhage:

c. Incomplete/Inevitable Abortion:

5. What are the contraindication, side effects, and adverse effects of oxytocin?

6. Complete the following dosage calculation:

a. The physician has ordered 1000 mL Lactated Ringers (LR) with 10 units IV oxytocin. Begin at 1 mU/min and then increase by 1 mU/min every 30 minutes until regular contractions occur. Maximum dose is 20 mU/min.

i. What is the beginning IV rate in mL/hr?

ii. What is the maximum IV rate in mL/hr?

7. What is the indication for Methergine, and what is a normal dose?

a. What are contraindications for Methergine?

b. What are the adverse reactions or possible side effects for Methergine?

8. What interventions would you anticipate in the event of a postpartum hemorrhage (independent and dependent nursing interventions)? List at least 5 interventions in order of priority.

nursing

Templates

· Diabetes Mellitus Management : Using Regular insulin Peak ,Onset , and Duration – Medication Templates.

· Information Technology : Reporting a Care Deficit – Basic Concept template

· Mobility and Immobility : Priority action for a client who is immobile – System disorder templates

· Nutrition and oral Hydration : addressing physical limitations with feedings – Basic concepts templates

· Nutrition and oral hydration: Calculating intake . Basic concept templates

· Pressure Ulcers, Wounds, and Wound Management : Laboratory values indicating infection . – Basic concepts . templates .

· Thorax, Heart and Abdomen : Sequence for auscultating bowel sounds. – Nursing skills templates.

Nursing

Describe the measurable nursing outcome desired related to the improvement of the patient’s condition-Fully stated the desired and measurable nursing outcome related to the improvement of the patient’s condition.

Identify a nursing theory to align with the plan of care to improve this patient’s outcome-Completely identified and thoroughly described a nursing theory aligned with a plan of care to improve this patient outcome.

Provide a summary explaining the nursing theory and alignment to nursing practice, critical thinking, and the clinical decision-making process.-Completely and fully defined the nursing theory concepts that align to nursing practice, critical thinking, and clinical decision-making processes.

Provide a summary explaining how the nursing theory and alignment of nursing practice, critical thinking, and the clinical decision-making process can improve the nursing care plan.-Completely and thoroughly described how the alignment of nursing theory concepts and nursing practice, critical thinking, and clinical decision-making process can improve the nursing care plan.

Create a concept map.-Create a complete and detailed concept map using visual presentation software from the college of education technology resource library that correctly showed the integration of the nursing theory into the plan of care.

APA Guidelines-Properly formatted according to APA guidelines, and it included correct APA citations for all sources.

nursing

Templates

· Diabetes Mellitus Management : Using Regular insulin Peak ,Onset , and Duration – Medication Templates.

· Information Technology : Reporting a Care Deficit – Basic Concept template

· Mobility and Immobility : Priority action for a client who is immobile – System disorder templates

· Nutrition and oral Hydration : addressing physical limitations with feedings – Basic concepts templates

· Nutrition and oral hydration: Calculating intake . Basic concept templates

· Pressure Ulcers, Wounds, and Wound Management : Laboratory values indicating infection . – Basic concepts . templates .

· Thorax, Heart and Abdomen : Sequence for auscultating bowel sounds. – Nursing skills templates.

nursing

1

Gastroenteritis

Name

United State University

Primary Health of Acute Client/Family Across the Lifespan: xxx

Professor xxxxx

Gastroenteritis in Children

Introduction

The presentation of the 6-months old male patient, brought in by the mother to the clinic is a requirement since the prenatal consent is needed for the best intervention. There was no medical history since when the baby was born healthy and has an exclusive breastfeeding that indicate that there are no previous warning signs.

Below are the questions I would ask the mother.

1. Ask of the mother about the onset of the symptoms, knowing when the symptoms began can assist determine the severity of the dehydration

2. Ask the mother, when she check the temperature of the baby, what does the thermometer show?

3. Have you given any over-the counter medication to help with the fever and diarrhea? If so, what medication is it, how often do you give it to the child, and when was the last time you gave it to him?

4. How many times has the child had diarrhea in a single day, what are the features of the baby’s feces in terms of color, volume, and frequency and how many soiled diapers do you change every day on average?

5. Apart from your baby, is there anyone in your household that is ill? Is there a recent travel with the baby?

The questions directed to the mother of the 6-months old baby is important for the nurse practitioner to get the information that would drive the evaluation and diagnosis of the diseases. The mother sharing about the latest over-the counter medication would guide about the intervention that would be done that would ensure that there is no reaction that might affect the baby in a detrimental manner (Fries, 2020). The nurse practitioner’s questions are critical in guiding about the experiences with the baby since there was no medical history and gives a hint about the differential diagnoses that would be focused on to offer quality evaluation and care.

Addition symptoms and Signs that Needs ER

At 100.4 degrees Fahrenheit, a person has a fever. In many cases, doctors advise against treating fevers below 101°F. Due to the body’s natural response to infection, a fever is a common sign of illness. Fever is a sign that your child’s immune system is working properly (Fields, 2016). In case the child temperature is measured and stated temperature above 100.3°F, are sluggish, and aren’t taking in any fluids should be sent to the emergency room immediately.

Continuous Vomiting

A consistent vomiting in the 6-months baby is a serious condition that demands for an immediate intervention and the child must be taken in an emergency room. Vomiting result to an excessive loss of fluids in the body of the baby and this puts the life at high risk (Fields, 2016). Taking the baby to the emergency room makes sure that the lost fluid is restored.

Fast breathing and Breathing Problems

The baby should be taken to an emergency room when fast breathing or difficulty is experienced because it is considered part of pediatric emergency. The issue of breathing challenges is an urgent intervention that a doctor needs to undertake taking the baby to the emergency room.

Other additional signs are difficult-to-rouse child with no tears or mucous membranes, blood in the stool, higher or lower respiration, reduced urine output, pale cool complexion with irritation, hollow eyes, and sunken fontanelles would all indicate that the infant should be taken to the ED (Munde, 2019).

Top 3 Differential Diagnoses

The differential diagnosis is an important clinical exercise that makes sure that the nurse practitioners highlight the disease that the patient is suffering from by eliminating those that share some signs and symptoms. Based on the patient’s mother and the medical history that shows that the baby was well all along until the current symptoms of diarrhea and fever, there are three top differential diagnosis that include

Parasitic gastroenteritis: ICD-10-CM B82.9 is a contagious disease or spread by an invading organism.

Rotavirus: ICD-10-CM A08.0 is a viral infection that produces gastrointestinal symptoms such as diarrhea and other gastrointestinal issues.

Acute Gastroenteritis: ICD-10-CM A08.19 is a condition caused by pathogenic bacteria such as Clostridium and Vibrio cholera present in the food or water supply

The three diseases are the top because they have related symptoms that can be confused by the nurse practitioners during diagnosis. The highlighted signs that is diarrhea and fever are present in the diseases highlighted and they also have kind of interrelation, and this demands for differential diagnosis to get the right disease for medication (Fries, 2020).

One of the most common causes of death among children in the U.S is gastroenteritis. To put it another way, it is when you get diarrhea for no apparent reason other than dehydration, and it might come on suddenly or gradually. Prevalence is highest amongst children as young age 5. Diarrhea in children is the most common reason for their hospitalization. The bacteria salmonella and shigella also cause severe gastroenteritis in children younger than five years old, but they are not the only cause. Giardia fragilis and Cryptosporidium are two parasites that can cause gastroenteritis in a tiny percentage of the population (Ögren et al., 2020). For children who can take oral hydration but are vomiting, professionally prepared oral hydration might be an option. Start with little amounts of liquid and gradually increase the amount of liquid as the youngster is able to handle. A trip to the emergency room is necessary if a child is critically dehydrated and needs intravenous fluids and hemodynamic monitoring (Malbrain et al., 2020). Proper handwashing is the first step in preventing gastroenteritis. Teaching children, mothers, and their caregivers how to wash their hands properly is critical, as is making sure they are aware of the dangers of food contamination that has been improperly stored.

