Question 3234

Question GU CRITICAL THINKING Jason is a 48-year-old accountant who is… GU CRITICAL THINKINGJason is a 48-year-old accountant who is admitted to the hospital with a diagnosis of acute post-streptococcal glomerulonephritis. He was seen at the local walk in clinic because of swelling around his eyes and rusty-colored urine. His history from the walk-in clinic indicates that he had a sore throat several weeks ago that resolved in 4 to 5 days and did not seek medical assessment for. His past medical history is positive for type 1 diabetes mellitus since the age of 7. However, he has maintained excellent control of his serum glucose levels via intensive insulin therapy.PMHX: generally healthy, Type 1 diabetes since age 7. 180cm tall, 60 kg, non-smoker, Alcohol consumption – 3-4 drinks/week, works out in the gym for 60 minutes, 3 x/week.Social: Jason is single, no children. Lives with his girlfriend of 5 years. Jason works full time as a forensic accountant at a local law firm, on average of 60 h/week. He has limited family support, as his parents and siblings all live in Vancouver.  Family Hx – Father had Colon Cancer at age 65. Mother has hypertension and high cholesterol. Paternal grandfather died of acute renal failure at 70y/o.Before caring for Jason you review his admission laboratory findings, which reveal gross hematuria, moderate proteinuria, and RBC casts in the urine, a BUN of 28 mg/dl a creatinine of 1.4 mg/dl. During the morning assessment of Jason, his vital signs are as follows: TPR – 37.1° C / 86 (regular) / 16 (regular) blood pressure 146/92 mm Hg, he has periorbital edema and 2+ pitting edema of his ankles, denies any pain. His urinary output from the previous 8 hours was 200 ml.Jason’s latest lab results include BUN 32 mg/dl, creatinine 1.8 mg/dl, Hb 9.2 g/dl (92 g/L), K+ 6.8 mEq/L, and Na+ 142 mEq/L.  His urine output is less than 400 ml/day and his blood pressure ranges from 104/90 to 168/104 mm Hg.  transfer the given information to the appropriate area (note information can be included in several systems) (If an area has significant abnormal findings, a more focused assessment is required)·     Using your clinical nursing knowledge, identify the missing information: 1. Write the specific question you would ask to complete the assessment and why would your ask that question for each system being assessed. Note questions can be in the form of open or closed ended. 2. Write the test or procedure who you anticipate the patient to have and why. ·      Finally develop a tentative prioritized plan of care (see page 7) Date of admission: Date of admission: Date of your assessment: (indicate the date the assignment is due) Age: Gender Identification: Allergies: (if allergies- describe reaction) Admitting Diagnosis (medical diagnosis) Past Medical History (diagnosis and date of diagnosis if possible) Past Surgical history (diagnosis and date of diagnosis if possible) Medication Summary – add additional sheets if necessary, include scheduled, OTC meds and PRN medsMedication Dose Route Frequency Reason YOUR patient is taking the medication Vital SignsTempHRBPRRO2Sat on R/A or amount of O2 PainO = OnsetP = Palliation / ProvocationQ = Quality/QuantityR = Radiation / RegionS = Associated S&ST = TimingU = UnderstandingLast Pain Medication?Effect if received? Sleep & RestSleeping patters (#hours/day/night)NapsUse of sedationFeeling rested? Mobility* these are some of the areas to be address but not inclusive (refer to your assessment slides and other resources posted)Level of assistance required for movement (transferring, getting out of bed, walking, eating)Ambulation- Independently ambulatory, W/C, Walker, Cane, Crutches, Bed ridden Strength: Upper and Lower body strengthGait, balance Neurological (including Psychosocial) * these are some of the areas to be address but not inclusive (refer to your assessment slides other resources posted)Level of ConsciousnessOrientationMental StatusGCS NumberCommunicationVision Hearing Family/significant othersAffect_______________________If any neuro