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Galen College of Nursing *
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6053
Subject
Nursing
Date
Apr 29, 2024
Type
docx
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Uploaded by Classof2022BSN
1
Week 3 Assignment
Name
Walden University
NURS 6512: Advanced Health Assessment
Professor
Date
2
Chief Complaint
The patient's chief complaint is slurred speech, and he presents with significantly elevated blood pressure (210/100).
Essential Physical Examinations and Diagnostic Tests
Neurological Exam:
Essential for evaluating brain functions, particularly those related to
speech, muscle coordination, sensation, and reflexes. This examination is crucial for someone presenting with slurred speech to pinpoint potential neurological disorders.
Blood Pressure Verification:
Re-measuring the blood pressure in both arms is necessary
to confirm the initial elevated readings. Continuous high measurements warrant an in-depth investigation into the underlying causes and severity of hypertension.
Blood Work:
This should include a complete blood count (CBC), electrolyte panel, renal
function tests, and cardiac enzyme tests. These tests help identify infections, electrolyte imbalances, kidney issues, or cardiac conditions.
Brain Imaging (CT scan or MRI):
These tests are critical for spotting acute conditions like stroke or bleeding, offering detailed images of the brain to locate bleeds, stroke damage, tumors, or other irregularities.
Electrocardiogram (EKG):
An EKG can detect heart problems that might contribute to high blood pressure or neurological symptoms by recording the heart's electrical activity.
Interpreting Results for Diagnosis
Neurological Exam Outcomes:
This may reveal neurological deficits indicative of conditions such as a stroke.
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Related Questions
Questions for the Case Study:1. Make a table of the medications prescribed to the patient. Include the indication, mechanism of action, standard dose, and frequency.
2. Analyze the case and identify the adverse reaction/s that occurred. What type of ADR happened?
3. What should be done to avoid the type of adverse reaction that happened to the patient?
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nurse intervention for Mr. Reddy is a 62 yo presenting to ED at 1500hrs. He was preparing the gas cylinder for a Sunday BBQ when it suddenly exploded while he was trying to connect the hose. Family standing by tried to extinguish the fire with their hands and tried to remove his clothing. Burns 30% TBSA – Face, hands, bilateral lower limbs. Complaints of severe pain and burning 10/10. Past Medical History: Hypertension, Type II DM Regular medications – Candesartan 8mg, Glimepiride 4mg, Metformin 500mg and Pravastatin 20mg. Fully vaccinated against COVID.
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Question: Make a nursing care plan for heart failure:
Past health history: constipation for the last 7 days accompanied by difficulty of breathing (DOB) and Abdominal pain.
Present Health history:
chief complaint of Abdominal pain. Prior to admission, facial edema and bipedal edema was notice during physical assessment.
Laboratory:
Temperature 36°c, Pulse Rate -127, Respiratory Rate- 22,Blood Pressure -120/90,URIC ACID :10.20 mg/dL,CREATININE :1.33 mg/dL
Clinical impressions:
Kidney failure
Laboratory ultrasound report impressions:
1.enlarges liver(but no pqrenchymal disease or lesion)
2.partial and mild(grade 1)acute medical renal disease right kidney
3.pleural effusion: right henitrox volume=850 cc.
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Make a Discharge Planning
Diagnosis:
Impaired comfort related to tissue trauma and edema in the episiotomy site as evidenced by right mediolateral episiotomy, 1 cm of edema and ecchymosis around her episiotomy site, Patient is pale and tired,droopy/hanging eyelids, has dark circles under the eyes, pale skin, are indicative of both sleep deprivation and looking fatigue. Reports of dizziness and light-headedness when standing up, feeling disturbed with the episiotomy as verbalized I'm scared cause the stitch might rip if I forced it” Reports pain "I'm scared cause the stitches hurt and might be rippen."
I. Specific Objectives
1.
2.
3.
4.
5.
II. Health Teaching
1. Knowledge
a.
b.
c.
d.
e.
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Question:Make nursing care plan(ncp)
Past health history: constipation for the last 7 days accompanied by difficulty of breathing (DOB) and Abdominal pain.
Present Health history:
chief complaint of Abdominal pain. Prior to admission, facial edema and bipedal edema was notice during physical assessment.
