PAST MEDICAL HISTORY

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Running Head: DISCUSSION WEEK 14

 

 

 

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Running Head: DISCUSSION WEEK 14

 

 

 

 

Discussion Week 14

Physical Assessment in Healthcare

Daylamis Gonzalez

Florida National University

 

 

 

 

 

 

 

 

 

 

 

 

Name: Jessica Date 11/28/2017

DOB: 11/11/1985 Tine 11:47 AM

Age 32 Sexo Female

Address 1245 west 47 st Hialeah Florida 33012 Ethics Hispanic

Nationality Cuban Occupation Math teacher

Allergies NDKA

Marital status

What is your highest education? Bachelor’s degree in mathematics and a master’s degree in education

Medications that you are now taking No

 

PAST MEDICAL HISTORY

Paralysis No

Smoking Quit smoking 10 years ago (two packs daily for 5 years)

Alcohol Occasional wine cooler

Previous Surgery Tonsillectomy/adenoidectomy at age 11

Chronic Health Condition No

Children 4

C-section No Vaginal Delivers 4 Abortions No

Epilepsy No Stroke No Chickenpox Yes Rubella No

Asthma No Lupus No Cancer No Diabetes No Cardiac Disease No

Kidney Disease No Hemophilia No Hypertension No GI Disease No

Herpes No HIV No Syphilis No Hepatitis No

If any of the answers is yes, explain: chickenpox at age 10

FAMILY HISTORY

Mother Hypertension

Father Coronary artery disease (he had a stent placed at age 67)

EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:

Maternal relatives N/A

Paternal relatives N/A

Assessment

BP 135/85 mm/Hg HR 64 BPM Temp 98.5°F Resp 16 breath for min Pain 0

Nursing Note

Patient come to Emergency department with a friend for evaluation of sudden decrease of vision in the left eye. She denies any trauma or injury. It started this morning when she woke up and has progressively worsened over the past few hours. She had some blurring of her vision 1 month ago and thinks that may have been related to getting overheated, since it improved when she was able to get in a cool, air-conditioned environment. She has some pain if she tries to move her eye, but none when she just rests. She is also unable to determine colors. She denies tearing or redness or exposure to any chemicals. Nothing has made it better or worse.

Upon assessment, Patient AAOx3, hemodynamic stable. Patient able to answer all question. Afebrile. Resp. even and unlabored. No respiratory distress noted. Patient denies fever, chills, night sweats, weight loss, fatigue, headache, changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain or palpitations, shortness of breath or cough, abdominal pain, diarrhea, constipation, dysuria, vaginal discharge, swelling in the legs, polyuria, polydipsia, and polyphagia. Bowel sound present in 4 quadrants. Visual acuity 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctivae clear. Unable to assess visual fields in the left side; visual fields on the right eye are intact. Pupil response to light is diminished in the left eye and brisk in the right eye. The optic disc is swollen. Full range of motions; no swelling or deformity. Cranial nerves: I-XII intact; horizontal nystagmus is present. Muscles with normal bulk and tone; Normal finger to nose, negative Romberg. Intact to temperature, vibration, and two-point discrimination in upper and lower extremities. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achiles tendons; no Babinski.

NURSING DIAGNOSIS

Risk for injuries due to impaired vision

Risk factor: falls

Desired outcome: Maintain safety without falls

Nursing Intervention: Environmental management

Teaching:

· Instruct patient to avoid rug

· Use appropriate lighting

· Orient patient to unfamiliar environment

Fear and Anxiety relate to visual impairment

Risk factor: lost vision

Desired outcome: Patient verbalizes feeling.

Nursing Intervention: Assess the patient’s fear related to feel depended.

Allow patients to verbalize feelings regarding recurrent visual problem,

Teaching:

· Teach patient how to manage anxiety, fear and stress

· Instruct patient to follow MD instruction as order

 

Pain

Risk Factor: Uncontrolled Pain

Desired outcome: Maintain pain controlled

Nursing Intervention: Assess patient pain level and take medication around the clock.

 

 

 

 

 

Bibliography Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s Guide to Physical Examination (8th ed.). St. Louis, MO: Elsevier/Mosby.

 

http://medicinebtg.com/nanda-nursing-diagnosis-for-vision-impairment/

http://allnurses.com/general-nursing-student/looking-for-nursing-185929.html

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· Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.