Conclusion

To conclude, acute diarrhea in children should be treated as quickly as possible in order to avoid dehydration. The initial treatment for mild dehydration is oral rehydration. Children should be taught proper hygiene, for which cleaning hands properly prevent gastroenteritis.


References

Fields, L. (2016). 7 Serious Symptoms in Babies and Toddlers. WebMD. Retrieved 12 January 2022, from
https://www.webmd.com/children/features/serious-symptoms-babies-toddlers

Malbrain, M. L., Langer, T., Annane, D., Gattinoni, L., Elbers, P., Hahn, R. G., … & Van Regenmortel, N. (2020). Intravenous fluid therapy in the perioperative and critical care setting: executive summary of the International Fluid Academy (IFA). Annals of Intensive Care10(1), 1-19.

Munde, C. (2019). Hydriatic Treatment of Scarlet Fever in its Different Forms. Good Press.

Ögren, J., Dienus, O., & Matussek, A. (2020). Optimization of routine microscopic and molecular detection of parasitic protozoa in SAF-fixed faecal samples in Sweden. Infectious Diseases52(2), 87-96.

Nursing

Describe the measurable nursing outcome desired related to the improvement of the patient’s condition-Fully stated the desired and measurable nursing outcome related to the improvement of the patient’s condition.

Identify a nursing theory to align with the plan of care to improve this patient’s outcome-Completely identified and thoroughly described a nursing theory aligned with a plan of care to improve this patient outcome.

Provide a summary explaining the nursing theory and alignment to nursing practice, critical thinking, and the clinical decision-making process.-Completely and fully defined the nursing theory concepts that align to nursing practice, critical thinking, and clinical decision-making processes.

Provide a summary explaining how the nursing theory and alignment of nursing practice, critical thinking, and the clinical decision-making process can improve the nursing care plan.-Completely and thoroughly described how the alignment of nursing theory concepts and nursing practice, critical thinking, and clinical decision-making process can improve the nursing care plan.

Create a concept map.-Create a complete and detailed concept map using visual presentation software from the college of education technology resource library that correctly showed the integration of the nursing theory into the plan of care.

APA Guidelines-Properly formatted according to APA guidelines, and it included correct APA citations for all sources.

nursing

1

Gastroenteritis

Name

United State University

Primary Health of Acute Client/Family Across the Lifespan: xxx

Professor xxxxx

Gastroenteritis in Children

Introduction

The presentation of the 6-months old male patient, brought in by the mother to the clinic is a requirement since the prenatal consent is needed for the best intervention. There was no medical history since when the baby was born healthy and has an exclusive breastfeeding that indicate that there are no previous warning signs.

Below are the questions I would ask the mother.

1. Ask of the mother about the onset of the symptoms, knowing when the symptoms began can assist determine the severity of the dehydration

2. Ask the mother, when she check the temperature of the baby, what does the thermometer show?

3. Have you given any over-the counter medication to help with the fever and diarrhea? If so, what medication is it, how often do you give it to the child, and when was the last time you gave it to him?

4. How many times has the child had diarrhea in a single day, what are the features of the baby’s feces in terms of color, volume, and frequency and how many soiled diapers do you change every day on average?

5. Apart from your baby, is there anyone in your household that is ill? Is there a recent travel with the baby?

The questions directed to the mother of the 6-months old baby is important for the nurse practitioner to get the information that would drive the evaluation and diagnosis of the diseases. The mother sharing about the latest over-the counter medication would guide about the intervention that would be done that would ensure that there is no reaction that might affect the baby in a detrimental manner (Fries, 2020). The nurse practitioner’s questions are critical in guiding about the experiences with the baby since there was no medical history and gives a hint about the differential diagnoses that would be focused on to offer quality evaluation and care.

Addition symptoms and Signs that Needs ER

At 100.4 degrees Fahrenheit, a person has a fever. In many cases, doctors advise against treating fevers below 101°F. Due to the body’s natural response to infection, a fever is a common sign of illness. Fever is a sign that your child’s immune system is working properly (Fields, 2016). In case the child temperature is measured and stated temperature above 100.3°F, are sluggish, and aren’t taking in any fluids should be sent to the emergency room immediately.

Continuous Vomiting

A consistent vomiting in the 6-months baby is a serious condition that demands for an immediate intervention and the child must be taken in an emergency room. Vomiting result to an excessive loss of fluids in the body of the baby and this puts the life at high risk (Fields, 2016). Taking the baby to the emergency room makes sure that the lost fluid is restored.

Fast breathing and Breathing Problems

The baby should be taken to an emergency room when fast breathing or difficulty is experienced because it is considered part of pediatric emergency. The issue of breathing challenges is an urgent intervention that a doctor needs to undertake taking the baby to the emergency room.

Other additional signs are difficult-to-rouse child with no tears or mucous membranes, blood in the stool, higher or lower respiration, reduced urine output, pale cool complexion with irritation, hollow eyes, and sunken fontanelles would all indicate that the infant should be taken to the ED (Munde, 2019).

Top 3 Differential Diagnoses

The differential diagnosis is an important clinical exercise that makes sure that the nurse practitioners highlight the disease that the patient is suffering from by eliminating those that share some signs and symptoms. Based on the patient’s mother and the medical history that shows that the baby was well all along until the current symptoms of diarrhea and fever, there are three top differential diagnosis that include

Parasitic gastroenteritis: ICD-10-CM B82.9 is a contagious disease or spread by an invading organism.

Rotavirus: ICD-10-CM A08.0 is a viral infection that produces gastrointestinal symptoms such as diarrhea and other gastrointestinal issues.

Acute Gastroenteritis: ICD-10-CM A08.19 is a condition caused by pathogenic bacteria such as Clostridium and Vibrio cholera present in the food or water supply

The three diseases are the top because they have related symptoms that can be confused by the nurse practitioners during diagnosis. The highlighted signs that is diarrhea and fever are present in the diseases highlighted and they also have kind of interrelation, and this demands for differential diagnosis to get the right disease for medication (Fries, 2020).

One of the most common causes of death among children in the U.S is gastroenteritis. To put it another way, it is when you get diarrhea for no apparent reason other than dehydration, and it might come on suddenly or gradually. Prevalence is highest amongst children as young age 5. Diarrhea in children is the most common reason for their hospitalization. The bacteria salmonella and shigella also cause severe gastroenteritis in children younger than five years old, but they are not the only cause. Giardia fragilis and Cryptosporidium are two parasites that can cause gastroenteritis in a tiny percentage of the population (Ögren et al., 2020). For children who can take oral hydration but are vomiting, professionally prepared oral hydration might be an option. Start with little amounts of liquid and gradually increase the amount of liquid as the youngster is able to handle. A trip to the emergency room is necessary if a child is critically dehydrated and needs intravenous fluids and hemodynamic monitoring (Malbrain et al., 2020). Proper handwashing is the first step in preventing gastroenteritis. Teaching children, mothers, and their caregivers how to wash their hands properly is critical, as is making sure they are aware of the dangers of food contamination that has been improperly stored.

Conclusion

To conclude, acute diarrhea in children should be treated as quickly as possible in order to avoid dehydration. The initial treatment for mild dehydration is oral rehydration. Children should be taught proper hygiene, for which cleaning hands properly prevent gastroenteritis.


References

Fields, L. (2016). 7 Serious Symptoms in Babies and Toddlers. WebMD. Retrieved 12 January 2022, from
https://www.webmd.com/children/features/serious-symptoms-babies-toddlers

Malbrain, M. L., Langer, T., Annane, D., Gattinoni, L., Elbers, P., Hahn, R. G., … & Van Regenmortel, N. (2020). Intravenous fluid therapy in the perioperative and critical care setting: executive summary of the International Fluid Academy (IFA). Annals of Intensive Care10(1), 1-19.

