Combined written portion packet (1)

NSG120 Patient Case Study Packet Group Member Names: Liynah, Kristin, Anortia, Skyler & Ashley Instructions: During the NSG120 course students will work as a group to complete Patient Case Packet as follows: Full Care Plan (Care Plan Parts I-VII) based on a patient case your group creates based on the disease process assigned to you by your instructor. Care Plan/Client Concept Map Components: * Care Plan Part I History and Physical a. Patient data base- health history • Basic Conditioning Factors • Chief complaint b. Health History c. Physical Assessment • Vital signs • General physical exam * Care Plan Part II: Medications * Care Plan Part III: Diagnostic Studies & Interpretation * Care Plan Part IV: Nurses note * Care Plan Part V: Client Concept map a. Client Concept Map Part I: Assessment/Recognize Cues b. Client Concept Map Part II: Patient Problem & Care Plan * Care Plan Part VI: Interdisciplinary Plan of Care * Care Plan Part VII: Client Educational Handout for the disease process

NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Group Member Names: Nursing Care Plan Part I: Basic Conditioning Factors Patient Demographics: Physician (s): Age: 42 Gender: F Isolation: Allergies: (include type of reaction) - NKA Caucasian Ht: 5’4 Wt . 210 Code Status : FULL CODE Chief Complaint (Go into detail on the next page) Abdominal pain, nausea, vomiting, indigestion, diarrhea, pain on right side Health States Date of visit: 11/30/2022 Activity level: Moderate Diet: Fall risk Client’s description of health status (define chronic state) Dull and cramping pain Client’s past medical surgical history Appendectomy, ACL repair Completed therapies: Physical therapy Current therapies: Socio-cultural Orientation Cultural and Ethnic Caucasian, Italian descent Background Socialization: Part of a book club, goes bowling every weekend with her husband and

NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Group Member Names: Part I a. Patient Name: Kimberly Kraft Date: 11/30/2022 Chief Complaint: Abdominal pain Patient states she has been having intermittent abdominal pain in the right upper quadrant for the past few weeks but the pain has increased in intensity in the past 6 hours. Current Complaint Given in Detail (PQRSTU): P: Nothing. Pain spontaneously alleviates and subsides. Q: Pain is dull & cramping R: Pain radiates to her right shoulder. S: Pain is 8/10. T: Pain is usually sudden but has been consistent for the past 6 hours. U: She thinks she may have gotten the flu from one of her students. Use the below acronym and definitions to complete the section above. Provocative or Palliative: What makes your symptoms better or worse? Quality: sharp, Dull, Constant, Intermittent, Ache, Burn, etc. Region or Radiation: Where specifically are you having your symptoms/pain? Does it move? Severity: On a scale of 0-10, how bad is it? Timing: When did it start? How often does it occur? How long does it last? Understanding: What do you think is causing your symptoms? How are your daily activities affected?

NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Group Member Names: Part I b. Focused Health History Patient Name: ________________________________________Date of Birth: _____________________ Age:____ ______ Do you have, or have you ever had, any of the following MEDICAL PROBLEMS: Circle your answer: List details to these or any OTHER Medical Problems you have or have had: Heart attack YES NO High blood pressure YES NO High cholesterol YES NO Diabetes YES NO Stroke YES NO Asthma YES NO Emphysema/COPD YES NO Ulcers/Reflux YES NO Rheumatoid arthritis YES NO Gout YES NO Seizures/Epilepsy YES NO Thyroid disease YES NO Hepatitis YES NO HIV/AIDS YES NO Cancer YES NO List any DRUG ALLERGIES: Penicillin Circle any of the following if you are ALLERGIC: Iodine IV Contrast Shellfish Latex SOCIAL HISTORY: Are you employed? YES NO Occupation 2 nd grade ELA Teacher Date last worked: 11/25/2022 Do or did you ever smoke? YES NO 5 Packs per day for 20 years Did you quit? YES NO If so, when did you quit?_ 7 years ago Other tobacco/nicotine products? YES NO What kind? Drink alcohol? YES NO How much and how often? Social drinker maybe once or twice a month History of illegal drugs/substance abuse? YES NO What kind? Adderol in college Are you: Single Married Divorced Separated Widowed Do you live alone? YES NO Do you Exercise? Never Rarely Weekly Daily What type? Walking with weights Perception of Own Health (circle one): Excellent Good Fair Poor List any SURGERIES you have had and, if known, the YEAR : Appendectomy when she was 15, 1995 ACL repair in 1997 FAMILY HISTORY Do any of your grandparents, parents or siblings have any of the following: Diabetes High blood pressure Heart attack Stroke Rheumatoid arthritis Bleeding disorders Cancer YES YES YES YES YES YES YES NO Other Significant NO Family History: NO NO NO NO NO REVIEW OF SYSTEMS: Do you have NOW, or have you had RECENTLY, problems with any of the following: Circle your answer: Fevers, chills, weight loss Eyes Ears, Nose, Throat Teeth, Mouth Chest pain, Heart Problems Shortness of Breath, Lungs Constipation, Diarrhea Urinary tract infection Joint pain, Joint stiffness Skin rashes, lesions Migraines, Headaches Blackouts/Falling Balance problems Psychological problems/Depression High cholesterol Diabetes Bleeding disorders Blood clots, DVT Seasonal allergies YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO

