CASO 282

Caso 282 - Nursing
PLACE ORDER
CASO HIPOTETICO 2 82 M Chief Complaint Date: 09/15/21 Time: 09:25 Chief Complaint: Falling due to legs weakness Source: Family (daughter) Accompained by:: daughter) - History of Present Illness HPI: 82 y/o male with PMHx of HTN, DM, Renal disease and Stroke is brought to ER by EMS accompanied bye her daughter after falling and hitting the back of the head due to legs weakness when he tries to get up from his walker. Daughter states weakness began last Friday and he had to start using his walker. - Allergies Allergies/Adverse Reactions: Allergies Allergy/AdvReac Type Severity Reaction Status Date / Time JUEYES METFORMIN Allergy Swelling Uncoded 09/14/21 20:25 of Lip/Tongue/Throat - Home Medications Home Medications: Home Medications Medication Instructions Recorded Confirmed Type Amlodipine Besylate [Norvasc] 1 tab PO DAILY 09/14/21 09/14/21 History Humulin N 20 unit SUB-Q BEFORE BREAKFAST 09/14/21 09/14/21 History Losartan Potassium [Losartan 50 mg PO DAILY 09/14/21 09/14/21 History Potassium 50 mg Tablet] Simvastatin [Simvastatin 40Mg 40 mg PO DAILY 09/14/21 09/14/21 History Tablet] - Travel Risk - Coronavirus Travel Risk: No Contact Risk: No Has patient experienced symptoms?: No Past Medical History - Information Attestation statement: The following information was validated with the patient or family. Source: Obtained From Family Accompained name: DAUGHTER - Past Medical History Medical History: CVA, Diabetes, Hypertension, Renal Disease Surgical History Male: No Surgical History Psychiatric History: No Psych History In the past week, have you been having thoughts about killing yourself?: No - Family History Family History: Diabetes, Hypertension - Social History Smoking Status: Never Smoker Alcohol Use: No Alcohol Intake: Former Sustance Use: No Review of Systems - Constitutional Constitutional: Report: Weakness - Eye Eyes: Report: No symptoms reported - Ear Ear: Report: No Symptoms Reported - Nose, Mouth and Throat Nose, Mouth and Throat: Report: No Symptoms Reported - Breast Breast: Report: No Symtoms Resorted - Cardiovascular Cardiovascular: Report: High blood pressure, Other (distant heart sounds) - Respiratory Respiratory: Report: No Symptoms Reported - Gastrointestinal / Abdominal Gastrointestinal/Abdominal: Report: Constipation - Genitourinary Genitourinary Male: Report: No Symtoms Reported - Musculoskeletal Musculoskeletal: Report: Muscle weakness - Skin Skin: Report: No Symptoms Reported - Neurological Neurological: Report: Abnormal gait, Focal weakness, Gait disturbance, Speech disturbance, Speech slurred, Stroke, Weakness, Weakness lower extremity, Weakness upper extremity - Psychiatric Psychiatric: Report: No Symptoms Reported - Endocrine Endocrine: Report: No Symptoms Reported - Hematology / Lymphatic Hematologic/Lymphatic: Report: No Symptoms Reported - Immunology / Allergies Immunology/Allergies: Report: No Symptoms Reported - All Other System Report: Reviewed and Negative Physical Examination - Measurement Vital Signs: Last Vital Signs Temp 36.7 C 09/14/21 20:21 Pulse 71 09/14/21 20:21 Resp 18 09/14/21 20:21 BP 143/70 H 09/14/21 20:21 Pulse Ox 97 09/14/21 20:21 Height & Weight: Height 5 ft 2 in Weight 58.967 kg - General Exam General Condition: Oriented x3, Awake, Alert, Active Physical Exam General Appearance: Comfortable, Cooperative, No Pain Physical Exam General Nutrition: Normal Weight - Head Exam Head Exam: Normal Exam - Eyes Exam Physical Exam Eyes: Normal Appearance, EOMI Abnormal (delay ) - ENT Exam Physical Exam ENT: Normal Exam - Ear Exam Physical Exam Ears: Normal Exam - Nose Exam Normal Exam - Mouth Exam Physical Exam Mouth: Normal External Inspection - Neck Exam Normal Inspection, Normal Position, Non-Tenderness, No Lymphadenopathy, No Thyromegaly, Non Jugular Vein Distention - Thyroid Exam Physical Exam Thyroid: Normal Inspection - Cervical Lymph Node Exam No Lymphadenopathy - Chest Exam Physical Exam Chest: Normal Inspection - Respiratory Exam Respiratory Exam: Normal Expansion, Normal Lung Sounds, Normal Respiratory Effort, No Respiratory Distress, Chest No-Tenderness - Cardiovascular Exam Normal Heart Sounds (distant ) Peripheral Pulses: 2+: Carotid Right, Carotid Left, Radial Left, Radial Right, Dorsalis Pedis Left, Dorsalis Pedis Right, Posterior Tibialis Left, Posterior Tibialis Right - GI/Abdominal Exam Flat, Soft, Diminished Bowel Sounds - Extremities Exam Other (Upper limbs weakness Rt>Lt) General: Normal Inspection - Upper Extremity Exam Shoulder Exam: Normal Inspection Arm Exam: Normal Inspection Elbow Exam: Normal Extension Forearm/Wrist Exam: Normal Inspection Hand Exam: Normal Inspection - Lower Extremity Exam Upper Leg: Other (Weakness rt>lt) Knee: Other (Weakness rt>lt) Ankle: Other (Weakness rt>lt) Lower Leg: Other (Weakness rt>lt) Leg Edema: None Foot/Toe: No Edema - Neurological Exam Neurologic Exam: Normal Mood / Affect, Oriented x3, Alert, Motor Deficit, Other (brocca aphasia ) Patient Oriented To: Person, Place Speech: Expressive Aphasia, Garbled, Slurred Motor strength: LLE 3/5, LUE 3/5, RLE 1/5, RUE 2/5 Cerebellar Function: Abnormal finger to nose (bilateral) - Glasgow Coma Scale (4) Open Spontaneously Best Verbal Response (Glasgow): (5) Oriented Best Motor Response: (6) Obeys Commands Glasgow Total: 15 - Psychiatric Exam Normal Affect, Normal Mood - All Other System All Other System: Are not pertinent at the moment Diagnosis Impression (1) CVA (cerebral vascular accident) Code(s): I63.9 - Cerebral infarction, unspecified Status: Acute Qualifiers: CVA mechanism: thrombosis Laterality of affected vessel: unspecified (2) Acute focal neurological deficit Code(s): R29.818 - Other symptoms and signs involving the nervous system Status: Acute - Assessment and Plan Assessment and Plan: 82 y/o male with PMHx of HTN, DM, Renal disease and Stroke is brought to ER by EMS accompanied bye her daughter after falling and hitting the back of the head due to legs weakness yesterday. Head CT wo contrast shows no evidence of hemorrhages , Right basal ganglia and frontal corona radiata subacute or chronic infarct. Small cystic structure in the left side of the pons may relate to a perivascular space or chronic lacunar infarct. Moderate chronic white matter small vessel disease and cerebral atherosclerosis. Pertinent labs results below shos Cr. 2.86, BUN 38 and glucose 110. Vital signs pertinent for BP 143/70. Physical examination shows weakness of upper and lower extremities RT>LT, expressive aphasia and grip myotonia. Patient admitted with diagnosis of Recurrent ischemic stroke/ acute ischemic stroke. Will f/u with Brain MRI, Carotids ultrasound, heart echocardiography. Laboratory Tests 09/14/21 09/14/21 22:30 22:30 RBC 4.57 L Hgb 12.3 L Hct 39.4 L MCHC 31.2 L Neut # (Auto) 6.91 H Immature Gran # (Auto) 0.04 H BUN 38 H Creatinine 2.86 H Glucose 110 H - Labs 09/14/21 22:30 [Image 0] 09/14/21 22:30 [Image 1] Labs Result: Coagulation Labs PT 11.6 Secs (9.1-12.1) 09/14/21 22:30 INR 1.009 09/14/21 22:30 APTT 28.7 Secs (25.3-38.0) 09/14/21 22:30 Abnormal lab results 09/14/21 09/14/21 Range/Units 22:30 22:30 RBC 4.57 L (4.63-6.08) X10^6/uL Hgb 12.3 L (13.7-17.5) g/dL Hct 39.4 L (40.1-51.0) \% MCHC 31.2 L (32.2-36.5) g/dL Neut # (Auto) 6.91 H (1.56-6.13) X10^3/uL Immature Gran # (Auto) 0.04 H (0.00-0.03) X10^3/uL BUN 38 H (9-20) mg/dL Creatinine 2.86 H (0.66-1.25) mg/dL Glucose 110 H (74-106) mg/dL Admission Note - Admission Information Date of Admission: 09/15/21 Time of Admission: 10:32 Admission Diagnosis: Recurrent ischemic stroke / acute ischemic stroke Admission Note: 82 y/o male with PMHx of HTN, DM, Renal disease and Stroke is brought to ER by EMS accompanied bye her daughter after falling and hitting the back of the head due to legs weakness yesterday. Head CT wo contrast shows no evidence of hemorrhages , Right basal ganglia and frontal corona radiata subacute or chronic infarct. Small cystic structure in the left side of the pons may relate to a perivascular space or chronic lacunar infarct. Moderate chronic white matter small vessel disease and cerebral atherosclerosis. Pertinent labs results below shos Cr. 2.86, BUN 38 and glucose 110. Vital signs pertinent for BP 143/70. Physical examination