Expert_researcher | Nursing homework help

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

 

Calculate your paper price
Pages (550 words)
Approximate price: -

Why Choose Us

Quality Papers

We value our clients. For this reason, we ensure that each paper is written carefully as per the instructions provided by the client. Our editing team also checks all the papers to ensure that they have been completed as per the expectations.

Professional Academic Writers

Over the years, our Acme Homework has managed to secure the most qualified, reliable and experienced team of writers. The company has also ensured continued training and development of the team members to ensure that it keep up with the rising Academic Trends.

Affordable Prices

Our prices are fairly priced in such a way that ensures affordability. Additionally, you can get a free price quotation by clicking on the "Place Order" button.

On-Time delivery

We pay strict attention on deadlines. For this reason, we ensure that all papers are submitted earlier, even before the deadline indicated by the customer. For this reason, the client can go through the work and review everything.

100% Originality

At Papers Owl, all papers are plagiarism-free as they are written from scratch. We have taken strict measures to ensure that there is no similarity on all papers and that citations are included as per the standards set.

Customer Support 24/7

Our support team is readily available to provide any guidance/help on our platform at any time of the day/night. Feel free to contact us via the Chat window or support email: support@acmehomework.com.

Try it now!

Calculate the price of your order

We'll send you the first draft for approval by at
Total price:
$0.00

How it works?

Follow these simple steps to get your paper done

Place your order

Fill in the order form and provide all details of your assignment.

Proceed with the payment

Choose the payment system that suits you most.

Receive the final file

Once your paper is ready, we will email it to you.

Our Services

Papers Owl has stood as the world’s leading custom essay writing services providers. Once you enter all the details in the order form under the place order button, the rest is up to us.

Essays

Essay Writing Services

At Papers Owl, we prioritize on all aspects that bring about a good grade such as impeccable grammar, proper structure, zero-plagiarism and conformance to guidelines. Our experienced team of writers will help you completed your essays and other assignments.

Admissions

Admission and Business Papers

Be assured that you’ll definitely get accepted to the Master’s level program at any university once you enter all the details in the order form. We won’t leave you here; we will also help you secure a good position in your aspired workplace by creating an outstanding resume or portfolio once you place an order.

Editing

Editing and Proofreading

Our skilled editing and writing team will help you restructure you paper, paraphrase, correct grammar and replace plagiarized sections on your paper just on time. The service is geared toward eliminating any mistakes and rather enhancing better quality.

Coursework

Technical papers

We have writers in almost all fields including the most technical fields. You don’t have to worry about the complexity of your paper. Simply enter as much details as possible in the place order section.

error: Content is protected !!