Need assistance completing the Week6 MHCarePlan NUR4020
\nPATIENT\/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET<\/p>\n
Student Name:\tWeek: 2\tDates of Care:5\/20\/2023<\/p>\n
Patient Initials<\/p>\n
CV\tSex<\/p>\n
M\tAge<\/p>\n
47\tRoom<\/p>\n
837\tAdmitting Date<\/p>\n
5\/19\/2023\tAdmitting Chief Complaint: What symptoms cause the patient to come to the hospital?<\/p>\n
Intractable headache<\/p>\n
Attending physician\/Treatment team:<\/p>\n
Ayman M. Jabr, MD<\/p>\n
Consults:<\/p>\n
No consult
\nPresent Diagnosis: (Why patient is currently in the hospital)<\/p>\n
Headache and dizziness<\/p>\n
ER Management: (if applicable)<\/p>\n
Nile Township high school<\/p>\n
Allergies:<\/p>\n
Shrimp, Ibuprofen, Aspirin
\nCode Status:<\/p>\n
Full code\tIsolation: (type and reason)<\/p>\n
none
\nAdmission Height:<\/p>\n
165.1 centimeters (5,5)\tAdmission Weight:<\/p>\n
107.9 kilograms (237 lbs)\tArm Band Location (colors & reasons)
\non the right arm and it’s white<\/p>\n
Communication needs: (verbal, nonverbal, barriers, languages)<\/p>\n
the patient has no communication barriers<\/p>\n
Past Medical History: (pertinent & how managed)<\/p>\n
diabetes mellitus
\ngerd
\nhypertension
\nobstructive sleep apnea
\nsciatica
\nspinal stenosis
\ndegenerative joint disease<\/p>\n
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)<\/p>\n
Tests\/Treatments\/Interventions impacting clinical day\u2019s care (include current orders)<\/p>\n
Assessments and interventions: (Include all pertinent data)
\nVital signs: (2 sets per day)<\/p>\n
Time\t8: 00
\nT\t98.6
\nP\t96
\nR\t18
\nB\/P\t138\/80<\/p>\n
Time\t13: 00
\nT\t97.9
\nP\t98
\nR\t20
\nB\/P\t111\/73
\nGI:<\/p>\n
Diet: Regular
\nSwallow precautions:
\nTube feedings:
\nNG \/ G tube:
\nBlood Glucose: (time & date)
\nLast bowel movement: (time & date)
\nPertinent Labs\/Test:
\nAssessments\/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)<\/p>\n
Respiratory:<\/p>\n
02 modalities:
\n02 Saturation: 96
\nSuction:
\nResp Rx\u2019s:
\nTrach: none
\nChest Tubes: none
\nPertinent Labs\/Test:
\nAssessments\/Interventions: (Lung sounds, cough, sputum, SOB)<\/p>\n
Neurosensory:<\/p>\n
Neuro checks:
\nAlert & Orientated: x4
\nFollows commands: yes
\nSpeech Comprehensible: yes
\nPertinent Labs\/Test:
\nAssessments\/Interventions:
\n(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
\npatient had dizziness and headache
\nCardiovascular:<\/p>\n
Telemetry:
\nPacemaker\/IAD:
\nDVT Prevention: heparin (5000 units)
\nDaily Weights:
\nPertinent Labs\/Test:
\nAssessments\/Interventions:
\n(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)
\nMusculoskeletal:<\/p>\n
Activity: independent
\nTraction: none
\nCasts\/Slings:
\nPertinent Labs\/Test:
\nAssessments\/Interventions:
\n(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps<\/p>\n
Renal:<\/p>\n
Catheter (indwelling\/external):
\nCBI:
\nDialysis:
\nA\/V access:
\nPertinent Labs\/Test:
\nAssessments\/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)<\/p>\n
Skin:<\/p>\n
Braden Score:
\nPertinent Labs\/Test:
\nAssessments\/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)<\/p>\n
Pain:<\/p>\n
Pain score: 10 in the head
\nAssessments\/Interventions: acetaminophen was given
\n(scale used, location, duration, intensity, character, exacerbation, relief, interventions)
\nmorphine<\/p>\n
Vascular Access: (IV site)<\/p>\n
Assessments\/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)<\/p>\n
Gyn:<\/p>\n
Gravida\/Para: none
\nLMP: none
\nLast Pap: none
\nBreast exam: none
\nPertinent Labs\/Test
\nAssessment\/Interventions: (bleeding, discharge) none<\/p>\n
Post-operative \/procedural:<\/p>\n
Assessments\/Interventions: none
\n(immediate post procedure care)<\/p>\n
Safety:<\/p>\n
Call light:
\nBed Rails:
\nBed alarms: no need
\nFall risk: not at 4 risk
\nAssistive Devices: none
\nSitter use: none
\nRestraints (type, duration & reason):
\nAssessment\/Interventions (modifications to room, environment, Patient)<\/p>\n
Advance Directives\/Ethical considerations:<\/p>\n
DPOA: has no advanced directives
\nHospice:<\/p>\n
Pertinent Data (Labs, X-rays, Etc.)\tResults\tNormal Lab Values\tSignificance to your patient
\nWBC\t7.2
\nRBC\t5.37
\nHGB\t17.3
\nHCT\t48.9
\nMCV\t91.0
\nMCH\t32.3
\nMCHC\t35.5
\nPlatelets\t207
\nRDW\t14.5
\nMPV\t8.3
\nCBC
\nPT
\nINR
\nAPTT<\/p>\n
Glucose\t225
\nBUN\t14
\nCreatinine\t0.86
\nSodium\t134
\nPotassium\t5.3
\nCloride\t97
\nCalcium\t9.0
\nT Protein\t6.4
\nAlbumin\t3.8
\nSGOT
\nSGPT
\nAlk Phos\t69
\nMagnesium
\nAmylase
\nLipase<\/p>\n
CPK
\nLDH
\nCholestrol<\/p>\n
CK
\nCK-MB
\nTroponin I
\nMyoglobin
\nLDI<\/p>\n
Urinalysis
\nColor
\nCharacter
\nSpec. Grav.