shows weakness of upper and lower extremities RT>LT, expressive aphasia and grip myotonia. Patient admitted with diagnosis of Recurrent ischemic stroke/ acute ischemic stroke. Will f/u with Brain MRI, Carotids ultrasound, heart echocardiography. Education Given on Admission: Diagnosis, Treatment, Medications, Procedure Orientation to: Patient, Daugther - Vaccine Hx Influenza Vaccination: No Hx Pneumococcal Vaccination: No Hx COVID Vaccination: Yes Admission Orders - Admission Orders 09/15/21 08:50 Admit as Inpatient [ADMISSION] Routine 09/15/21 08:58 MR head/brain wo con [MR] Stat 09/15/21 08:59 CA echo transthoracic complete Stat 09/15/21 09:00 US carotid duplex BI [US] Stat 09/15/21 Lunch NPO Diet [DIETARY] 09/16/21 05:00 BMP [Basic Metabolic Panel] [CHEM] DAILY CBC [Complete Blood Cell Count] [HEME] DAILY 09/17/21 05:00 BMP [Basic Metabolic Panel] [CHEM] DAILY CBC [Complete Blood Cell Count] [HEME] DAILY 09/18/21 05:00 BMP [Basic Metabolic Panel] [CHEM] DAILY Dr. Manuel Colón Álvarez, RN-MSN Universidad Interamericana de Puerto Rico Recinto de Guayama Departamento de Ciencias de la Salud Programa de Enfermería Estudiante: ____________________________ Sección: ______________ Fecha: _______________________ Profesor:______________________________ Código y nombre del curso: NURS 2234- Práctica Adulto II Datos del Paciente Edad Ocupación Sexo Orientación Religiosa Estado Civil Admitido en el Departamento de: Nacionalidad Diagnóstico Médico Etapa de Crecimiento y Desarrollo Etapa en que se encuentra el cliente: Nombre del teorizante Tareas de crecimiento y desarrollo que caracterizan la etapa: Tareas de crecimiento y desarrollo observadas en el cliente: Dr. Manuel Colón Álvarez, RN-MSN Hallazgos significativos del historial pasado Hallazgos significativos del historial presente utilizando los patrones de salud (Hospitalizaciones y diagnósticos médicos, enfermedades desde la niñez, vacunas) Historial Familiar Patrón de Manejo y Percepción de la Salud Patrón Nutricional Metabólico Patrón de Eliminación Patrón de Actividad y Ejercicio Patrón de Descanso y Sueño Patrón Cognitivo-Perceptual Patrón Autopercepción y auto concepto Patrón Rol y Relaciones Patrón Sexual Reproductivo Dr. Manuel Colón Álvarez, RN-MSN Diagnóstico Médico: Definición Epidemiología Etiología Patofisiología Signos y Síntomas Dr. Manuel Colón Álvarez, RN-MSN Procedimientos Diagnósticos Nombre del estudio o prueba y su propósito Preparación y cuidado del cliente Niveles o valores normales Resultados del cliente Interpretación de los resultados (relación con el diagnóstico médico) Hematología CBC Escribir la preparación y cuidado del cliente: RBC Eritrocitos WBC Leucocitos Hematocrito Hemoglobina (Hbg) Plaquetas Neutrófilos Eosinofilos Basófilos Linfocitos Monocitos Otros: Dr. Manuel Colón Álvarez, RN-MSN Perfil metabólico CMP o BMP Escribir la preparación y cuidado del cliente: Interpretación de los resultados Niveles o valores normales Resultados del cliente (relación con el diagnóstico médico) Glucosa BUN Creatinina Albumina Colesterol Bilirrubina total Sodio Potasio Cloro Proteína total Dr. Manuel Colón Álvarez, RN-MSN Urinálisis Escribir la preparación y cuidado del cliente Niveles o valores normales Resultados del cliente Interpretación de los resultados Color Apariencia Gravedad especifica PH Proteína Glucosa Cetonas Bilirrubina WBC (Células blancas) RBC (Células rojas) Bacterias Dr. Manuel Colón Álvarez, RN-MSN Estudios (Placas, ecocardiogramas, CT, MRI, Endoscopias, colonoscopia, otros) Nombre del estudio o prueba y propósito Preparación y cuidado del cliente Niveles normales Resultados del cliente Interpretación de los resultados Dr. Manuel Colón Álvarez, RN-MSN Procedimientos Diagnósticos Nombre del estudio o prueba y su propósito Preparación y cuidado del cliente Niveles o valores normales Resultados del cliente Interpretación de los resultados (relación con el diagnóstico médico) OTROS LABORATORIOS Escribir la preparación y cuidado del cliente: Dr. Manuel Colón Álvarez, RN-MSN Medicamentos Utilizados (Orden médica en el hospital) Nombre, Dosis, Frecuencia y Vía