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https://stahlonline-cambridge-org—Volume 1, Case #5: The sleepy woman with anxiety.

· Go to the Stahl Online website and examine the case study you were assigned.

· Take the pretest for the case study.

· Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.

· Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).

· Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.

· Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.

· Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.

 

 

QUESTIONS

List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.

List two pharmacologic agents and their dosing that would be appropriate for the patient’s sleep/wake therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.

The post · Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office. appeared first on Infinite Essays.

Describe the setting and access to potential subjects. If there is a need for a consent or approval form, then one must be created. Although you will not be submitting the consent or approval form(s) in Topic 5 with the narrative, the consent or approval form(s) should be placed in the appendices for the final paper.

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In 750 words (not including the title page and reference page), provide a description of the methods to be used to implement the proposed solution. Include the following:

  1. Describe the setting and access to potential subjects. If there is a need for a consent or approval form, then one must be created. Although you will not be submitting the consent or approval form(s) in Topic 5 with the narrative, the consent or approval form(s) should be placed in the appendices for the final paper.
  2. Describe the amount of time needed to complete this project. Create a timeline. Make sure the timeline is general enough that it can be implemented at any date. Although you will not be submitting the timeline in Topic 5 with the narrative, the timeline should be placed in the appendices for the final paper.
  3. Describe the resources (human, fiscal, and other) or changes needed in the implementation of the solution. Consider the clinical tools or process changes that would need to take place. Provide a resource list. Although you will not be submitting the resource list in Topic 5 with the narrative, the resource list should be placed in the appendices for the final paper.
  4. Describe the methods and instruments, such as a questionnaire, scale, or test to be used for monitoring the implementation of the proposed solution. Develop the instruments. Although you will not be submitting the individual instruments in Topic 5 with the narrative, the instruments should be placed in the appendices for the final paper.
  5. Explain the process for delivering the (intervention) solution and indicate if any training will be needed.
  6. Provide an outline of the data collection plan. Describe how data management will be maintained and by whom. Furthermore, provide an explanation of how the data analysis and interpretation process will be conducted. Develop the data collection tools that will be needed. Although you will not be submitting the data collection tools in Topic 5 with the narrative, the data collection tools should be placed in the appendices for the final paper.
  7. Describe the strategies to deal with the management of any barriers, facilitators, and challenges.
  8. Establish the feasibility of the implementation plan. Address the costs for personnel, consumable supplies, equipment (if not provided by the institute), computer related costs (librarian consultation, database access, etc.), and other costs (travel, presentation development). Make sure to provide a brief rationale for each. Develop a budget plan. Although you will not be submitting the budget plan in Topic 5 with the narrative, the budget plan should be placed in the appendices for the final paper.
  9. Describe the plans to maintain, extend, revise, and discontinue a proposed solution after implementation.

The post Describe the setting and access to potential subjects. If there is a need for a consent or approval form, then one must be created. Although you will not be submitting the consent or approval form(s) in Topic 5 with the narrative, the consent or approval form(s) should be placed in the appendices for the final paper. appeared first on Infinite Essays.

Week 5: Literature Search, Rapid Critical Appraisal, and Sum

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Week 5 Nursing 350

Week 5: Literature Search, Rapid Critical Appraisal, and Summary

For this assignment, you will locate a minimum of four research articles related to the topic and PICOT questions that you developed in Week 2. The articles must be published in the last five years (2014 to the present). Two articles must be quantitative, and two articles must be qualitative. 

· Articles used for one assignment cannot be used for the other assignments. (Students should find new research articles for each assignment.)

· The selected articles should be original research articles. Review articles, meta-analysis, meta-synthesis, and systemic review should not be used.

· Mixed-methods studies should not be used.

There are two parts to this assignment.

Part 1: Complete a Rapid Critical Appraisal Checklist chart for each research article (4 total).

· Download the Rapid Critical Appraisal Checklist here (PDF—use with Adobe Acrobat)

· Download the Rapid Critical Appraisal Checklist here (Word document)

Part II: Write a summary (2–3 pages)

· Compare and contrast the similarities and differences among the four research articles.

· Submit the 4 completed CHECKLISTS along with your summary.

You should:

· Use current APA Style to format your paper and to cite your sources.

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