Generic Patient Report paper.
Generic Patient Report paper.
according to patient size, and the use of iterative reconstruction technique. Liver: Normal in size, contour, and attenuation. Gallbladder: Status post cholecystectomy. Pancreas: Normal in size, contour, and attenuation. Adrenals: Normal in size, contour, and attenuation. COMPARISON: CT of the abdomen and pelvis performed 01/21/2020 SBAR Communication Worksheet
ORDER CUSTOM, PLAGIARISM-FREE PAPER
This is not part of the medical record Patient Initials: __L.M___________ Patient Date of Birth: __12/17/1960_____________________________ Room Number ___31____________ Date: __09/30/2021_______________ Time: __12pm____Inova Alexandria__________ Location: _____________________________________________ Pre-call preparation: Gather the following information: Patient’s name; age; chart. Rehearse in your mind what you plan to say. Run it by another nurse if unsure. If calling about pain, when and what was last pain medication? If calling about fever, what was the most recent temperature? If calling about an abnormal lab, what was the result of the last test? What is the goal of your call? Remember to start by introducing yourself by name and location. Use area below as a checklist to gather your thoughts and prepare. Situation: Briefly describe the current situation.
Give a clear, succinct overview of pertinent issues : _______Hello Dr, Mich this is nurse Xty calling from Inova North 4. The reason for my call is to inform you that Ms. L.M your patient in room 31 is complaining of pain around the abdominal area. She states that the pain persists at the site of previous seromas, located to the right to midline and rated pain 5 out of 10 on the scale of 0 to 10, ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________ B ackground: Briefly state the pertinent history. What got us to this point?: ______Ms. L.M is 60 year old female who presents for percutaneous drainage and possible drain placement of abdominal wall seroma versus abscess status post bilateral mastecomies with DIEP flap reconstruction on 6/15/2021. Patient has been seen by Dr. Gab and has had multiple drainage abdominal wall seroma. 10 CT abdomen pelvis perfomed on 9/17/2021 demonstrated persistent abdominal wall seroma and patient sent for elective drain placement. She states that since 9/17/21 she has experienced fevers and lethargy. Last fever was yesterday evening and was 103.6 F. She has been taking Tylenol which helped in controlling the fever. Patient denies any antiplatelet or anticoagulant use. Denies current chest pain, shortness of breath, dysuria, cough. She is on 2 antibiotics but does not know the name._______________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ _________________________________________________________________________________________________________ A ssessment: Summarize the facts and give your best assessment. What is going on? Use your best judgement: _____Ms T.J vital signs are BP 120/79, Temp 97 F Pulse 77 Resp 19 oxygen saturation 98 room air. Her H & H are low with hemoglobin 8.3 and hematocrit 27.4 She has 22 gauge in eight upper arm and saline lock, no redness, infiltration or phlebitis, sinus rhyme, no accucheck, she wears abdominal binder , She is bathroom privilege with minimal assist and JP drainage in place with Right 30 mL and Left 10 mL.________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________ R ecommendation: What actions are you asking for? What do you want to happen next? __I would recommend will continue to monitor her labs, control her pain, at adequate level as identified by patient, prevent fall and infection during her hospital stay. Is there anything you would like me to do?_________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Follow-up Action (Next Steps): Document the call and “read back” orders to ensure accuracy. Is there a change in the plan of care? Yes No ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ List of Problems can be actual, risk or potential with supporting subjective or objective data Risk for infection related to abscess formed at the abdominal cavity as evidenced by collection of pus in the peritoneum. Acute pain related to trauma to tissues as evidenced by patient verbalization of pain on the abdomen and rated pain 5 out of 10 Nursing Diagnosis with supporting objective/subjective data Risk for infection related to abscess formed at the abdominal cavity as evidenced by collection of pus in the peritoneum. 11 Goal with expected outcome should be (S specific, M measurable, A achievable, R reality based, T time oriented)