Munde, C. (2019). Hydriatic Treatment of Scarlet Fever in its Different Forms. Good Press.

Ögren, J., Dienus, O., & Matussek, A. (2020). Optimization of routine microscopic and molecular detection of parasitic protozoa in SAF-fixed faecal samples in Sweden. Infectious Diseases52(2), 87-96.

nursing

1

Well Exam Child Soap Note

Name xxx

United State University

Primary Health of Acute Clients/Families Across the Lifespan-Clinical Practicum xxx

Professor xxx

Date xxx

Well Exam Child Soap Note

SUBJECTIVE

ID: S.J, Age: 8, Race: African American, Gender: Female, Date of Birth: January 15, 2014, Insurance: N/A

CC: “I came for my annual wellness visit.”

HPI: S.J is an eight-year-old female who presents to the clinic for her annualwellness examination alongside her mother. The patient comes in for a her annual checkup and currently has no worrying medical concerns. The patient answers questions accurately and looks healthy. She leaves with her father, mother, and 2 siblings. Her last wellness exam was done on January 5, 2021, and she turned out to be healthy.

PAST MEDICAL HISTORY: The patient was treated for pneumonia in May 2020 using amoxicillin. No surgery history.

CURRENT MEDICATIONS: None.

IMMUNIZATION: Patient has received all recommended immunizations for her age, including Tetanus diphtheria, Tdap, Hpv human papillomavirus, meningococcal, pneumonia, hepatitis B, hepatitis A, Polio, MMR measles, mumps, rubella, chickenpox vavicella, and flu vaccine.

PREGNANCY AND BIRTH HISTORY: Mother says she has never used illegal substances, smoked cigarettes, or consumed alcoholic beverages. She stated that the patient was delivered vaginally at full term, and patient was able to breastfeed without difficulty.

Developmental History: According to the patient’s mother, the patient met all developmental age-related milestones on time.

FAMILY HISTORY: The parents of the patient are both alive and together. The father is 41 years old and is allergic to pollen. The mother is 37 years old and suffers from hypertension, which she manages by a healthy lifestyle and Losartan 25mg PO. The patient has 4 years old twin brothers who are healthy and have no medical history. The patient’s paternal grandmother is 69 years old and suffers from arthritis. The grandmother has been on nonsteroidal anti-inflammatory drugs to manage the condition. The paternal grandfather is 74 years old and suffers from mild dementia. His memory is deteriorating, and he is having difficulties remembering past events. He has been in therapy to help him with his memory.

SOCIAL HISTORY: The patient lives with her father, mother, and younger brother. She studies at a school near her home. She is a performer and wants to be a surgeon when she grows up. She has a friend she schools with called Emma. Both enjoy dancing and are in a dancing class. She enjoys eating pancakes and juice.

DIET: The patient claims to consume red meat twice a week, enjoys cake and sugary drinks, and dislikes vegetables. However, she claims to eat an apple at least twice a week.

SLEEP/STRESS: She goes to bed between 8:00 and 9:00 p.m. and sleeps for at least nine hours.

SAFETY: When riding a bicycle or scooter, the patient take precautions such as wearing a helmet and knee protection. When she is in a vichicle, she also wears a belt.

SPIRITUAL AFFLIATIONS: Christian

REVIEW OF SYSTEMS

GENERAL: The patient disagrees with having a high fever, weight increase, night sweats, change in appetite, weight loss, low exercise tolerance, and fatigue.

HAIR, SKIN, AND NAILS: The patient denies rashes, no color changes, no sunburns, and nodes.

HEAD: The patient denies frequent headaches, visual changes, redness, no injury, or drainage.

NECK: The patient does not feel pain or stiffness in the neck—no noted masses or edema.

EYES: No scotomata, no tearing, no pain. The patient has normal vision. She has itchy eyes due to landscaping.

EARS: The patient denies bleeding, having any hearing difficulties, bleeding, tinnitus. No vertigo.

NOSE: Denies nasal drainage and congestion. Throat: Denies throat or neck pain, sore throat, edema, hoarseness, difficulty swallowing.

MOUTH & THROAT: The patient denies edema, sore throat, complications absorption, hoarseness, no dental complications, no use of dentures.

CARDIOVASCULAR: The patient doesn’t suffer from peripheral edema, chest pain, or palpitations.

GASTROINTESTINAL: The patient disagrees with having abdominal pain. She disagrees with having nausea, disgorging, or cramps.

PULMONARY: Normal

ENDOCRINE: The patient has a normal appetite and denies extreme thirst or unconscious prejudice.

LYMPHATICS: The patient has no tender lymph nodes.

GENITOURINARY: The patient has negative dysuria. Denies difficulty starting/stopping a stream of urine or incontinence.

HAEMATOLOGICAL: denies bruising, blood clots, or history of blood transfusions.

MUSCULOSKELETAL: The patient refutes redness and edema to muscles.

INTEGUMENTARY: Denies rash, hives, dry skin, lesions.

NEUROLOGICAL: The patient has no memory loss or confusion problems.

PSYCHIATRIC: The patient denies extreme sadness, mood fluctuations, or sleeplessness.

ALLERGIC: smoke from cigarettes, pollen.

OBJECTIVE

VITAL SIGNS: Temp 97.8 F, RR 32, HR 85, B/P 100/70, SpO2 100%, BMI 25.63 kg/m², Wt 70 lb , Ht 4.2″.

PHYSICAL EXAMINATION

GENERAL APPEARANCE: Vigilant, well-groomed female. No acute pains were detected. She is presentable.

HEENT: Normocephalic. Atraumatic. Eyes: PERRLA. NAOMI. No nystagmus bilateral, Pupils are equal, round, and sensitive to light reconciliation. Ears: Bilateral outer ears are normal—free from drainage. Nose: Sputum is midline. No alterations. It is symmetrical, and vessels expound in the mutual snout with transparent drainage. 

NECK: Flexible and balanced. No tracheal variation. No goiter noted—no inflamed lymph node.

ABDOMEN: The patient has a gentle and non-tender flat belly. There was no inguinal found. No ascites were discovered.

RESPIRATORY: Normal

CARDIOVASCULAR: Denies chest pains, palpitations, extremity swelling, or chest stiffness.

GENITOURINARY: No wing, suprapubic sympathy, or CVA devotion.

SKIN: Skin looks hydrated and glowing. 

MUSCULOSKELETAL: No joint malformation was noticed. Her spine aroused straight calibration without any curving. 

NEUROLOGIC: No cerebellar signs or symptoms, no neural shortfall.

PSYCHIATRIC: Factual to time. Content and appropriate.

ASSESSMENT

DIFFERENTIAL DX:

Wellness Exam: ICD-10 CM Z00.129. A healthy female who came for a well exam. According to the American Academy of Pediatrics, surveillance should be done at each clinic visit for formal developmental screening.

Other nonmedicinal substance allergy status: ICD-10-CM Z91.048. Patient is allergic to smoke from cigarettes, and pollen, evidenced by patient verbalizing that she experiences sneezing, watering, itchy and red eyes

Dietary surveillance and counseling ICD-10-CM Z71.3 Healthy growth and development of a child are aided by nutritious meals. Following the CACFP, a child should be provided nutritious foods in appropriate portion sizes. The meals include fruits, diary, bread, grains, vegetables and meat or meat substitutes. In addition, the child should be taught about good dietary habits. Juices and sugary drinks should be avoided at all costs. It is important to urge them to drink milk and water.

FINAL DIAGNOSIS: Wellness: ICD-10-CM Z00.129

PLAN

CBC for overall wellness check

Annaul well exam to follow up on immunizations, development, and safety issues.