7 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Part I c.: Physical Assessment Vital Signs Pulse: 78 BPM RR: 18 BP: : 100/60 Temp: 98F O2Sat: 98 Pain Assessment: 8 Self-care assessment: Include identified knowledge deficits In self-care: Patient appears well groomed Intake: 300mL Output: 140mL IV Location: Medial Cuboidal Vein Assessment: No drainage, no fluid leakage, redness, pain, tenderness or pain. LOC-Orientation/ Cognition Level of consciousness and orientation: Patient is alert and orientated to person, place and time. General survey/appearance/facial expression/mood/affect/speech: Patient looks like she is in pain. Guarding her ride side. Glascow Coma Scale (If appropriate): ______________________________________________ HEENT / Sensory Perception Vital Signs (normal or abnormal) daily weight if indicated Pain level (0-10 numeric scale OR other appropriate scale) 8 out of 0-10 PERRLA: Pupils are equal, round and reactive. Oral mucous membranes, oral cavity, dentition: Mucous membranes are pink and moist, a few cavities Presence of hearing aids or eyeglasses: Patient wears glasses for myopia Respiratory/ Oxygenation Respiratory effort & use of oxygen: Symmetrical, sternum is midline, expansion of the chest on both sides, no use of accessory muscles Oxygen Saturations: _______________________98%_________________________________________

8 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Effort of breathing:__________________________________________________________________ Lung Sounds: Right : Breath sounds are heard, no adventitious lung sounds Lung Sounds: Left: Breath sounds are heard, no adventitious lung sounds Cough & Deep Breathe, any mucous? Color & amount? None Cardiac - Peripheral Vascular/ Perfusion Skin Color: Normal for patients skin tone, to redness, no enlargement of the neck vein Heart sounds: ___________________Clear and regular heart rate, no murmur sound present ____________________________________________________ Capillary refill: Less than 3 seconds Pretibial edema: R ____None__________L ______None_____________ Dorsalis pedis pulse: R_________78__________ L ________78_________ CMS (circulation, motion, sensation) 5 P ’ s : ___Pain in upper right quadrant and right shoulder, no pulselessness, no pallor, no paresthesia, no paralysis, no pallor _________________________________ _______________________________________________________________________________________ DVT assessment (TED hose or SCD hose): __________SCD hose _____________________________ Skin Integrity: 22 Skin Turgor: __Normal skin turgor ______________________________________________________________________

10 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Psychosocial, Safety, Care & Comfort Support at home:_______Support from husband, 2 oldest children and siblings______________________________________________________________ Safety interventions: Self-care needs: Care of surgical site Risk for Depression/suicide: ___Low risk ___________________________________________________ Teaching & learning needs: Post-op care Psychosocial & Spiritual concerns: None noted __________________________________________________

8 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Part II: Medication Reconciliation and New medications for disease process List all medications, dosages, classifications and the rational for the medications you feel would be prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication. ALLERGIES: No allergies Medication Classification Dosage Purpose/Mechanism of Action NaCl 0.9% IV Isotonic solution 1000 mL Hydration ,sodium and chloride ions in maintaining the fluid and electrolyte balance Dexamethasone IV Corticosteroids 8 mg Reduce swelling and decrease immune response Oxycodone PO Opiate Analgesic 5 mg Pain,binding to a receptor, inhibition of adenylyl-cyclase and hyperpolarisation of neurons. Ox Bile Supplement PO Bile Salts 500mg For help digesting dietary fats and absorbing vitamins A, D, E, K Cholestyramine PO Bile acid sequestrants 4g Decreases the laxative effects of bile , binds to bile salts and redirects them to excretion Newly prescribed (or dosage changes) medications

13 NSG120 Patient Case Study I Care Plan & Client Concept Normal values Initial results Most current results How is this related to the disease process? Pertinent nursing interventions, if applicable What expected assessment findings correlate with this result? URINALYSIS pH Protein Glucose Ketones Bilirubin WBC RBC CHEMISTRY Glucose BUN Creatinine GFR Potassium Calcium Sodium Phosphorus Amylase Lipase Albumin Ammonium Cholesterol Triglycerides HDL LDL Ashley's Part not complete