• Patient will be able to avoid the development an infection during her hospital stay Nursing actions to meet goals Rational for each nursing action (EBP) 1. Assess vital signs observe for any signs of To assess for the evidence of ongoing infection. Sepsis or infection of the blood may develop from peritonitis, and can be evidenced by fever accompanied by respiratory distress. infection as well as for signs of respiratory distress, and gastrointestinal problems such as diarrhea, nausea, and vomiting. 2. Perform a focused assessment on the abdominal region, particularly checking for Peritonitis is a serious complication of pancreatitis, diverticulitis, trauma, liver disease, or kidney disease. It is evidenced by abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness. pain, abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness. 3. Administer antibiotics as prescribed To treat the underlying infection with broad spectrum antibiotics, then switch with the type of antibiotics to which the causative bacteria are sensitive. This is also done to prevent the risk of developing sepsis in patient with peritonitis. Evaluation of outcome Goal met. Patient was free from infection at during hospital and was discharge with no infection Educational Nursing Diagnosis with supporting objective/subjective data Deficient knowledge related to how past medical history of diverticulitis caused present illness of abdominal wall abscess as evidenced by patient inaccurate follow through of instruction. Goal with expected outcome should be (S specific, M measurable, A achievable, R reality based, T time oriented) Patient will identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors during my 12 hour shift Nursing actions to meet goals Rational for each nursing action (EBP) 12 1. Review underlying disease process and Provides knowledge base from which patient can make informed choices. recovery expectations 2. Identify signs and symptoms requiring Early recognition and treatment of developing complications may prevent more serious illness and injury. medical evaluation: recurrent abdominal pain and distension, vomiting, fever, chills or presence of purulent drainage, swelling, erythema of surgical incision. 3. Demonstrate aseptic dressing change, Reduces risk of contamination. Provides opportunity to evaluate healing process. wound care. Evaluation of outcome Goal met. Patient verbalized understanding of how her history diverticulitis caused her present diagnosis of abdominal wall abscess. 13 Stratford University School of Nursing Medication Administration Record NSG 240/245/ 430 (Attach I have confirmed I have the right patient, drug, dose, If not administered, route, and time. Select a reason for not administering I have completed my THREE checks (i.e. medication safety retrieved/pulled, when I am preparing/pouring the medication, and right before I give the medication to the patient) Patient Secondary ID Check Full name 1 Refused 2 NPO 3 Nauseated 4 Unable to swallow 5 Off unit 6 Wasted/ Dropped 7 Drug not available 8 Other Birth Date Medication /classification Dosage /route/ Reason for frequency administration Nursing consideration/ Side effects Administer Acetaminophen(Tylen ol)/Analgesics 500 To relieve mg/oral/every 6 pain/fever hours scheduled Nursing consideration: Do not exceed 4g of acetaminophen per day to limit risk for liver, renal, and cardiac damage Administer ed Not Administer Enter code Side Effect: Nausea, stomach pain, loss of appetite, dark urine, claycolored stools or jaundice. Acyclovir(Zovirax) capsule/Antivirals 200 mg/oral/daily Used to decrease pain and speed the healing of sores or blisters in people who have varicella(chickenp ox), prophylaxis for genital herpes simplex Nursing consideration: Monitor for signs and symptoms of reinfection in pregnent patients. Acyclovir induced neurologic symptoms in patients with history of neurologic problems; drug resistance in immunocompromised patient receiving prolonged or repeated therapy; acute Administer ed 14 renal failure with concomitant use with other nephrotoxic drugs or preexisting renal disease. Side Effects: Malaise, nausea, headache, abdominal pain, diarrhea. Carvedilol(Coreg) tablet/Beta blocker 6.25 To treat high Nursing consideration: mg/orally/every blood pressure and Monitor