EDUCATION: the patient was advised to continue maintaining a healthy lifestyle, take in a lot of water, fruits, vegetable, whole grains, fat-free and low diary products. A good vriety of protein-rich food, healthy oils derived from fish and vegetables and (Goolamally et al., 2019). She was also advised to take food rich in calcium to help maintain strong bones. Educate the patient on the importance of having an adult oversee them at all times when swimming to avoid a drowning accident. Educate the mother to seek emergency medical attention if the child experience severe shortness of breath or any other symptoms of an exacerbated allergic response.

Follow up in a month to discuss dietary modifications that will help the child maintain a healthy weight and avoid obesity.

REFERRALS: None at this time

Reference

Goolamally, N., Hamid, S. A., Ramli, A. Z., & Rahim, R. A. (2019). Application of rasch model in measuring the quality of health and wellness final exam questions.

nursing

ACTIVE LEARNING TEMPLATES TherapeuTic procedure A1

Basic Concept
STUDENT NAME _____________________________________

CONCEPT ______________________________________________________________________________ REVIEW MODULE CHAPTER ___________

ACTIVE LEARNING TEMPLATE:

Related Content
(E.G., DELEGATION,
LEVELS OF PREVENTION,
ADVANCE DIRECTIVES)

Underlying Principles Nursing Interventions
WHO? WHEN? WHY? HOW?

  1. STUDENT NAME:
  2. CONCEPT:
  3. REVIEW MODULE CHAPTER:
  4. Related Content:
  5. Underlying Principles:
  6. Nursing Interventions:

Nursing

1. In a two-page APA formatted paper, discuss the following:

2. The staff are following the Parkland Formula for fluid resuscitation. The client arrived at 0200 and was admitted at 0400. She weighs 110 pounds. Calculate her fluid requirement, using the Parkland formula. Explain the time intervals and amounts for each.

3. The client was sleeping when the fire started and managed to make her way out of the house through thick smoke. You are concerned about possible smoke inhalation. What assessment finding would corroborate this concern?

4. The client is in severe pain. What is the drug of choice for pain relief and how should it be given?

5. What nutritional requirements are necessary for the client’s burns to heal?

6. What measures are taken with the client to prevent infection?

nursing

Nursing Care of the Older Adult

Module 05 Assignment – Case Study Concept Map and Plan of Care


Concept Map:

Primary Medical Diagnosis:

·

Prioritized Nursing Dx# 2

·

Prioritized Nursing Dx# 6

·

Prioritized Nursing Dx# 5

·

Prioritized Nursing Dx# 3

·

Prioritized Nursing Dx# 1

·

Prioritized Nursing Dx# 4

·


Nursing Plan of Care

Prioritized Nursing Diagnoses

Goal

Nursing Interventions

nursing

1

Well Exam Child Soap Note

Name xxx

United State University

Primary Health of Acute Clients/Families Across the Lifespan-Clinical Practicum xxx

Professor xxx

Date xxx

Well Exam Child Soap Note

SUBJECTIVE

ID: S.J, Age: 8, Race: African American, Gender: Female, Date of Birth: January 15, 2014, Insurance: N/A

CC: “I came for my annual wellness visit.”

HPI: S.J is an eight-year-old female who presents to the clinic for her annualwellness examination alongside her mother. The patient comes in for a her annual checkup and currently has no worrying medical concerns. The patient answers questions accurately and looks healthy. She leaves with her father, mother, and 2 siblings. Her last wellness exam was done on January 5, 2021, and she turned out to be healthy.

PAST MEDICAL HISTORY: The patient was treated for pneumonia in May 2020 using amoxicillin. No surgery history.

CURRENT MEDICATIONS: None.

IMMUNIZATION: Patient has received all recommended immunizations for her age, including Tetanus diphtheria, Tdap, Hpv human papillomavirus, meningococcal, pneumonia, hepatitis B, hepatitis A, Polio, MMR measles, mumps, rubella, chickenpox vavicella, and flu vaccine.

PREGNANCY AND BIRTH HISTORY: Mother says she has never used illegal substances, smoked cigarettes, or consumed alcoholic beverages. She stated that the patient was delivered vaginally at full term, and patient was able to breastfeed without difficulty.

Developmental History: According to the patient’s mother, the patient met all developmental age-related milestones on time.

FAMILY HISTORY: The parents of the patient are both alive and together. The father is 41 years old and is allergic to pollen. The mother is 37 years old and suffers from hypertension, which she manages by a healthy lifestyle and Losartan 25mg PO. The patient has 4 years old twin brothers who are healthy and have no medical history. The patient’s paternal grandmother is 69 years old and suffers from arthritis. The grandmother has been on nonsteroidal anti-inflammatory drugs to manage the condition. The paternal grandfather is 74 years old and suffers from mild dementia. His memory is deteriorating, and he is having difficulties remembering past events. He has been in therapy to help him with his memory.

SOCIAL HISTORY: The patient lives with her father, mother, and younger brother. She studies at a school near her home. She is a performer and wants to be a surgeon when she grows up. She has a friend she schools with called Emma. Both enjoy dancing and are in a dancing class. She enjoys eating pancakes and juice.

DIET: The patient claims to consume red meat twice a week, enjoys cake and sugary drinks, and dislikes vegetables. However, she claims to eat an apple at least twice a week.

SLEEP/STRESS: She goes to bed between 8:00 and 9:00 p.m. and sleeps for at least nine hours.

SAFETY: When riding a bicycle or scooter, the patient take precautions such as wearing a helmet and knee protection. When she is in a vichicle, she also wears a belt.

SPIRITUAL AFFLIATIONS: Christian

REVIEW OF SYSTEMS

GENERAL: The patient disagrees with having a high fever, weight increase, night sweats, change in appetite, weight loss, low exercise tolerance, and fatigue.

HAIR, SKIN, AND NAILS: The patient denies rashes, no color changes, no sunburns, and nodes.

HEAD: The patient denies frequent headaches, visual changes, redness, no injury, or drainage.

NECK: The patient does not feel pain or stiffness in the neck—no noted masses or edema.

EYES: No scotomata, no tearing, no pain. The patient has normal vision. She has itchy eyes due to landscaping.

EARS: The patient denies bleeding, having any hearing difficulties, bleeding, tinnitus. No vertigo.

NOSE: Denies nasal drainage and congestion. Throat: Denies throat or neck pain, sore throat, edema, hoarseness, difficulty swallowing.

MOUTH & THROAT: The patient denies edema, sore throat, complications absorption, hoarseness, no dental complications, no use of dentures.

CARDIOVASCULAR: The patient doesn’t suffer from peripheral edema, chest pain, or palpitations.

GASTROINTESTINAL: The patient disagrees with having abdominal pain. She disagrees with having nausea, disgorging, or cramps.

PULMONARY: Normal

ENDOCRINE: The patient has a normal appetite and denies extreme thirst or unconscious prejudice.

LYMPHATICS: The patient has no tender lymph nodes.

GENITOURINARY: The patient has negative dysuria. Denies difficulty starting/stopping a stream of urine or incontinence.

HAEMATOLOGICAL: denies bruising, blood clots, or history of blood transfusions.

MUSCULOSKELETAL: The patient refutes redness and edema to muscles.

INTEGUMENTARY: Denies rash, hives, dry skin, lesions.

NEUROLOGICAL: The patient has no memory loss or confusion problems.

PSYCHIATRIC: The patient denies extreme sadness, mood fluctuations, or sleeplessness.

ALLERGIC: smoke from cigarettes, pollen.

OBJECTIVE

VITAL SIGNS: Temp 97.8 F, RR 32, HR 85, B/P 100/70, SpO2 100%, BMI 25.63 kg/m², Wt 70 lb , Ht 4.2″.

PHYSICAL EXAMINATION

GENERAL APPEARANCE: Vigilant, well-groomed female. No acute pains were detected. She is presentable.

