In this second submission of your Course Project, you will be completing a health history, physical assessment, and client interview and determining their nursing diagnoses. This wr
In this second submission of your Course Project, you will be completing a health history, physical assessment, and client interview and determining their nursing diagnoses. This written assignment should include the following
Describe the medical diagnoses of your assigned client (you need to search it). Include the admitting diagnosis as number one and then four other medical diagnoses (for a total of 5). The admitting diagnosis and reason for being in the facility. If post-surgical, include surgery and reason for surgery. The secondary diagnoses include a history of pre-existing medical diagnoses). You need to include 4 secondary diagnoses. For each diagnosis, provide at least a 5-sentence explanation of the pathophysiology of the condition/problem. MAKE SURE YOU CITE YOUR SOURCES
Write a detailed physical assessment and interview on your case study client. You will have to know what to expect in your client by using the information from #1 above and your case study. You will have to be creative.
3. 5 Nursing diagnoses (only the NDx, you will complete the care plan for week10). Make sure they are in the correct format. If you give me only the label you will not get any points for nursing diagnoses.
6
FUNDAMENTALS COURSE PROJECT (GROUP)
Introduction
Family History: Mr. Brown is from a family of six. He’s the only male child in the family with five siblings. He lost both his parent to high blood pressure when he was at the age of 35. Currently, Mr. Brown has been battling this condition for the past six years. During my assessment, his blood pressure was 165/90 which indicates that he is also experiencing high blood pressure, which is family heredity. Our focus for this project is the disease Mr. Brown is experiencing the T3 disease
Question One
Drug Name Trade & generic name, dose, route & frequency |
Pharmacological & therapeutic drug class & Expected action in the body |
What medical diagnosis is your patient taking this drug for? How will it help them? |
Side Effects & Adverse Reactions/ Complications/Top drug interactions |
Nursing Administration Special Instructions and Assessments |
Client Education Evaluation of Medication Effectiveness (e.g. Pain Scale) |
– Dosage: 5mg – route: rectally -frequency: 3 days daily – generic: Bisacodyl -Trade: Dulcolax (Gunnström et al., 2022). |
– Therapeutic: Fluid is altered which results in the colon. fluid buildup |
– T3 burst Fracture: -the patient has agonized injury in the spinal cord, this will assist in colon clearing. – also the patient has a problem with his bladder and bowel. This medication aids in making the bowel soft when he is constipating. |
-Anxiety, memory loss, blurred vision, insomnia, depression, fatigue, dizziness, – interactions: no applicable drug interactions (Vallerand, 2021). |
– Assess for abdominal distention and bowel function – evaluate intake and output ratios in the body. |
– Do not take the dose twice or skip the dose as prescribed. – if a dose is skipped it ought to be taken immediately and given a duration of 6 hours before the next dosage (Gunnström et al., 2022). |
Trade: Gablofen, – route: Orally. – dose: 5mg -frequency: Daily4 times – generic: baclofen |
– Therapeutic: Muscle skeletal relaxant – contains impulses at the spine. Therapeutic effects: bladder and bowel purpose may also be enhanced (Gunnström et al., 2022). |
The patient has a problem with his bowel and Bladder hence the medication may help mend his bowel and bladder function (Vallerand , 2020). |
Side effects nasal congestion, insomnia, headache, hypotension, pruritus, fatigue, – interactions: Hypnotics, Analgesics, and alcohol (Vallerand, 2020). |
– Assess – Monitor patient closely during test dose. -preventive apparatus ought to be present for unendurable effects on the body (Gunnström et al., 2022). |
– Advice the patient to take medication as prescribed. – instruct the patient to avoid continuous usage of alcohol while undergoing medication. (Vallerand, 2020). |
Trade: Sertraline Dose: 100mg Frequency: Daily Generic: Zoloft |
– Therapeutic: pharmacologic: discerning serotonin reuptake inhibitors -Contains serotonin in the CNS hence Helping with Serotonin activities. Therapeutic effects: decreased incidence of Panic attacks and Antidepressant Action (Vallerand, 2020). |
-Patient lives alone and does not have close family members. -He has persistent painful damage which has made him became paralyzed from the abdomen downwards. Sertraline can assist him in lessening his depression and anxiety (Vallerand, 2020). |