Laboratory:
Temperature 36°c, Pulse Rate -127, Respiratory Rate- 22,Blood Pressure -120/90,URIC ACID :10.20 mg/dL,CREATININE :1.33 mg/dL
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Provide the appropriate nursing interventions based on the signs and symptoms presented
SIGNS and SYMPTOMS
NURSING INTERVENTIONS
1. Baby Rina 9 months old is hot to touch with temperature of 38.2C.
2. Lola Remedios complaints of difficulty of breathing.
3. Mrs. Gravida just gave birth to baby Nicolai. With foley catheter and has not taken a bath.
4. Lolo Carding complaints of muscle stiffness of the fingers and knees.
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create a nursing care plan according to the nursing process for Mr SA

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Identify the correct CPT and ICD 10 CM codes
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ASAP: please fill out I have provided the information
patient information;
Name: Sam
Age: 43
No allergies
The reason for admission is: CVA post-resection
Illnesses: stroke, dysphagia, UTI urinary tract infection, vertigo and meningioma of brian
His vital signs were in the normal range
Mobility status: wheelchair
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TOPIC: PHARMACOLOGY
Instructions:1. Thoroughly review the clinical case presented below.2. Formulate and discuss the nursing diagnosis.3. Formulate and discuss the nursing care plan.4. Using references from recently published peer-reviewed journal articles, discuss aspects ofthe pharmacology of the drugs of choice for treating this patient.
HPI:55-year-old J.D. male presents to the oncology clinic with severe pain in his lower back and righthip which started one week ago. He describes the pain as constant, dull, and achy, withintermittent sharp shooting sensations, which have significantly worsened over the past week.He rates the pain on a scale of 9/10, and is made worse with movement, especially walking andstanding and has some relief with rest and changes in position. J.D. reports increased fatigue,reduced appetite, and disturbed sleep due to the pain.
PMH: J.D. has a history of Stage IV Lung Cancer: Diagnosed a year ago with metastases to bonesand liver and experiences episodes…
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UNIT 7 CRITICAL THINKING QUESTIONS
Critical Thinking Questions
1. Imagine that there has been an emergency and you are calling 911. Write a brief
paragraph describing the situation and giving what necessary information you would give
on the phone call.
2. Under what circumstances would a health care professional not begin an exarsination by
checking the vital signs?
3. If a woman is in an accident and her blood pressure is high immediately afterwards, is this
an indication of a health problem?
4. The unit discusses the importance of hand washing in health care. Think of three other
industries that would need to be especially careful about hand washing and explain its
important in these fields.
5. Think about the kinds of common errors in health care described in Unit 6. How could root
cause analysis be used to help health care facilities avoid errors?
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Assessment of Patient 2
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Please answer the second question
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Document the following senario using SOAPIE documentation
Mr. Smith is one day post-operative (Post-up) abdominal surgery. He complains of (c/lo) "severe pain" to his abdomen and rates his pain level as an 8 on a scale of 1-10. he is grimacing. His heart rate is 92. The nurse administers morphone sulfate 4mg IV. The nurse evaluates Mr. Smith's pain after administering the morphine sulfate. Mr. Smith says his pain has decreased and now rates his pain level as a 2. HE is no longer grimacing and his heart rate is 72.
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Directions: Supply the correct abbreviation for each medical term. You can also
Assessment 7.10
Identifying Abbreviations
complete this activity online using EduHub.
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QUESTIONS. (see pictures for the case scenario and the CHART)
1. Create CHART (C-omplaint, H-istory, A-ssessment, R-x - Drugs, T-reatment) documentation for the patient.
2. What is the discharge goal for the patient? Create discharge plan for the patient using METHOD. (M-edications, E-nvironment, T-reatment, H-ealth teaching, O-ut patient referral, D-iet) see photo for reference
Thank you! :)
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Identify course of action, nursing management including medications and possible medical management using the basic techniques of triage and emergency care within the first, most critical hour, of a patient’s arrival at the hospital.
Patient RT 57/M came in due to chest pain, pain rate of 9/10. He described the pain as excruciating, radiating to shoulder and back, he is also nauseated, experienced vomiting, lightheadedness, and headache prior to arrival at ER. History shows smoking for 40 years approximately 1 pack per day, works as company driver, weighs 90kgs and 5’5” in height. He is not known diabetic nor hypertensive, no check-up records, no laboratory records and he self-medicate when he is not feeling well. Initial vital signs showed, temperature of 36.7 RR of 32, PR 44, BP 210/100. After 5 minutes vital signs showed BP of 0, breathing 0 and PR 0.