de administración Indicación (uso) y acción deseada Reacciones adversas principales y contraindicaciones Implicaciones de enfermería Nombre Medicamento: Dosis: Frecuencia: Vía: Uso: Acción deseada: Reacciones adversas: Contraindicaciones: Nombre Medicamento: Dosis: Frecuencia: Vía: Uso: Acción deseada: Reacciones adversas: Contraindicaciones: Dr. Manuel Colón Álvarez, RN-MSN Nombre, Dosis, Frecuencia y Vía de administración Indicación (uso) y acción deseada Reacciones adversas principales y contraindicaciones Implicaciones de enfermería Nombre: Dosis: Frecuencia: Vía de adm: Uso: Acción deseada: Reacciones adversas: Contraindicaciones: Nombre: Dosis: Frecuencia: Vía de adm: Uso: Acción deseada: Reacciones adversas: Contraindicaciones: Dr. Manuel Colón Álvarez, RN-MSN Tratamientos Tratamientos Prescritos Racional Científico Dieta Tipo de dieta Composición de la dieta Racional científico ¿Porque el paciente recibe este tipo de dieta? Curso y Pronóstico de la enfermedad Dr. Manuel Colón Álvarez, RN-MSN Patrón funcional de salud alterado (problema) Diagnósticos de enfermería (NANDA) Metas, objetivos o resultados esperados (NOC) Intervenciones (actividades) de enfermería con racional científico (NIC) mínimo 5 actividades Racional Científico Evaluación Patrón de salud alterado: Problema (s): Código: Definición: PES Código: Definición: Metas: Indicadores (3): Tiempo: Código: Definición: Dr. Manuel Colón Álvarez, RN-MSN Plan de Cuidado Patrón funcional de salud alterado (problema) Diagnósticos de enfermería (NANDA) Metas, objetivos o resultados esperados (NOC) Intervenciones (actividades) de enfermería con racional científico (NIC) mínimo 5 actividades Racional Científico Evaluación Patrón de salud alterado: Problema (s): Código: Definición: PES Código: Definición: Metas: Indicadores (3): Tiempo: Código: Definición: Dr. Manuel Colón Álvarez, RN-MSN Plan de Cuidado Patrón funcional de salud alterado (problema) Diagnósticos de enfermería (NANDA) Metas, objetivos o resultados esperados (NOC) Intervenciones (actividades) de enfermería con racional científico (NIC) mínimo 5 actividades Racional Científico Evaluación Patrón de salud alterado: Problema (s): Código: Definición: PES Código: Metas: Indicadores (3): Tiempo: Código: Dr. Manuel Colón Álvarez, RN-MSN Fuentes de información utilizadas para la recopilación de datos del cliente: Referencias (Libros, revistas) Usar el Formato APA 6ta. Edición: Referencias obtenida por línea (WEB) Usar el Formato APA 7ma. Edición:
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Your assignment may be more than 5 paragraphs but not less. INSTRUCTIONS:  To access the FNU Online Library for journals and articles you can go the FNU library link here:  https://www.fnu.edu/library/ In order to n that draws upon the theoretical reading to explain and contextualize the design choices. Be sure to directly quote or paraphrase the reading ce to the vaccine. Your campaign must educate and inform the audience on the benefits but also create for safe and open dialogue. A key metric of your campaign will be the direct increase in numbers.  Key outcomes: The approach that you take must be clear Mechanical Engineering Organic chemistry Geometry nment Topic You will need to pick one topic for your project (5 pts) Literature search You will need to perform a literature search for your topic Geophysics you been involved with a company doing a redesign of business processes Communication on Customer Relations. Discuss how two-way communication on social media channels impacts businesses both positively and negatively. Provide any personal examples from your experience od pressure and hypertension via a community-wide intervention that targets the problem across the lifespan (i.e. includes all ages). Develop a community-wide intervention to reduce elevated blood pressure and hypertension in the State of Alabama that in in body of the report Conclusions References (8 References Minimum) *** Words count = 2000 words. *** In-Text Citations and References using Harvard style. *** In Task section I’ve chose (Economic issues in overseas contracting)" Electromagnetism w or quality improvement; it was just all part of good nursing care.  