Side effects: nervousness, Suicidal thoughts, diabetes, and agitation Interactions: Simultaneous use of alcohol is prohibited |
– Monitor appetite and nutritional intake. – evaluate for serotonin syndrome, particularly in patients taking other serotonergic drugs – Evaluate for suicidal trends, specifically during therapy (Gunnström et al., 2022). |
– Instruct client to take medication regularly without missing a dose. – Advise patient to consult the doctor if side effects persist. – emphasize on alcohol avoidance during therapy sections (Vallerand, 2020). |
Route: orally Frequency: after every six hours Dosage: 5/325 -generic: hydrocodone -Trade: Anexsia Norco |
– Therapeutic: allergy, cold, and cough remedies, opioid analgesic. -Therapeutic effects: -Decrease in rigorousness of pain and dominance of the cough reflex (Gunnström et al., 2022). |
– Patient has a stage 3 pressure ulcer to his coccyx. The hydrocodone will assist in relieving pain in the body. -Hydrocodone is also an anticholinergic and could aid with his urine incontinence (Vallerand, 2020). |
side effects -Sedation, euphoria, hallucinations, diplopia, dyspepsia, – interactions: Use with benzodiazepines as alcohol may cause profound sedation leading to death (Vallerand, 2020). |
– Assess blood pressure before and periodically in the course of intake. – Check the functioning of the bowel frequently (Vallerand, 2020). |
– Instruct patient on how and when to ask for and take pain medication. -Recommend to the patient that hydrocodone is a drug to make him heal. – instruct the patient to inform the doctor if pain persists. (Vallerand, 2020). |
Frequency: after every three days Route: Taken Orally -Trade ProAmatine -Generic: Midodrine Dosage: 10mg |
– Therapeutic: vasopressor – pharmacologic: alpha-1 agonists -Stimulation of alpha1- adrenergic receptors in veins and arteries Therapeutic effects: -blood pressure and vascular tone increase (Vallerand 2020). |
Paraplegia: -This prescription is used in the indicative monitoring of hypotension in impaired patients. -Urinary sickness this medicine can assist in preventing urinary incontinence (Vallerand, 2020). |
Side effects – hypertension, dizziness, urinary urge, nervousness, and confusion -Drug interaction: Simultaneous use of alcohol (Vallerand,2020). |
– check the patient’s blood pressure often. – analyze if the drug therapy is successful in the incidence of reducing hypotension – monitor and report signs of CNS toxicity – if the medication is used to Protect the Incontinence in the urine, evaluate the inconsistency to assist in determining if drug therapy is effective – evaluate for paresthesia (Gunnström et al., 2022). |
– Ask the patient to report cases of side effects in the body (Gunnström et al., 2022). |
Question Two
Labs and Diagnostic Tests
CMP lab test might be considered in order to monitor glucose levels. The normal range would be 65-110 mg/dL if an abnormal finding is seen it could indicate pre-diabetes or diabetes for our client (Rasmussen University, 2021). A CBC could also be considered in this case in order to check his WBC due to his pressure ulcer. White blood cell normally ranges the count between 5,000 to 10,000 mm³, while an eminent white blood cell count ranges more than 11,000, which would indicate inflammation or invasive infection (Rasmussen University, 2021). A diagnostic test could be used to determine the level of depression experienced by the patient.
Most depressed people will score between 50 and 69; if he scores between these ranges, he is at greater risk for depression (Gunnström et al., 2022). A CRP test could be ordered to determine the amount of CRP in the blood. If our patient’s CRP is persistently high following his surgery, it could indicate the presence of postoperative infection.
Conclusion
A set of core competencies can help advance adherence to rules of a newly designed health care system as shown by the report, which aims to provide patient-centered treatment, work in multidisciplinary teams, use evidence-based procedure, implement improvement activities, and utilize informatics. Finally, as the committee stresses, narrowing the quality gap can be realized at least in part by transforming health professions’ education.
References
Gunnström, M., Zdolsek, J. H., & Hahn, R. G. (2022). Plasma volume expansion and fluid kinetics of 20% albumin during general anesthesia and surgery lasting for more than 5 hours. Anesthesia & Analgesia, 134(6), 1270-1279.
Rasmussen University. (2021). Laboratory Values Resources.
Vallerand, A. H. (2020). Davis's Drug Guide for Nurses (17th Edition). F. A. Davis Company.
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