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Case:Location: Medical-Surgical UnitTime: 0800Report from night shift charge nurse:Situation:Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.Background:Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.Assessment:Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing…
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Case:Location: Medical-Surgical UnitTime: 0800Report from night shift charge nurse:Situation:Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.Background:Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.Assessment:Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing…
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Case:Location: Medical-Surgical UnitTime: 0800Report from night shift charge nurse:Situation:Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.Background:Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.Assessment:Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing…
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Case:Location: Medical-Surgical UnitTime: 0800Report from night shift charge nurse:Situation:Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.Background:Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.Assessment:Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing…
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Bradley Buchanan presents to the neighborhood nurse-run clinic with shortness of breath, a persistent cough with blood-tinged sputum, recent weight loss, and night sweats. On initial assessment, the client has a fever of 101.4°F and pain in his chest. His other vital signs are as follows: pulse 98 beats per minute; respirations 26 per minute; blood pressure 110/76 mm Hg; height 68 inches; and weight 140 pounds. Mr. Buchanan is 45 years old. He is employed as a dishwasher at a local restaurant and lives at the local shelter with his wife, who is 8 months pregnant, and his 13-year-old son. Mr. Buchanan is concerned that if he cannot go to work, he will lose the family’s only income. At this point, although Mr. Buchanan’s signs and symptoms and his purified protein derivative test results seem to indicate that he may have tuberculosis, the nurse must pursue further confirmation of the diagnosis.
Questions for students:
What would be the nurse’s next action?
Should the nurse do any…
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Please review the following orders and answer the questions below.
Admit for outpatient observation
Start IV per facility protocol
MS04 2.0 mg IV q 4hrs PRN
CBC, CMP, TS, Coag panel
VS QD, call with out of range
ASA 81 mg chewable QD
Xanax .25 PO TID
Ativan 2.0 mg/d IV
LR 125 mL/hr
Psych consult
why do these orders need clarification? Please provide an explanation.
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CASE STUDY:
Patient X, 3-year-old female came in because of difficulty of breathing.
Condition started 4 days prior to admission when periorbital edema was noted
which progressed and became generalized. Condition was associated with
nonproductive cough & low-grade fever, relieved by Paracetamol. Three days.
prior to admission, tea colored urine was noted. There was neither dysuria nor
urinary frequency. Two days prior to admission, consult was sought with a
private physician and was given Amoxicillin 53 mg/kg/day. Few hours PTA,
patient was noted to be dyspneic hence consultation was sought at emergency
room and subsequently admitted.
Past Medical History: No previous admission. No allergic reaction.
Family History: Denies of any heredofamilial diseases.
Personal/Social History: Patient was delivered at home assisted by a hilot by
NSVD with no complication. Breastfeeding was given until 11 months old and
solids were started at 6 months.
Immunization: Complete primary immunization…
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TRAUMATIC BRAIN INJURY CASE SCENARIO
QUESTIONS.
1. On the given case scenario, present the relevance of each diagnostic and laboratory tests to the patient. (see photo attached)
2. In relation to the patient’s case, trace the pathophysiology of the disease. (see photo attached)
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A GIPO PU 32 weeks was brought to the ER because of severe headache and blurring of vision. BP was 170/110 mm Hg. Fundic height was 30 cms, FB on the left, FHT 157/min. There was also grade Il bipedal edema, edema of hands and face. The nurse should correctly identify that which of the following should be done first?