The goal for quality improvement is to monitor patient outcomes using statistics for comparison to standards of care for different diseases e a 1 to 2 slide Microsoft PowerPoint presentation on the different models of case management.  Include speaker notes... .....Describe three different models of case management. visual representations of information. They can include numbers SSAY ame workbook for all 3 milestones. You do not need to download a new copy for Milestones 2 or 3. When you submit Milestone 3 pages): Provide a description of an existing intervention in Canada making the appropriate buying decisions in an ethical and professional manner. Topic: Purchasing and Technology You read about blockchain ledger technology. Now do some additional research out on the Internet and share your URL with the rest of the class be aware of which features their competitors are opting to include so the product development teams can design similar or enhanced features to attract more of the market. The more unique low (The Top Health Industry Trends to Watch in 2015) to assist you with this discussion.         https://youtu.be/fRym_jyuBc0 Next year the $2.8 trillion U.S. healthcare industry will   finally begin to look and feel more like the rest of the business wo evidence-based primary care curriculum. Throughout your nurse practitioner program Vignette Understanding Gender Fluidity Providing Inclusive Quality Care Affirming Clinical Encounters Conclusion References Nurse Practitioner Knowledge Mechanics and word limit is unit as a guide only. The assessment may be re-attempted on two further occasions (maximum three attempts in total). All assessments must be resubmitted 3 days within receiving your unsatisfactory grade. You must clearly indicate “Re-su Trigonometry Article writing Other 5. June 29 After the components sending to the manufacturing house 1. In 1972 the Furman v. Georgia case resulted in a decision that would put action into motion. Furman was originally sentenced to death because of a murder he committed in Georgia but the court debated whether or not this was a violation of his 8th amend One of the first conflicts that would need to be investigated would be whether the human service professional followed the responsibility to client ethical standard.  While developing a relationship with client it is important to clarify that if danger or Ethical behavior is a critical topic in the workplace because the impact of it can make or break a business No matter which type of health care organization With a direct sale During the pandemic Computers are being used to monitor the spread of outbreaks in different areas of the world and with this record 3. Furman v. Georgia is a U.S Supreme Court case that resolves around the Eighth Amendments ban on cruel and unsual punishment in death penalty cases. The Furman v. Georgia case was based on Furman being convicted of murder in Georgia. Furman was caught i One major ethical conflict that may arise in my investigation is the Responsibility to Client in both Standard 3 and Standard 4 of the Ethical Standards for Human Service Professionals (2015).  Making sure we do not disclose information without consent ev 4. Identify two examples of real world problems that you have observed in your personal Summary & Evaluation: Reference & 188. Academic Search Ultimate Ethics We can mention at least one example of how the violation of ethical standards can be prevented. Many organizations promote ethical self-regulation by creating moral codes to help direct their business activities *DDB is used for the first three years For example The inbound logistics for William Instrument refer to purchase components from various electronic firms. During the purchase process William need to consider the quality and price of the components. In this case 4. A U.S. Supreme Court case known as Furman v. Georgia (1972) is a landmark case that involved Eighth Amendment’s ban of unusual and cruel punishment in death penalty