HEENT: Normocephalic. Atraumatic. Eyes: PERRLA. NAOMI. No nystagmus bilateral, Pupils are equal, round, and sensitive to light reconciliation. Ears: Bilateral outer ears are normal—free from drainage. Nose: Sputum is midline. No alterations. It is symmetrical, and vessels expound in the mutual snout with transparent drainage. 

NECK: Flexible and balanced. No tracheal variation. No goiter noted—no inflamed lymph node.

ABDOMEN: The patient has a gentle and non-tender flat belly. There was no inguinal found. No ascites were discovered.

RESPIRATORY: Normal

CARDIOVASCULAR: Denies chest pains, palpitations, extremity swelling, or chest stiffness.

GENITOURINARY: No wing, suprapubic sympathy, or CVA devotion.

SKIN: Skin looks hydrated and glowing. 

MUSCULOSKELETAL: No joint malformation was noticed. Her spine aroused straight calibration without any curving. 

NEUROLOGIC: No cerebellar signs or symptoms, no neural shortfall.

PSYCHIATRIC: Factual to time. Content and appropriate.

ASSESSMENT

DIFFERENTIAL DX:

Wellness Exam: ICD-10 CM Z00.129. A healthy female who came for a well exam. According to the American Academy of Pediatrics, surveillance should be done at each clinic visit for formal developmental screening.

Other nonmedicinal substance allergy status: ICD-10-CM Z91.048. Patient is allergic to smoke from cigarettes, and pollen, evidenced by patient verbalizing that she experiences sneezing, watering, itchy and red eyes

Dietary surveillance and counseling ICD-10-CM Z71.3 Healthy growth and development of a child are aided by nutritious meals. Following the CACFP, a child should be provided nutritious foods in appropriate portion sizes. The meals include fruits, diary, bread, grains, vegetables and meat or meat substitutes. In addition, the child should be taught about good dietary habits. Juices and sugary drinks should be avoided at all costs. It is important to urge them to drink milk and water.

FINAL DIAGNOSIS: Wellness: ICD-10-CM Z00.129

PLAN

CBC for overall wellness check

Annaul well exam to follow up on immunizations, development, and safety issues.

EDUCATION: the patient was advised to continue maintaining a healthy lifestyle, take in a lot of water, fruits, vegetable, whole grains, fat-free and low diary products. A good vriety of protein-rich food, healthy oils derived from fish and vegetables and (Goolamally et al., 2019). She was also advised to take food rich in calcium to help maintain strong bones. Educate the patient on the importance of having an adult oversee them at all times when swimming to avoid a drowning accident. Educate the mother to seek emergency medical attention if the child experience severe shortness of breath or any other symptoms of an exacerbated allergic response.

Follow up in a month to discuss dietary modifications that will help the child maintain a healthy weight and avoid obesity.

REFERRALS: None at this time

Reference

Goolamally, N., Hamid, S. A., Ramli, A. Z., & Rahim, R. A. (2019). Application of rasch model in measuring the quality of health and wellness final exam questions.

Nursing

1. In a two-page APA formatted paper, discuss the following:

2. The staff are following the Parkland Formula for fluid resuscitation. The client arrived at 0200 and was admitted at 0400. She weighs 110 pounds. Calculate her fluid requirement, using the Parkland formula. Explain the time intervals and amounts for each.

3. The client was sleeping when the fire started and managed to make her way out of the house through thick smoke. You are concerned about possible smoke inhalation. What assessment finding would corroborate this concern?

4. The client is in severe pain. What is the drug of choice for pain relief and how should it be given?

5. What nutritional requirements are necessary for the client’s burns to heal?

6. What measures are taken with the client to prevent infection?

nursing

ACTIVE LEARNING TEMPLATES TherapeuTic procedure A11

System Disorder
STUDENT NAME _____________________________________

DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________

ACTIVE LEARNING TEMPLATE:

ASSESSMENT SAFETY
CONSIDERATIONS

PATIENT-CENTERED CARE

Alterations in
Health (Diagnosis)

Pathophysiology Related
to Client Problem

Health Promotion and
Disease Prevention

Risk Factors Expected Findings

Laboratory Tests Diagnostic Procedures

Complications

Therapeutic Procedures Interprofessional Care

Nursing Care Client EducationMedications

  1. STUDENT NAME:
  2. DISORDERDISEASE PROCESS:
  3. REVIEW MODULE CHAPTER:
  4. Pathophysiology Related to Client Problem:
  5. Health Promotion and Disease Prevention:
  6. Risk Factors:
  7. Expected Findings:
  8. Laboratory Tests:
  9. Diagnostic Procedures:
  10. Nursing Care:
  11. Therapeutic Procedures:
  12. Medications:
  13. Client Education:
  14. Interprofessional Care:
  15. Alterations in Health:
  16. Safety Considerations:
  17. Complications:

Nursing

 

Assignment Prompt

A 6-month-old male patient presents to your clinic with his mother. The mother’s chief complaint is that the baby has had a fever and diarrhea for several days and is not nursing as much as usual. The infant is quiet and warm, lung sounds are clear, heart sounds normal. No medical history, born healthy at 39 weeks 5 days via uncomplicated vaginal delivery, he is exclusively breastfed and is up-to-date on his vaccinations. 

  • What are 5 questions you would ask the mother next?(Include rationales for questions)
  • What additional signs/symptoms would alert you that this infant may need to be transferred to the ER?
  • What are your top 3 differential diagnoses? (Include ICD codes and rationales)

Submission should be in APA format. Include an introduction/conclusion, etc. Review rubric carefully before submitting.

nursing

ACTIVE LEARNING TEMPLATES TherapeuTic procedure A7

Medication
STUDENT NAME _____________________________________

MEDICATION __________________________________________________________________________ REVIEW MODULE CHAPTER ___________

CATEGORY CLASS ______________________________________________________________________

ACTIVE LEARNING TEMPLATE:

PURPOSE OF MEDICATION

Expected Pharmacological Action

Complications

Contraindications/Precautions

Interactions

Medication Administration

Evaluation of Medication Effectiveness

Therapeutic Use

Nursing Interventions

Client Education

  1. STUDENT NAME:
  2. MEDICATION:
  3. REVIEW MODULE CHAPTER:
  4. CATEGORY CLASS:
  5. Therapeutic Use:
  6. Complications:
  7. Contraindications/Precautions:
  8. Interactions:
  9. Evaluation of Medication Effectiveness:
  10. Expected Pharmacological Action:
  11. Nursing Interventions:
  12. Medication Administration:
  13. Client Education:

Nursing

Adult Health

Hypertension Case study Paper


Category


Points

Percentage

Description

Pathology:

15 pts

· Define the patient’s disease process

· Explain the etiology of the disease process.

· Thoroughly explain signs and symptoms of disease process.

· State and explain any diagnostic measures utilized with this disease process.

· Cite sources

Assessment Data

10pt

· Clearly explain the difference between subjective and objection data.

· Identify Subjection and objection data that would be important to understand.

· Explain the information that would be information to understand from the chart.

· Identify the information from the chart that would be most helpful

· Identify what labs would be important to your assessment and why.

Medications

10pt

· Understand & explain first line treatment for the disease.

· Understand & explain second line treatment and why you would use second line treatment.

· Explain the patient’s medication: minimum of 3-5 medications.

· Explain the class of medication.

· Explain alternative therapies.

· Explain any Black Box warnings, contraindications, and nursing considerations for the medications.

· Identify 3-5 common side effects.

· Identify any medication interactions

· State the common indication for the prescribed medication.

· Explain 2 challenges that might prevent them from taking medication as prescribed.

· Cite sources

Diagnosis

10pt

· Provide 3 nursing diagnosis for the patients (primary physical, psychosocial and education) pertinent to this client’s medical diagnosis.