Do immediate CS
Load MgSO4
Give Hydralazine
Administer Diazepam IV
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Related Questions
- Questions for the Case Study:1. Make a table of the medications prescribed to the patient. Include the indication, mechanism of action, standard dose, and frequency. 2. Analyze the case and identify the adverse reaction/s that occurred. What type of ADR happened? 3. What should be done to avoid the type of adverse reaction that happened to the patient?arrow_forwardnurse intervention for Mr. Reddy is a 62 yo presenting to ED at 1500hrs. He was preparing the gas cylinder for a Sunday BBQ when it suddenly exploded while he was trying to connect the hose. Family standing by tried to extinguish the fire with their hands and tried to remove his clothing. Burns 30% TBSA – Face, hands, bilateral lower limbs. Complaints of severe pain and burning 10/10. Past Medical History: Hypertension, Type II DM Regular medications – Candesartan 8mg, Glimepiride 4mg, Metformin 500mg and Pravastatin 20mg. Fully vaccinated against COVID.arrow_forwardQuestion: Make a nursing care plan for heart failure: Past health history: constipation for the last 7 days accompanied by difficulty of breathing (DOB) and Abdominal pain. Present Health history: chief complaint of Abdominal pain. Prior to admission, facial edema and bipedal edema was notice during physical assessment. Laboratory: Temperature 36°c, Pulse Rate -127, Respiratory Rate- 22,Blood Pressure -120/90,URIC ACID :10.20 mg/dL,CREATININE :1.33 mg/dL Clinical impressions: Kidney failure Laboratory ultrasound report impressions: 1.enlarges liver(but no pqrenchymal disease or lesion) 2.partial and mild(grade 1)acute medical renal disease right kidney 3.pleural effusion: right henitrox volume=850 cc.arrow_forward
- Make a Discharge Planning Diagnosis: Impaired comfort related to tissue trauma and edema in the episiotomy site as evidenced by right mediolateral episiotomy, 1 cm of edema and ecchymosis around her episiotomy site, Patient is pale and tired,droopy/hanging eyelids, has dark circles under the eyes, pale skin, are indicative of both sleep deprivation and looking fatigue. Reports of dizziness and light-headedness when standing up, feeling disturbed with the episiotomy as verbalized I'm scared cause the stitch might rip if I forced it” Reports pain "I'm scared cause the stitches hurt and might be rippen." I. Specific Objectives 1. 2. 3. 4. 5. II. Health Teaching 1. Knowledge a. b. c. d. e.arrow_forwardQuestion:Make nursing care plan(ncp) Past health history: constipation for the last 7 days accompanied by difficulty of breathing (DOB) and Abdominal pain. Present Health history: chief complaint of Abdominal pain. Prior to admission, facial edema and bipedal edema was notice during physical assessment. Laboratory: Temperature 36°c, Pulse Rate -127, Respiratory Rate- 22,Blood Pressure -120/90,URIC ACID :10.20 mg/dL,CREATININE :1.33 mg/dLarrow_forwardProvide the appropriate nursing interventions based on the signs and symptoms presented SIGNS and SYMPTOMS NURSING INTERVENTIONS 1. Baby Rina 9 months old is hot to touch with temperature of 38.2C. 2. Lola Remedios complaints of difficulty of breathing. 3. Mrs. Gravida just gave birth to baby Nicolai. With foley catheter and has not taken a bath. 4. Lolo Carding complaints of muscle stiffness of the fingers and knees.arrow_forward
- create a nursing care plan according to the nursing process for Mr SA arrow_forwardIdentify the correct CPT and ICD 10 CM codesarrow_forwardASAP: please fill out I have provided the information patient information; Name: Sam Age: 43 No allergies The reason for admission is: CVA post-resection Illnesses: stroke, dysphagia, UTI urinary tract infection, vertigo and meningioma of brian His vital signs were in the normal range Mobility status: wheelchairarrow_forward
- TOPIC: PHARMACOLOGY Instructions:1. Thoroughly review the clinical case presented below.2. Formulate and discuss the nursing diagnosis.3. Formulate and discuss the nursing care plan.4. Using references from recently published peer-reviewed journal articles, discuss aspects ofthe pharmacology of the drugs of choice for treating this patient. HPI:55-year-old J.D. male presents to the oncology clinic with severe pain in his lower back and righthip which started one week ago. He describes the pain as constant, dull, and achy, withintermittent sharp shooting sensations, which have significantly worsened over the past week.He rates the pain on a scale of 9/10, and is made worse with movement, especially walking andstanding and has some relief with rest and changes in position. J.D. reports increased fatigue,reduced appetite, and disturbed sleep due to the pain. PMH: J.D. has a history of Stage IV Lung Cancer: Diagnosed a year ago with metastases to bonesand liver and experiences episodes…arrow_forwardUNIT 7 CRITICAL THINKING QUESTIONS Critical Thinking Questions 1. Imagine that there has been an emergency and you are calling 911. Write a brief paragraph describing the situation and giving what necessary information you would give on the phone call. 2. Under what circumstances would a health care professional not begin an exarsination by checking the vital signs? 3. If a woman is in an accident and her blood pressure is high immediately afterwards, is this an indication of a health problem? 4. The unit discusses the importance of hand washing in health care. Think of three other industries that would need to be especially careful about hand washing and explain its important in these fields. 5. Think about the kinds of common errors in health care described in Unit 6. How could root cause analysis be used to help health care facilities avoid errors?arrow_forwardAssessment of Patient 2arrow_forward
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