cases (Furman v. Georgia (1972) With covid coming into place In my opinion with Not necessarily all home buyers are the same! When you choose to work with we buy ugly houses Baltimore & nationwide USA The ability to view ourselves from an unbiased perspective allows us to critically assess our personal strengths and weaknesses. This is an important step in the process of finding the right resources for our personal learning style. Ego and pride can be · By Day 1 of this week While you must form your answers to the questions below from our assigned reading material CliftonLarsonAllen LLP (2013) 5 The family dynamic is awkward at first since the most outgoing and straight forward person in the family in Linda Urien The most important benefit of my statistical analysis would be the accuracy with which I interpret the data. The greatest obstacle From a similar but larger point of view 4 In order to get the entire family to come back for another session I would suggest coming in on a day the restaurant is not open When seeking to identify a patient’s health condition After viewing the you tube videos on prayer Your paper must be at least two pages in length (not counting the title and reference pages) The word assimilate is negative to me. I believe everyone should learn about a country that they are going to live in. It doesnt mean that they have to believe that everything in America is better than where they came from. It means that they care enough Data collection Single Subject Chris is a social worker in a geriatric case management program located in a midsize Northeastern town. She has an MSW and is part of a team of case managers that likes to continuously improve on its practice. The team is currently using an I would start off with Linda on repeating her options for the child and going over what she is feeling with each option.  I would want to find out what she is afraid of.  I would avoid asking her any “why” questions because I want her to be in the here an Summarize the advantages and disadvantages of using an Internet site as means of collecting data for psychological research (Comp 2.1) 25.0\% Summarization of the advantages and disadvantages of using an Internet site as means of collecting data for psych Identify the type of research used in a chosen study Compose a 1 Optics effect relationship becomes more difficult—as the researcher cannot enact total control of another person even in an experimental environment. Social workers serve clients in highly complex real-world environments. Clients often implement recommended inte I think knowing more about you will allow you to be able to choose the right resources Be 4 pages in length soft MB-920 dumps review and documentation and high-quality listing pdf MB-920 braindumps also recommended and approved by Microsoft experts. The practical test g One thing you will need to do in college is learn how to find and use references. References support your ideas. College-level work must be supported by research. You are expected to do that for this paper. You will research Elaborate on any potential confounds or ethical concerns while participating in the psychological study 20.0\% Elaboration on any potential confounds or ethical concerns while participating in the psychological study is missing. Elaboration on any potenti 3 The first thing I would do in the family’s first session is develop a genogram of the family to get an idea of all the individuals who play a major role in Linda’s life. After establishing where each member is in relation to the family A Health in All Policies approach Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum Chen Read Connecting Communities and Complexity: A Case Study in Creating the Conditions for Transformational Change Read Reflections on Cultural Humility Read A Basic Guide to ABCD Community Organizing Use the bolded black section and sub-section titles below to organize your paper. For each section Losinski forwarded the article on a priority basis to Mary Scott Losinksi wanted details on use of the ED at CGH. He asked the administrative resident