· List health assessment priorities for the nursing diagnosis.

· State 5 or more appropriate interventions with evidence-based practiced rationale for each action stated for each of the 3 primary nursing diagnosis (cite sources).

· Explain relevant lab work that is required with this medical diagnosis.

· Cite sources

Plan of care

15pt

· Explain what the patient is at risk for.

· Articulate safety concerns or issues at home.

· Explain 2 challenges that might prevent the patient from seeking medical care.

· Articulate all patient education for the patient and treatment plan.

· Explain an understanding of the diagnosis and treatment.

· Identify 2 short-term goals & 2 long-term goals.

· Identify 2 outcomes for the patients.

· Cite sources.

Discharge Instructions

10pt

· Articulate appropriate discharge instructions for these patients.

· Articulate appropriate follow-up care.

· Cite sources.

SOAPIE Note

10pt

The required elements include the following:

· Clear statement of subjective findings.

· Clear statement of objective findings.

· Clear statement of assessment findings.

· Clear statement of plan.

· Clear statement of interventions

· Clear statement of Evaluation

APA

20pts

All information taken from another source must be included on a reference listing using the 7th edition APA as per the Stratford University policy as of October 5th, 2020.

You are NOT allowed to use your book as a source Reference: You must use Peer Reviewed Sources/Articles.

Total

100

100

Nursing

Adult Health Case study

Hypertension

Professor Gallegos


HPI:

E.W. is a 40-year old African American male, who has had difficulty controlling his HTN lately. He is visiting his primary care provider for a thorough physical examination and to renew a prescription to continue his blood pressure medication.

PMH:

· Chronic sinus infections

· Hypertension for approximately 11 years

· Pneumonia 6 years ago that resolved with antibiotic therapy

· One major episode of major depressive illness caused by the suicide of his wife of 15 years, 5 years ago.

· No surgeries

· Allergies to Penicillin (Rash)

FH:

· Father died at age 49 from AMI; had HTN

· Mother has DM and HTN

· Brother died at age 20 from complication of CF

· Two younger sisters are A & W

SH:

The patient is a widower and lives alone. He has a 15-year-old son who lives with a maternal aunt. He has not spoken with his son for four years. The patient is an air traffic controller at the local airport. He smoked cigarettes for approximately 10 years but stopped smoking when he was diagnosed with HTN. He drinks “several beers every evening to relax” and does not pay particular attention to the sodium, fat or carbohydrate content of the foods that he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted. He takes an occasional walk but has no regular daily exercise program.

Meds:

· Hydrochlorothiazide 50 mg PO QD

· Pseudoephedrine hydrochloride 60 mg PO Q6hr prn

· Beclomethasone dipropionate 1 spray into each nostril Q6 hr prn

Review of Systems:

· States that his overall health has been fair to good during the past 12 months

· Weight has increased by approximately 20 pounds during the last year

· Denies chest pain, shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis

· Reports some shortness of breath with activity, especially when climbing stairs, and that breathing difficulties are getting worse

· Denies any nausea, vomiting, diarrhea, or blood in the stool

· Self-treats occasional right knee pain with OTC extra-strength acetaminophen

· Denies any genitourinary symptoms

Physical Exam and Lab tests

General:

The patient is an obese black man in no apparent distress. He appears to be his stated age.

Vital Signs:

BP: 155/96 sitting

HR: 73, regular

RR: 15, unlabored

Temp: 98.8 degrees F

Height: 5’11”

Weight: 221 lb

BMI: 31.

HEENT:

· Tympanic membrane intact and clear throughout

· No nasal drainage

· No exudates or erythema in oropharynx

· PERRLA, pupil diameter 3. mm bilaterally

· Sclera without icterus

· EOMI

· Fundoscopy reveals mild arteriolar narrowing with no nicking, hemorrhages, exudates, or papilledema.

Supple without masses or bruits

Thyroid normal

Negative lymphadenopathy

Lungs:

Mild basilar crackles bilaterally

No wheezes

Heart:

RRR

Prominent S3 sound

No murmurs or rubs

ABD:

Soft and nondistended

Non tender with no guarding or rebound

No masses, bruits, or organomegaly

Normal bowel sounds

Rectal/GU

Normal size prostate without nodules or asymmetry

Heme negative stool

Normal penis and testes

Ext:

No CCE

Limited ROM right knee

Neuro

No sensory or motor abnormalities

CNs II-XII intact

Negative Babinski

DTRs=2+

Muscle tone = 5/5 throughout

Laboratory tests

Na 139meq/L

RBC 5.9mil/mm33

Mg 2.4mg/dL

K 3.9meq/L

WBC 7,100/mm3

P04 3.9mg/dL

Cl 102meq/L

AST 29 IU/L

Uric acid 7.3mg/dL

HCO3 27 meq/L

ALT 43 IU/L

Glu, fasting 110mg/dL

BUN 17mg/dL

ALK phos 123 IU/L

T. Chol 275mg/dL

Cr 1.0mg/dL

GGT 119 IU/L

HDL 31mg/dL

HgB 16.9g/dL

T. Bilirubin 0.9mg/dL

LDL 179mg/dL

Hct 48%

T. protein 6.0g/dL

Trig 290mg/dL

Plt 235,000/mm3

Ca 9.3mg/dL

PSA 1.3ng/mL

Urinalysis results:

Appearance- clear, amber in color

Specific gravity- 1.017

Ph- 5.3

Protein- negative

RBC- 0

WBC- 0

Bacteria- negative

ECG:

Increased QRS voltage suggestive of LVH

ECHO:

Moderate LVH with EF = 46%

nursing

ACTIVE LEARNING TEMPLATES TherapeuTic procedure A9

Nursing Skill
STUDENT NAME _____________________________________

SKILL NAME ____________________________________________________________________________ REVIEW MODULE CHAPTER ___________

ACTIVE LEARNING TEMPLATE:

Description of Skill

Indications

Outcomes/Evaluation

CONSIDERATIONS

Nursing Interventions (pre, intra, post)

Potential Complications

Client Education

Nursing Interventions

  1. STUDENT NAME:
  2. SKILL NAME:
  3. REVIEW MODULE CHAPTER:
  4. Indications:
  5. Outcomes/Evaluation:
  6. Client Education:
  7. Potential Complications:
  8. Description of Skill:
  9. Nursing Interventions:
  10. Nursing Interventions (pre, intra, post):

Nursing

Adult Health Case study

Hypertension

Professor Gallegos


HPI:

E.W. is a 40-year old African American male, who has had difficulty controlling his HTN lately. He is visiting his primary care provider for a thorough physical examination and to renew a prescription to continue his blood pressure medication.

PMH:

· Chronic sinus infections

· Hypertension for approximately 11 years

· Pneumonia 6 years ago that resolved with antibiotic therapy

· One major episode of major depressive illness caused by the suicide of his wife of 15 years, 5 years ago.

· No surgeries

· Allergies to Penicillin (Rash)

FH:

· Father died at age 49 from AMI; had HTN

· Mother has DM and HTN

· Brother died at age 20 from complication of CF

· Two younger sisters are A & W

SH:

The patient is a widower and lives alone. He has a 15-year-old son who lives with a maternal aunt. He has not spoken with his son for four years. The patient is an air traffic controller at the local airport. He smoked cigarettes for approximately 10 years but stopped smoking when he was diagnosed with HTN. He drinks “several beers every evening to relax” and does not pay particular attention to the sodium, fat or carbohydrate content of the foods that he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted. He takes an occasional walk but has no regular daily exercise program.