14 NSG120 Patient Case Study I Care Plan & Client Concept Normal values Initial results Most current results How is this related to the disease process? Pertinent nursing interventions, if applicable What expected assessment findings correlate with this result? Radiology EKG CT MRI Ultrasound Endoscopy X-Ray Additional Labs, Tests, or Special Procedures Ashley's Part not complete

13 NSG120 Patient Case Study I Care Plan & Client Concept CLIENT CONCEPT MAP- PART V a. – ASSESSMENT / RECOGNIZE CUES Identify relevant and important objective & subjective information from different sources (e.g. medical history, vital signs) You do not need to fill out each box. Only complete what is relevant to the patient’s diagnosis and assessment findings. PRIMARY ADMITTING DIAGNOSIS AND PATHOPHYSIOLOGY: NERVOUS SYSTEM/ COGNITION: RESPIRATORY SYSTEM: Cholecystitis, Inflammation of the Gallbladder due to blockage of the bile duct SUBJECTIVE N/A OBJECTIVE N/A SUBJECTIVE N/A OBJECTIVE N/A CARDIOVASCULAR SYSTEM: MUSCULSKELETAL AND MOBILITY: INTEGUMENTARY SYSTEM: SUBJECTIVE N/A OBJECTIVE Increased heart rate, increased blood Pressure due to pain SUBJECTIVE N/A OBJECTIVE N/A SUBJECTIVE N/A OBJECTIVE N/A GASTROINTESTINAL SYSTEM: URINARY SYSTEM: BLOOD, LYMPH, and/or ENDOCRINE SYSTEM: SUBJECTIVE Nausea, Pain in the RUQ OBJECTIVE Guarding SUBJECTIVE N/A OBJECTIVE Dark urine and dark stool SUBJECTIVE N/A OBJECTIVE N/A

17 NSG120 Patient Case Study I Care Plan & Client Concept PLANNING RESOURCE PATIENT PROBLEM (NURSING DIAGNOSIS) GOAL & OUTCOME CRITERIA PLANNING INTERVENTIONS (DO/IMPLEMENT) RATIONALES EDUCATION (Expected Outcomes) Patient Problem (based on your #1 priority from the concept map: Problem Statement: GOAL List 3 OUTCOMES: Identify expected outcomes and using hypotheses to define a set of interventions for the expected outcomes. ASSESS/MONITOR: 1. 2. 3. DO (INTERVENTIONS): 1. 2. 3. Why are you doing the interventions you listed? Identify 3 educational points based on your goals and interventions. CLIENT CONCEPT MAP- PART V b.-PRIORITY PATIENT PROBLEM PLAN OF CARE: use the information from part one to determine your priority PATIENT PROBLEM. You must use your Textbook All-in-ONE NURSING CARE for these sections. (Please delete red words ) Mrs. Perez said we don't need to do this page.

NSG120 Patient Case Study I Care Plan & Client Concept Map Packet CLIENT EDUCATIONAL HANDOUT- PART VII Create an appropriate educational handout for your patient based on their current disease process and diagnosis. Include the necessary interventions the patient should be doing at home, resources they should be using, medication information, and possible complications they may experience. You do not utilize the table below, you MUST create a hand out to give to the patient. It is there as a reminder to complete the education handout.

NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Case Study/Clinical Report Grading Rubric & Check-Off Sheet Category Value I. History & Physical 31 points a. Patient data base • Demographics appropriate for patient condition 3 • Chief complaint given in detail (PQRSTU) 4 b. Complete patient history • Patient’s medical history noted and appropriate 2 • Family medical history noted and appropriate 2 • Social history noted and appropriate 2 c. Physical Assessment • Vital signs present and appropriate for condition 4 • General Physical exam form complete and accurate 14 II. Medications 14 points • Preadmission medications 7 • New medications based on disease process 7 III. Diagnostic test 9 Points • Normal results listed 3 • Patient results listed and appropriate for condition 3 • All appropriate diagnostic testing listed in chart form 3 IV. Nurses note 12 points • Health History and Review of Symptoms 4 • Positive & Negative Physical Exam Findings 4 • Diagnostic Findings 4 V. Client Concept map 12 points • Part I: Assessment/Recognize Cues 6 • Part II: Patient Problem & Plan 6 VI. Interdisciplinary Plan of Care 12 points • Therapies (speech, physical, occupational) and rationales 3 • Referrals to Specialists and rationales 3 • Referrals to Community resources or agencies and rationales 3 • Alternative Therapies and rationales (if applicable) 3 VII. Education & Instructions Handout 10 points Participation 10 points APA, grammar, and spelling 10 points