GI SOAP NOTE Esther Park 634

document the following scenario using NARRATIVE documentation system

document the following scenario using SOAPIE documentation system

Write the nursing diagnoses for the case scenario below: Mrs. Carmen is a 70 year old female, widow with 3 children (oldest 38; youngest 30). She was diagnosed to have Gastric Ulcer, Upper gastrointestinal bleeding (UGIB) . She is newly admitted at the medical ward (Rm 2, Bed #1). Conscious, coherent, lying sideways on bed while holding her abdomen. Pale-looking. Usually frowns when she tries to speak, When asked about her abdominal pain scale, she says “Now, its 9, yesterday it was just around 7.” Vital signs are as follows: BP-130/90; PR-93; RR- 22; Temp 38.0 Present medical history reveals that she has been taking NSAIDs as she was complaining of knee pains. The client stated, “My doctor used to give me NSAIDs to relieve pain. Since it is an OTC drug, I kept on buying it and take it whenever I feel pain. I did not know I should have taken it with meals.” She was brought to the hospital after vomiting blood and passing out. Past medical history (+) HPN since 2007 (+) DM since 2003…

Patient Anne was recovering after delivering twin girls 46 hours ago. She complains of uterine pain and has mal odorous lochia. Her vital signs are the following: BP 120/80; PR 122; RR 20; Temp 101.2 F. Questions: 1. What do you suspect is happening to Patient Ana? 2. What are your priority nursing diagnosis? 3. What are your priority nursing interventions and include the rationale?

---A patient was brought into emergency department with an acute onset of central crushing chest pain. Outline four nursing actions and rationales that you would be required to deliver within the first two hours of patients admission to emergency department.

Subject Name : A theoretical health assessment. NOTE, Choose the correct answer without explaining please.

S B is a 54-year-old Latina female who went to her healthcare provider with complaints of heartburn, dysphagia, nausea, and chest pain. She feels bloated and obtains little or no relief from over-the-counter antacids. Her past medical history includes 2-pack-a-day cigarette smoking, stressful job, and chronic use of NSAIDs for chronic back pain. 3. What are nursing considerations that should be addressed to the client with a diagnosis of GERD?

Name: Patient XOXO Age: 54 y/o Patient XOXO, a teacher at public school in Caloocan City. She currently weighs 57kg and stands 5'4'' tall with medium body frame size. She was recently diagnosed with Dysphagia secondary to Neurologic Disorder. Her doctor prescribed a Level 1 Dysphagia diet  based on her tolerance after the swallowing assessment and recommendations of OT and PT. Create a one-day meal plan for Patient XOXO requiring such diet.

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…

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…

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…

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…

Identify the correct CPT and ICD 10 CM codes

Translate the following nurse's notes into layman's terms: 3 y.o. female pt. c/o otalgia, pyrexia, rhinorrhea

Name: ID #: Course Level & Group: Textbook: Roberts, D., & Plueger, M. D. (2020). Chronic Neurologic problems. In Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (Eds.), Lewis's medical-surgical nursing: Assessment and management of clinical problems (11th ed., pp. 1358-1364). St. Louis, MO: Elsevier. Shaw, T. (2020). Assessment: Nervous system. In Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (Eds.), Lewis's medical-surgical nursing: Assessment and management of clinical problems (11th ed., pp. 1279-1299). St. Louis, MO: Elsevier. Prep Questions: 1. Describe the following types of seizures and the clinical manifestations associated with each. Seizure Type 1. Tonic-Clonic Seizure 121 PREP WORK #8 EMILY VIOLET JACKSON 2. Absence Seizure 3. Myoclonic Seizure 4. Tonic Seizure 5. Clonic Seizure Clinical Manifestations

A nurse is assessing a client with suspected gout. Which of the following would support a diagnosis of gout? Select all that apply 1. Elevated serum uric acid level 2. A swollen, red joint 3. Reports of moderate fatigue 4. Distal extremities cool totoucho5. Pain associated with movement of the affected extremity 6. Intolerance of dairy products

what is the FOCUS documentation of the following senario? 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.

Create  a Care Plan for your patient using this diagnosis: " Activity intolerance related to fatigue and body mallaise secondary to ascites, as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion." In the care plan include the: Need(s) Objectives Nursing interventions Evaluation/outcomes

S B is a 54-year-old Latina female who went to her healthcare provider with complaints of heartburn, dysphagia, nausea, and chest pain. She feels bloated and obtains little or no relief from over-the-counter antacids. Her past medical history includes 2-pack-a-day cigarette smoking, stressful job, and chronic use of NSAIDs for chronic back pain. 2. What teaching would the nurse provide the client who is scheduled for an EGD? 3. What are nursing considerations that should be addressed to the client with a diagnosis of GERD?

1) The nurse receives an order to administer enteral tube feedings to a client with dysphagia. The order states:Administer 1500 mLs of enteral feeding over 18 hours via infusion pump.What will the mLs per hour be? Round to the nearest whole number.   2) A nurse is caring for a client with a diabetic ulcer which is has a bacterial infection. Identify the lab values the nurse will review to monitor for infection

History of present illness: Patient is a 67 year old thin Caucasian female presenting to her family practitioner with the main complaints of decreasing strength and  moderate back pain that radiates from the back to the sides of the her body.   Past medical history Irritable bowel disease. Right foot stress fracture last year while stepping off a small bench.   Family history Father dies of a heart attack at age 80. Mother has a history of Osteoporosis.   Social History Patient smoked 2 packs a week from age 25-50. Patient has a long history of alcohol use and abuse from age 20 to 45. She frequently got drunk during social occasions as well as during gatherings, as often as once a week. She stopped drinking 13 years ago.  Sedentary life style   Allergies None   Medications Multivitamins Calcium 1200 mg/day   Key Labs, images, or procedures performed in relation to current diagnosis. Bone Density: T score of -3.1 Estrogen levels: <30 pg/mL (decrease)   Key Physical Examination…

History of present illness: Patient is a 67 year old thin Caucasian female presenting to her family practitioner with the main complaints of decreasing strength and  moderate back pain that radiates from the back to the sides of the her body.   Past medical history Irritable bowel disease. Right foot stress fracture last year while stepping off a small bench.   Family history Father dies of a heart attack at age 80. Mother has a history of Osteoporosis.   Social History Patient smoked 2 packs a week from age 25-50. Patient has a long history of alcohol use and abuse from age 20 to 45. She frequently got drunk during social occasions as well as during gatherings, as often as once a week. She stopped drinking 13 years ago.  Sedentary life style   Allergies None   Medications Multivitamins Calcium 1200 mg/day   Key Labs, images, or procedures performed in relation to current diagnosis. Bone Density: T score of -3.1 Estrogen levels: <30 pg/mL (decrease)   Key Physical Examination…

Patient is a 38 year old female indicating to her psychiatrist feelings of: emptiness, helplessness, hopelessness, and a deep sense of guilt for no apparent reason. She also mentioned having low energy, (not wanting to cook for her family or wanting to be intimate with her husband). The patient indicated not caring for any of her regular hobbies or anything pleasurable, difficult concentrating, and even not remembering details. She is having problems sleeping and even contemplated going to bed and overdosing (just once)