Meds:

· Hydrochlorothiazide 50 mg PO QD

· Pseudoephedrine hydrochloride 60 mg PO Q6hr prn

· Beclomethasone dipropionate 1 spray into each nostril Q6 hr prn

Review of Systems:

· States that his overall health has been fair to good during the past 12 months

· Weight has increased by approximately 20 pounds during the last year

· Denies chest pain, shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis

· Reports some shortness of breath with activity, especially when climbing stairs, and that breathing difficulties are getting worse

· Denies any nausea, vomiting, diarrhea, or blood in the stool

· Self-treats occasional right knee pain with OTC extra-strength acetaminophen

· Denies any genitourinary symptoms

Physical Exam and Lab tests

General:

The patient is an obese black man in no apparent distress. He appears to be his stated age.

Vital Signs:

BP: 155/96 sitting

HR: 73, regular

RR: 15, unlabored

Temp: 98.8 degrees F

Height: 5’11”

Weight: 221 lb

BMI: 31.

HEENT:

· Tympanic membrane intact and clear throughout

· No nasal drainage

· No exudates or erythema in oropharynx

· PERRLA, pupil diameter 3. mm bilaterally

· Sclera without icterus

· EOMI

· Fundoscopy reveals mild arteriolar narrowing with no nicking, hemorrhages, exudates, or papilledema.

Supple without masses or bruits

Thyroid normal

Negative lymphadenopathy

Lungs:

Mild basilar crackles bilaterally

No wheezes

Heart:

RRR

Prominent S3 sound

No murmurs or rubs

ABD:

Soft and nondistended

Non tender with no guarding or rebound

No masses, bruits, or organomegaly

Normal bowel sounds

Rectal/GU

Normal size prostate without nodules or asymmetry

Heme negative stool

Normal penis and testes

Ext:

No CCE

Limited ROM right knee

Neuro

No sensory or motor abnormalities

CNs II-XII intact

Negative Babinski

DTRs=2+

Muscle tone = 5/5 throughout

Laboratory tests

Na 139meq/L

RBC 5.9mil/mm33

Mg 2.4mg/dL

K 3.9meq/L

WBC 7,100/mm3

P04 3.9mg/dL

Cl 102meq/L

AST 29 IU/L

Uric acid 7.3mg/dL

HCO3 27 meq/L

ALT 43 IU/L

Glu, fasting 110mg/dL

BUN 17mg/dL

ALK phos 123 IU/L

T. Chol 275mg/dL

Cr 1.0mg/dL

GGT 119 IU/L

HDL 31mg/dL

HgB 16.9g/dL

T. Bilirubin 0.9mg/dL

LDL 179mg/dL

Hct 48%

T. protein 6.0g/dL

Trig 290mg/dL

Plt 235,000/mm3

Ca 9.3mg/dL

PSA 1.3ng/mL

Urinalysis results:

Appearance- clear, amber in color

Specific gravity- 1.017

Ph- 5.3

Protein- negative

RBC- 0

WBC- 0

Bacteria- negative

ECG:

Increased QRS voltage suggestive of LVH

ECHO:

Moderate LVH with EF = 46%

Nursing

In this assignment, you will be looking at a case study of a real-world situation. You will decide on the outcome goal for the patient and select a theory that aligns to the care plan and facilitates the desired outcomes. You will then create a concept map depicting the relationships between the nursing theory and the care plan. And finally, you will summarize the contents of the concept map

 

Case Study

Read the following case study:

You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old Native American man who had coronary artery bypass graft surgery 4 days ago. The patient has a history of chronic obstructive pulmonary disease exacerbated by heavy smoking. His postoperative course has been difficult, and he has suffered several setbacks. Staff members, despite their diligent efforts, have not been able to wean him off the ventilator since the surgery. He has required frequent suctioning throughout the shift, and he is being evaluated for the development of ventilator-associated pneumonia.

 

Assignment

In 1 or 2 sentences, describe the measurable nursing outcome desired related to the improvement of the patient’s condition. Example: Patient will have a respiratory rate of less than 30 breaths per minute.

Identify a nursing theory to align with the plan of care to improve this patient’s outcome.

Create a concept map in which you show the relationship among the concepts of the nursing theory and alignment of nursing practice (including the critical thinking and clinical decision-making processes) for an improved the nursing care plan.

Provide a 700- to 875-word summary explaining the following from the concept map:

  • How the nursing theory concepts align to nursing practice, critical thinking, and the clinical decision-making process
  • How alignment of nursing theory concepts and nursing practice, critical thinking, and clinical decision-making processes can improve the nursing care plan

Include the measurable nursing outcome and the nursing theory you identified on the same document as the summary.

Use visual presentation software from the College of Education Technology Resource Library to create your concept map. To see your options, do the following:

  • Select Web Tools in the Table of Contents.
  • Select Collaboration & Productivity from the list of tools.

Include at least 2 scholarly resources from the University of Phoenix Library to support you work.

Cite and format your sources according to APA guidelines.

Submit your concept map and summary.

nursing

Title of Assignment

Professional Identity of the Nurse: Scope of Nursing Practice

Purpose of Assignment:

According to Larson, Brady, Engelmann, Perkins, and Shultz (2013), “the development of professional identity is a continuous process that begins with admission to the nursing program and evolves throughout one’s professional career in a dynamic and fluid process where interacting relationship of education and practice lead to self-reflection, growth, and human flourishing” (p. 138).

Larson, J., Brady, N., Engelmann, L., Perkins, B., & Shultz, C. (2013). The formation of professional identity in nursing. Nursing Education Perspectives.34 (2). p 138.

Course Competency(s):

Describe the foundations of nursing practice.

Explain the roles and scope of practice for members of the interprofessional team.

Describe principles of effective communication in the healthcare setting.

Instructions:

This course includes a project with three parts. Each part builds off prior knowledge to help you create your nurse professional identity. In the first part, you examine the role of the nurse and scope of practice, which will help you identify the nurse’s role. In the second part, you describe the importance of the code of ethics in nursing and examine the standards of nursing practice for the role you are obtaining during the nursing program. The final submission requires you to use the first two parts of your assignment to explain your belief of caring in nursing, describe your professional identity, and identify a potential professional organization that you may join to help support your development.

Content:

Prepare a two to three page written assignment that includes the following:

· Introduction to the assignment (sections of the assignment)

· Describe the importance of the code of ethics in nursing

· Identify the American Nurses Association Standards of Practice for the licensure you are obtaining (LPN or RN)

· Conclusion (reflect on the criteria of the assignment)

· Use at least two credible resources to support your findings. For example, one of the resources could be the ANA Standards of Practice, and another resource could be the ANA Code of Ethics. These resources must be integrated into the body of your paper using at least two in-text citations. Be sure to use proper APA format and style.

Format:

· Two to three page written assignment

· Standard American English (correct grammar, punctuation, etc.)

· Logical, original and insightful

· Professional organization, style, and mechanics in APA format

nursing

Title of Assignment

Professional Identity of the Nurse: Scope of Nursing Practice

Purpose of Assignment:

According to Larson, Brady, Engelmann, Perkins, and Shultz (2013), “the development of professional identity is a continuous process that begins with admission to the nursing program and evolves throughout one’s professional career in a dynamic and fluid process where interacting relationship of education and practice lead to self-reflection, growth, and human flourishing” (p. 138).

Larson, J., Brady, N., Engelmann, L., Perkins, B., & Shultz, C. (2013). The formation of professional identity in nursing. Nursing Education Perspectives.34 (2). p 138.

Course Competency(s):

Describe the foundations of nursing practice.

Explain the roles and scope of practice for members of the interprofessional team.

Describe principles of effective communication in the healthcare setting.

Instructions:

This course includes a project with three parts. Each part builds off prior knowledge to help you create your nurse professional identity. In the first part, you examine the role of the nurse and scope of practice, which will help you identify the nurse’s role. In the second part, you describe the importance of the code of ethics in nursing and examine the standards of nursing practice for the role you are obtaining during the nursing program. The final submission requires you to use the first two parts of your assignment to explain your belief of caring in nursing, describe your professional identity, and identify a potential professional organization that you may join to help support your development.