blood pressure and 12 hours heart failure pulse frequently during dose adjustment period and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position Monitor intake and output ratios and daily weight. Side effects: Tiredness, weakness, lightheadedness, dizziness, nausea, vomiting, diarrhea. Ceftriaxone(Rocephin) 1g : 200 /Cephalosporin mL/hr/intraven antibiotics ous/ every 24 hours It is used to treat infections caused by bacteria, pelvic inflammatory disease. Nursing consideration: Watch for seizures, monitor signs of pseudomembranous colitis, including diarrhea, abdominal pain, fever, pus or mucus in stools and other severe or prolonged GI problems(Nausea, vomiting, heartburn) Side effects: sore throat, shortness of breath, swollen gland, unusual bleeding or bruising, fever, chills, chest pain, black tarry stool. Lactobacillus/streptoco 1 ccus(Risaquad) capsule/oral/dai capsule/Antidiarrhea ly Agent It is a probiotic that is used to help maintain the number of healthy bacteria in the stomach and intestines. Nursing consideration: Monitor CBC periodically during therapy, assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Side effects: Trouble breathing, puffiness or swelling of the eyelids, face, Administer ed Not Adminis tered Administer ed 15 tongue or lips, tightness in the chest, dizziness, cough, fast heartbeat, bloating, flatulence. Levothyroxine(Synthro 50 id)/Thyroid products mcg/orally/dail y at 0600 It is administered to treat an underactive thyroid gland(hypothyroid ism). It is taken to replace the missing thyroid hormone. Nursing consideration: Should be taken on an empty stomach with water, at least 1 hour before eating. Even coffee has been shown to interfere with the absorption of T4. And levothyroxine is incompatible with many other medications, so it should be taken alone. Side effects: Weight gain or loss, headache, fever, changes in appetite, sensitivity to heat, changes in menstrual cycle. Not Adminis tered Mirtazapine(Remeron) 15 mg/oral/at /Antidepressants bedtime It is given to treat depression Nursing consideration: Assess changes in motor activity or muscle function. Assess dizziness and drowsiness that might affect gait, balance and other functional activities. Report severe or problematic twitching, increased muscle tone, or changes in muscle activity and motor abnormalities(hyperkinesia, hypokinesia) Side effects: Severe sedation, constipation, drowsiness, increased serum cholesterol, weight gain, fatigue, insomnia, and decrease appetite. Not Adminis tered Montelukast(Singulair) 10 mg/oral/at /Leukotriene receptor bedtime antagonists To treat mild asthma and can stop it from getting worst.
Nursing consideration: Patient should be instructed to take medications at the same time each day and at least two hours prior to exercise. They should not discontinue medications Not Adminis tered 16 without notifying the provider. Side effect: Upper respiratory infection, fever, headache, sore throat, cough, earache or ear infection, flu, runny nose and sinus infection. Administer ed Polyethylene 17 g/oral/daily glycol(Miralax)/Osmot ic laxatives It is given to treat constipation Nursing considerations. Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Assess color, consistency, and amount of stool produced.
Advise patient to notify provider if unusual cramps, bloating, or diarrhea occurs. Side effect: Nausea, vomiting, irritation of the rectum, excessive thirst, stomach cramps, abdominal bloating, malaise. Vitamin D(Cholecalciferol)/Vit amin D analogs To maintain proper bone structure. To treat and prevent vitamin D deficiency. Nursing consideration: Adminis Monitor for manifestations tered of hypercalcemia, if hypercalcemia occurs, discontinue. Report fall in serum alkaline phosphatase as this usually signal onset of hypercalcemia. Measure urinary calcium and phosphorus level q24h. Side effects: High blood calcium level, constipation, nausea, bone loss, worsen atherosclerosis. 25 mcg/oral/daily 17 18 19
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source. Generic Patient Report paper.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Generic Patient Report paper.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any as signment submitted after midnight on the last day of class will not be accepted for grading. Generic Patient Report paper.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Generic Patient Report paper.
Generic Patient Report paper.