clinical judgement plan fix again
Victoria Kazaryan Clinical Judgement Plan West Coast University Victoria Ogundeko May 17, 2024 SK/DW 2/22 pg. 1 Clinical Judgement Plan Instructor: DATE Care Provided and UNIT: I TH History of Present Illness (HPI) Patient Information (1) Patient Initials: S.A. Age & Gender: 77 years, male Height/Weight: 173cm, 65 kg Code Status: N/A Living Will/ DPOA: N/A Chief Complaint S.A., a 77-year-old male, fronts chest pains impaired by: • Inspiration • dyspnea, and • Easy fatigability. Admitting Diagnosis & Admission Date The admission Date is not available. S. A., who is a 77-year-old male patient of a nursing home, came into the hospital due to progressive conditions such as chest pains, especially with breathing, shortness of breath, and easily getting tired. S. A. had been progressively ill for a few days before hospitalization, showing symptoms such as fever, productive cough, and increased respiratory distress. When the patient came to the hospital, he was checked immediately and diagnosed with pneumonia. Subsequently, he has been putting up with medical therapies and procedures that are designed to control his symptoms and enhance his breathing function. Medical History: (SEE RUBRIC REQUIREMENTS) S. A. has a past medical history of COPD, HTN, and arrhythmia, which are chronic. COPD is a chronic inflammatory lung disease that is marked by airflow limitation, which results in dyspnea, chronic cough, and sputum production. It usually originates from long-term inhalation of irritants, e.g., cigarette smoke. In COPD, the airways get inflamed and shrunken, and the alveoli lose their elasticity, leading, in turn, to flow obstruction and oxygen exchange impairment. Hypertension or high blood pressure is reached when the pressure applied by the blood in the arteries exceeds their normal limits (CDC, 2023). It is a slow process that can harm the blood vessels and organs and may lead to heart disease, stroke, and complications in the end. Tachycardia, bradycardia, and ectopic heartbeats are examples of arrhythmias – these are abnormal heart rhythms. In general, arrhythmias may be caused by heart disease, electrolyte imbalance, and medication side effects, and these may lead to disrupted electrical activity of the heart and potential cardiac dysfunction (American Heart Association, 2023). S.A. has a number of high-risk aspects relative to pneumonia, including advanced age, immunocompromised status, chronic lung diseases like COPD, and aspiration. Complications of untreated pneumonia may include respiratory failure, sepsis, lung abscesses, pleural effusion, acute respiratory distress syndrome (ARDS), organ failure, pulmonary hypertension, and exercise intolerance. These patients may suffer considerable respiratory function decline, as well as general health impairment, which can eventually lead to permanent disability or death if proper management of the condition is not implemented (NIH, 2023). Surgical History: (SEE RUBRIC REQUIREMENTS) The patient has a history of CABG surgery, which happened a long time ago. CABG is a surgical intervention that helps to restore the blood flow to the heart muscle in cases of severe coronary artery disease (CAD) (NHS, 2024). During CABG, surgeons use a healthy blood vessel – typically from the leg or chest – as the graft to bypass the blockage in the coronary artery and bring blood flow to the heart muscle. The purpose of the procedure is to relieve chest pain (angina), prevent heart attacks, and improve the general functioning of the heart. Social History: S. A. has been a chronic smoker and an alcohol user. Cultural considerations include ethnicity, occupation, religion, family support, and insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH) (SEE RUBRIC REQUIREMENTS) S. A., who is a 77-year-old man living in a nursing home, possibly has little financial stability and uses Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective assessment) (SEE RUBRIC REQUIREMENTS) At 77 years old, S.A. is likely in Erikson’s stage of Integrity vs. Despair. This stage involves reflecting on life experiences, either achieving a sense of fulfillment (integrity) or experiencing regret (despair). Given S.A.’s age and medical history, supporting his sense of integrity through meaningful interventions is crucial for his psychological wellbeing (Chen, 2021). social services, indicating financial difficulties. His smoking and drinking heavily suggest a misled health knowledge, which calls for targeted interventions to promote health literacy. The ethnic and religious background of S.A., however, are omitted, notwithstanding it is essential to consider these features in the context of culturally and spiritually centered care. A nursing home setting implies insufficient family support and potential incompatibility of medical care and prompt interventions. S.’s health depends on the availability of top-notch healthcare facilities, considering his COPD, hypertension, arrhythmia, and a surgical history of CABG. The neighborhood and built environment of the nursing home, which is