concerns, complete:Cranial Nerves,Motor FunctionSensory FunctionCoordination Cardiovascular * these are some of the areas to be address but not inclusive (refer to your assessment slides other resources posted)Apical pulse – rate, rhythm, Heart valves – diaphragm & bell, characteristicCapillary RefillEdema – description, extent, pitting or non-pittingPeripheral Pulses X4 – rate, rhythm, strength, and equality Respiratory * these are some of the areas to be address but not inclusive (refer to your assessment slides other resources posted)Breath Sounds – Rate, Rhythm, Depth, Characteristics, Adventitious SoundsO2 SaturationCough (productive or non-productive)SecretionsSuction RequirementOxygen Therapy Gastrointestinal * these are some of the areas to be address but not inclusive (refer to your assessment slides other resources posted)Abdomen shape, Scars, LesionsUmbilicus midlineAbdominal pulsationsPeristaltic movement Bowel sounds,Palpation BM – last one, usual bowel patterns, Bristol bowel movement chartContinence/incontinenceHeightWeightBMI (please calculate and categorize)Diet:typeamount consumedability to eat Genitourinary * these are some of the areas to be address but not inclusive (refer to your assessment slides other resources posted)Continence/incontinence/catheterUrine Assessment – characteristics, amountCondition of Perineal SkinDischarge Musculoskeletal * these are some of the areas to be address but not inclusive (refer to your assessment slides other resources posted)ROM  Limb strength Transfers/mobility Integumentary * these are some of the areas to be address but not inclusive (refer to your assessment slides)ColourTemperatureSkin HydrationSkin TextureElasticitySkin TurgorLesionsWoundsScarsBraden scale Lab Values & Diagnostic Tests date of lab workWBCRBCHgbPltNa+K+CrGlucose Additional as related to disease/conditionTubes IV / central line / PICC, Foley catheter, NG, PEG/G-tube, drains(Insitu, site, solution, rate) Tentative Plan of Care: (this is not a nursing care plan)- What is the priority issue the patient is facing and the steps you would take to address the issue you have identified.Issue:Steps/Plans:——————————————————————————GASTROINTESTINAL NURSING CARE PLANA 22 year-old female named Angela, presents to the emergency room with the chief complaint of dizziness, diarrhea and rectal bleeding. She has been having recurrent episodes of vague abdominal pain, nausea, and diarrhea with occasional bright red blood seen in the toilet over the last 8 weeks. She has lost 8 pounds in the last month. She takes no medications but does take over the counter natural supplements. She has been only able to eat and drink small amounts.She describes her life as stressful, and feels sometimes that it is unmanageable. Insomnia occurs at least three times a week, as well as feeling anxious during the day. She admits to using alcohol at times to help her sleep. She lives in the dorm on campus. She works part time as a cashier in the food court. She is in her third semester of a local nursing program and hopes to graduate next year. She shares that her boyfriend recently broke up with her and she has been feeling down. PMx: UnremarkableFamily Hx: Mother age 48, well. Father age 50, hypertension. Paternal grandfather diagnosed with colon cancer at age 60. Angela meets with the gastroenterologist and is very overwhelmed with the diagnosis of ulcerative colitis.  She begins to cry and states “How will I ever finish nursing school? My life is over”. 0948 – Pt. up in chair, was feeling well. Stood up to go to W/R. Pt. felt dizzy and lightheaded. Assisted back to chair.Identify 1 priority nursing diagnosis.1 goal/objectiveEnsure your Assessments supports your nursing diagnosis and objective.4 nursing interventions (4 only) and rationaleNURSING DIAGNOSIS: GOAL/OBJECTIVE: ASSESSMENTS (S&S/FINDINGS/MANIFESTATIONS/DATA etc) Nursing Intervention:Research/Evidenced-Based Rationale:    Health Science Science Nursing NURSING 401 Share QuestionEmailCopy link Comments (0)

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