\npH
\nProtein
\nGlucose
\nAcetone
\nBilirubin
\nBlood
\nNitr
\nUrobili
\nRBC
\nWBC
\nEpithelium<\/p>\n
Urine Culture<\/p>\n
Chest X-ray<\/p>\n
MRI<\/p>\n
CT Scan<\/p>\n
Others test:<\/p>\n
Psycho\/Social: Assessment\/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal\/infant bonding, family dynamics)<\/p>\n
Cultural\/Spiritual needs: Assessment\/Interventions: (religious preference, adaptations & modifications, end of life decisions)
\nGrowth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:<\/p>\n
Current overall plan of care: (A short statement that summarizes the anticipated plan of care)<\/p>\n
Discharge plans and needs:<\/p>\n
Teaching needs:(Disease process, medications, safety, style, barriers)<\/p>\n
Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient\u2019s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient\u2019s overall prognosis. Include appropriate references and use APA format.<\/p>\n
Attach a research article pertaining to diagnosis of patient. Write a summary about the article.<\/p>\n
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.<\/p>\n
Priority\tNursing Diagnosis\tRelated to\tAs Evidence By\tRationale (reason for priority)
\n1<\/p>\n
2<\/p>\n
3<\/p>\n
4<\/p>\n
5<\/p>\n
Medications\tClassification\tDose\tRoute
\nFreq\tPurpose\/Mechanism of Action\tSignificant Side Effects \/ Adverse Reactions \tNursing Implications<\/p>\n
Ascorbic acid (Vitamin C)<\/p>\n
100 mg tablet\tOral\tDaily<\/p>\n
Atorvastatin (Lipitor)<\/p>\n
10 mg tablet\tOral\tDaily<\/p>\n
Dexamethasone (Decdron)<\/p>\n
8mg IM\tInjection\tIntravenous<\/p>\n
Acetaminophen<\/p>\n
650 mg\tOrally\tPRN<\/p>\n
Diphenhydramin (Benadryl)<\/p>\n
25 mg injection\tInjection\tIntravenous<\/p>\n
Enalapril (Vasotech)<\/p>\n
10 mg\tOral\tDaily<\/p>\n
Furosemide (Lasix)<\/p>\n
40 mg\tOral\tDaily<\/p>\n
Glucagon<\/p>\n
1 mg\tIM\tPRN<\/p>\n
Heparin<\/p>\n
5000 units\tIM\tContinuous
\nInsulin Aspart (Novolog)\t\t18 units\tIM, Subcontanous\t3 times daily with meals<\/p>\n
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand<\/p>\n
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis) \tPatient Goal(s)
\nStatement of purpose for the patient to achieve \tPatient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
\n(Must have at least two short term outcomes and two long term outcomes)
\nInterventions\/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient\u2019s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.\tEvaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date\/time is set)<\/p>\n
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand<\/p>\n
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis) \tPatient Goal(s)
\nStatement of purpose for the patient to achieve \tPatient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
\n(Must have at least two short term outcomes and two long term outcomes)
\nInterventions\/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient\u2019s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.\tEvaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date\/time is set)<\/p>\n","protected":false},"excerpt":{"rendered":"
Need assistance completing the Week6 MHCarePlan NUR4020 PATIENT\/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET Student Name: Week: 2 Dates of Care:5\/20\/2023 Patient Initials CV Sex M Age 47 Room 837 Admitting Date 5\/19\/2023 Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Intractable headache Attending physician\/Treatment team: Ayman M. Jabr, MD Consults: […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3695,3691,3690,1387,1388,1386,1385,3694,3689,3692,3688,1389,1390,3693],"tags":[1166,1175,1177,3701,3699,2875,3697,3700,3696,1176,1117,3698],"class_list":["post-8152","post","type-post","status-publish","format-standard","hentry","category-assignment-help-by-uks-no-1-writing-service","category-australia-essays","category-best-essay-writers-pinterest","category-cheap-essay-writer-australia","category-cheap-essay-writer-canada","category-cheap-essay-writer-uk","category-cheap-essay-writer-usa","category-dissertation-assignment-help-uae","category-do-my-university-assignment-for-me","category-essays-uk","category-homework-help-services-best-websites","category-homework-help-writing-service-usa","category-nursing-help-writing-service-usa","category-research-paper-ideas","tag-australia-dissertation-writers","tag-australia-essay-writers","tag-canada-essay-writers","tag-essay-pro-dissertation-writers","tag-i-need-help-writing-a-page-paper-assignment","tag-ireland-essay-writers","tag-masters-essays","tag-pay-someone-to-write-a-paper-for-you","tag-phd-assignment-help","tag-uae-essay-writers","tag-usa-essay-writers","tag-website-that-writes-assignments"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/8152","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/comments?post=8152"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/8152\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/media?parent=8152"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/categories?post=8152"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/tags?post=8152"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}