composed of air quality and accessibility to green spaces, is at the core of Tom’s respiratory challenges. Sufficient insurance coverage for S.A. must be ensured to address his health issues properly without risking more health problems. This evidence indicates a multidimensional approach that will not neglect Final Version 3/10/22 DW/ss & MS Team the economic, educational, social, and environmental health determinants. (Chen, 2021). Clinical Judgement Plan Medical Management and Collaborative Plan (From MD, P.T., O.T. notes…. etc.) *Consider the past 24 – 48 hours (SEE RUBRIC REQUIREMENTS) Instructor: DATE Care Provided and UNIT: TIME OUT!!! Student instructions: Include Relevant Diagnostic Procedures/Results and pertinent Lab tests/ Values (With normal ranges), include dates and rationales supported by Evidence-Based Citations Include 2-3 nursing interventions for abnormal labs and all diagnostic procedures Lab Tests or Diagnostic Scan Complete Blood Count (CBC) Normal Ranges Hb: 13.517.5 g/dL Admission Lab Values Hb: 12.8 g/dL Current Lab Values Hb: g/dL 11.8 Explain Abnormal Labs R/T Your Pt & N.I. (USE SEPARATE ATTACHED WORD DOC à WHEN NEEDED) Low Hemoglobin (Hb), increased white blood cell (WBC) count due to infection and reduced platelet count that can be caused by underlying inflammation (Pharmaceutical Journal, 2024)— calls for more research, and for altering the therapy regimen. Comprehensive Metabolic Panel (CMP) Sodium: 135-145 mEq/L Sodium: 138 mEq/L Sodium: 140 mEq/L Mild hyperglycemia, potentially induced by the stress response. In all other instances, values are within the normal range. They are monitoring for electrolyte imbalances. Arterial Blood Gas (ABG) pH: 7.357.45 pH: 7.38 pH: 7.37 The patient’s normal ABG values suggest sufficient oxygenation and ventilation, while a slightly alkalotic respiratory state is also present (NHS, 2024). Chest X-ray Clear lung fields Infiltrates in lower lobes Persistence of infiltrates On-going infection or complications requiring monitoring could be carried out, and possible intervention could be there, too. ANTICIPATED TRANSFER/ DISCHARGE PLANNING: Before discharging or transferring S. A., one of the priorities is to ensure that he has the equipment, medicines, and treatment regimens set up and ready for a seamless transition. In terms of equipment, coordination needs to be done for any wheelchair or any breathing devices he may need at home or at a new care facility. To control his chronic conditions and avoid exacerbations, there is a need for medication reconciliation and adequate prescription drugs for his use. Besides, a comprehensive treatment plan, such as follow-up appointments with specialists and rehabilitation services where needed, would have also pinned his effective recovery after discharge. Communicating with S.A., his healthcare team as well as caregivers regarding these aspects will constitute an integral part of our plan to help the patient make a successful transition and achieve the desired health outcomes. TIME OUT!!! Student instructions: (SEE RUBRIC REQUIREMENTS) Patient Education (In Pt.) for Referrals/ Discharge Planning REFERRALS NEEDED/CASE Management Referrals Needed/Case Management: S.A. needs attending physicians, including pulmonologists and cardiologists, for continuous care after being discharged. Care management will have a crucial role in coordinating referrals and removing logistical barriers to care access. Assessment of Learning Style: Discovering S. A.’s capacity to assimilate information (whether visual, auditory, or tactile) will serve as a guideline for the design of appropriate teaching aids. Considering possible challenges such as language proficiency or the level of education, providing a variety of resources like written materials, videos, and interactive tools will improve students’ understanding. Providing necessary assistive devices like glasses or hearing aids will, in a way, enhance S. A.’s learning experience. TIME OUT!!! Student instructions: Pathophysiology of Primary Medical Dx (reason for hospitalization) Support with Evidence-Based Citations Pathophysiology of Primary Medical Dx (reason for ) In COPD, the main pathological process is continued inflammation of the airways due to exposure to irritants such as cigarette smoke. The inhalation of these harmful gases results in an inflammatory reaction inside the lungs, with changes to their structure, including airway narrowing, mucus hypersecretion, and loss of lung elasticity, resulting in airflow limitation and respiratory symptoms. Final Version 3/10/22 DW/ss & MS Team Clinical Judgement Plan Instructor: TIME OUT!!! Student instructions: DATE Care Provided and UNIT: Medication Name Dose Medications & Allergies (2) Route Include BOTH Generic AND Trade names for R.X.; include OTC, herbal (nonpharmacological items) Freq. Indications Mechanism of Action NOTE: PRN ‘alone’ ≠ Freq (PRN meds must include M.D. ordered Indication) Amiodarone HCI Oral Tablet 200 MG (Cordarone) 200 mg G-Tube Daily Arrhythmia (Hold for Pulse
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