Content:

Prepare a two to three page written assignment that includes the following:

· Introduction to the assignment (sections of the assignment)

· Describe the importance of the code of ethics in nursing

· Identify the American Nurses Association Standards of Practice for the licensure you are obtaining (LPN or RN)

· Conclusion (reflect on the criteria of the assignment)

· Use at least two credible resources to support your findings. For example, one of the resources could be the ANA Standards of Practice, and another resource could be the ANA Code of Ethics. These resources must be integrated into the body of your paper using at least two in-text citations. Be sure to use proper APA format and style.

Format:

· Two to three page written assignment

· Standard American English (correct grammar, punctuation, etc.)

· Logical, original and insightful

· Professional organization, style, and mechanics in APA format

Nursing

TITLE PAGE

HYPERTENSION

INTRODUCTION————– 4-10 Sentences

PATHOLOGY

IT has to be intended with double space – Defination of patho 4-10 sentences

e.g

Sign and Symptoms

4-10 sentences

Diagnosis test

4-10

Please remember that the sentences must be backup with incite citation.

The SOAPIE should look like this

SOAPIE HYPERTENTION

Subjective date for hypertension patient will ………………………, the subjective data is going to be what is the patient going to say if they come to the emergency room, what they are going to tell me. 3-4 sentences for that.

Objective date for a patient with hypertension will present……….., and write what you think you might see in ABGs, what do we expect to see from the vital sign, what might I see in the blood work, what will the X-RAY show, what are we going to do for an assessement, plan of care, intervention. All will be like a sentence. All should be in paragraph form.

APA PAPER should be a third person paper, please don’t use the I, HE, SHE, they are all 1st person word, if use, that means 20% is gone for the paper already. PLEASE USE THIRD PERSON WORD.

PLEASE AM WRITING YOU THIS WORD SO THAT YOU CAN FOLLOW ALL THE RUBICS FOR ME TO BE ABLE TO SCORE A GOOD GRADE

nursing

Evidence-Based Practice Project Proposal: Identification of Nursing Practice Problem

Learners will select a valid nursing practice problem for an evidence-based practice project proposal. The

project will be completed in sections, beginning in NUR-550 and culminating in a final written paper

detailing the evidence-based practice proposal in NUR-590.

The purpose of this assignment is to select a relevant nursing practice problem for your evidence-based

practice project proposal. To identify a relevant problem, consider problems generally faced in nursing

practice (coordination of health care, assessment, education, patient support, trauma prevention,

recovery, health screenings, etc.). Use the “PICOT Draft” template to complete this assignment.

Use a national, state or local population health care database to research indicators of disparity. Choose a

mortality/morbidity indicator to identify a clinical problem or issue that you want to explore pertaining to

a population of focus. Use this indicator to begin to formulate a PICOT statement.

Refer to the “Evidence-Based Practice Project Proposal – Assignment Overview” document for an

overview of the evidence-based practice project proposal assignments.

You are required to cite one peer-reviewed source to complete this assignment. Sources must be

published within the last 5 years and appropriate for the assignment criteria and nursing content.

solid academic writing is expected, and documentation of sources should be presented using APA

formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become

familiar with the expectations for successful completion.

  • Evidence-Based Practice Project Proposal: Identification of Nursing Practice Problem

Nursing

 Case Study Concept Map and Plan of Care

  1. Course Competency :
    • Design plans for care specific to the older adult.
    • Consider the scenario below, then follow the instructions underneath it to complete the assignment.

      Mrs. Y
      Mrs. Y is an 84-year-old client who was recently discharged from the hospital for an infected diabetic ulcer on her left leg. During her hospitalization, Mrs. Y required intravenous antibiotic therapy through a peripherally inserted central catheter (PICC) line.
      Due to Mrs. Y’s long history of diabetes, her physician ordered that intravenous antibiotic therapy be continued at home. Subsequently, home health services were initiated, a home health nurse was assigned to Mrs. Y’s case, and an initial home visit was scheduled.
      The home health nurse arrives at Mrs. Y’s home and introduces herself to the client and the family. The nurse explains the home nursing services that will be provided, including the PICC line and intravenous antibiotic therapy treatments.
      During the initial home visit, the nurse assessed the physiological, psychological, functional, and safety needs of the client. The nurse’s findings were as follows:

    • Mrs. Y lives alone; however, her daughter checks on her frequently throughout the day.
    • The client is noted to have moderate functional issues and ambulates with a cane.
    • The client has several throw rugs in the main walking quarters and minimal lighting throughout the hallways.
    • Mrs. Y states “I used to get around my house with ease, but now I get a little tired and have to sit down and rest frequently.”
    • Consider Mrs. Y’s current health status and functional decline, then address the following:
    • Download the Concept Map and Plan of Care worksheet below. An example is also provided for your reference.
    • Concept Map and Plan of Care worksheet

      Concept Map and Plan of Care example

    • Identify three (3) priority nursing diagnoses for Mrs. Y. Visit the School of Nursing Guide Nursing Reference eBooks section for resources to assist with nursing diagnoses. 
    • Create a visual representation of the three (3) priority nursing diagnoses by incorporating them into the Concept Map (template in the worksheet). Be sure each nursing diagnosis includes the following elements:
    • “related to (r/t)” — description of the client’s problem
    • “as evidenced by” — description of the client’s symptoms
    • Complete the Nursing Plan of Care (table in the worksheet) describing what should be implemented for Mrs. Y.
    • Goals: Establish at least one (1) goal for each of the nursing diagnoses you identified (for a total of 3 goals). Goals should be: patient specific, measurable, actionable, realistic, and time limited.
    • Nursing Interventions: Describe at least three (3) nursing interventions for each of the goals (for a total of 9 nursing interventions). Each intervention should be in alignment with the goal it is supporting.
    • Complete the assignment using proper spelling, grammar, and APA.
    • For information about creating a concept map, review the FAQ, What is a concept map and how do I create one?

      Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:

NURSING

Module 03 Content

1.

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Module 03 Content

 

It is nearly impossible to learn EVERYTHING about EVERY SINGLE drug we encounter. While it is important for us to look up select information about unfamiliar medications we administer, we can know the general indications and nursing interventions related to a drug if we learn key information about the drug classifications. For this assignment, you will be collecting information about different groups of drugs, or drug classifications, found in your Pharmacology textbook and creating a PowerPoint presentation (5-10 slides long).

Choose a drug classification (Examples: Typical or Atypical Antipsychotics, Anxiolytics, SSRI, Tricyclic Antidepressants, MAOI, mood stabilizers, opiates, NSAIDs, etc.) that is discussed in Unit Six or Unit Seven in Pharmacology: A Patient-Centered Nursing Process Approach textbook and then use your Davis’s Drug Guide or another SCHOLARLY source to provide the following information:

1. Summary of the Drug Classification (what different medical conditions are these drugs used to treat?) and list the names of 2-4 drugs in your chosen drug classification

2. Typical routes of administration

3. Common side effects and adverse effects common for the drug classification

4. Special considerations (caution with renal or liver insufficiency, harmful drug-drug interactions, etc.)

5. Common Nursing interventions and important client teaching

 

Please DO NOT just copy/paste your information from your textbook or drug guide–put the information into your own words. You DO NOT need to use APA formatting for your submission (because this is a PowerPoint), but please do include your references (in APA format) in the last slide. 

 


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nursing

You are a licensed practical nurse (LPN) working in an eye surgery center. A new client with type 2 diabetes mellitus presents to the office, referred by their primary care provider. Consider the association between diabetes and eye diseases, and discuss the following questions:

Diabetes increases the risk of which eye diseases, and why?

What are additional risk factors for these eye diseases?

How can clients with diabetes reduce their risk of vision complications?

post must contain at least two professional references, published within the past 5 years.