karen james case study
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
This is an Unfolding Case Study
Patient Details:
Print Phase Info
|
Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
FemaleKaren James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physicians office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.
You are currently working on Phase 1. You have completed Phase 0 of this scenario.
Patient Details:
Print Phase Info
|
Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
Female
Phase
1,
Wednesday
16:00You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.
Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:
1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?
2). What was the last documented temperature for Karen?
3). Does Ms. James use any sensory aides?
4) What does she rate her pain?
5) What is her MORSE Fall Risk Score?
Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?
[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]
When you are finished with this task, you may click Complete this Phase.
Patient InformationChief Informant:
Patient
Chief Complaint:
Shortness of breath, productive cough
History of Current Problem:
Patient states she has had 3-week history of influenza. Has now developed a severe cough approximately 3 days ago with shortness of breath. Unable to sleep due to cough, which often causes bronchospasms. Patient also complains of fever, fatigue, and right-sided chest pain. Seen in urgent care 3 days ago and given Z-pack. No improvement in symptoms.
Allergies:
None known
Family History:
Mother died at age of 72 with breast cancer. Father is alive at the age of 79 and has congestive heart failure.
Past Medical HistoryPrevious Illnesses:
Patient has asthma. Also states she gets bronchitis every 1-2 years.
Contagious Diseases:
None
Injuries or Trauma:
None
Surgical History:
Tonsillectomy and adenoidectomy as a child.
Dietary History:
Regular diet. Patient is 5’1″ and 140 pounds. Has recently lost 20 pounds on Weight Watchers diet.
Other:
—
Social History:
No smoking, no drugs. Uses alcohol in social situations.
Current Medications:
Tylenol 650 mg PO every 4 hours PRN pain or fever
Prozac 20 mg PO every day
Xanax 0.25 mg PO every 8 hours PRN
Xopenex HFA 2 puffs every 6 hours PRN
Review of SystemsIntegument:
Denies complaints.
HEENT:
States she had neck soreness related to influenza, with “swollen glands.”
Cardiovascular:
No complaints.
Respiratory:
Complains of shortness of breath, frequent productive cough. States her cough often turns into bronchospasms. Uses inhaler, peppermint tea, lozenges, and Vicks VapoRub.
Gastrointestinal:
Complains of decreased appetite.
Genitourinary:
No complaints.
Musculoskeletal:
Complains of generalized body aches.
Neurologic:
Alert and oriented.
Developmental:
Denies complaints.
Endocrine:
No complaints.
Genitalia:
No complaints.
Lymphatic:
No complaints.
Physical ExamGeneral:
57-year-old female in mild distress. Appears weak.
Vital Signs:
Temp: 103.2 F, Pulse: 114, Resp: 28, Blood pressure: 154/78 in office this morning
Integument:
Skin clear of rash.
HEENT:
Pupils equal and reactive. Nasal congestion. Neck supple.
Cardiovascular:
S1, S2, no murmur.
Respiratory:
Lungs clear with crepitation in right base.
Gastrointestinal:
Abdomen soft, active bowel sounds.
Genitourinary:
—
Musculoskeletal:
Moves all extremities well.
Neurologic:
Alert and oriented.
Developmental:
—
Endocrine:
—
Genitalia:
Not assessed. Seen by gynecologist recently. Negative pap smear and negative mammogram.
Lymphatic:
No lymph node swelling at this time.
Impressions:
Pneumonia
Plan:
The patient is admitted for IV antibiotics and close observation of respiratory status. Patient will need influenza and pneumonia vaccines.
Provider Signature:
Michael Foster, MD
Day:
Wednesday
Time:
12:45
Chief Complaint:
The patient is a 57-year-old female admitted today for chief complaint of shortness of breath.Patient’s labs were completed in the primary care provider’s office prior to admission and results include the following:
WBC: 20.2 x 109/L
RBC: 4.51 RBC x 106/ul
Hemoglobin: 14.0 g/dL
Hematocrit: 40.2%
Sodium: 139 mEq/L
Potassium: 4.2 mEq/L
Chloride: 105 mEq/L
CO2: 26 mEq/L
Glucose: 91 mg/dL
BUN: 17 mg/dL
Creatinine: 0.5 mg/dLShe is also febrile at 102.7.
Nursing will initiate IV antibiotics.
Showing 1 to 1 of 1 entries
FirstPrevious1NextLastChart Time
Temp
Resp
Pulse
BP
Sat%
Notes
Entry By
Wed 12:45
102.7
22
112
142/77
98
C Diaz, RN
Select Chart Type: Temperature Respiration Pulse Blood Pressure Oxygen Saturation
Select and drag to zoom in on a date range
102.7F/39.3CPatient Card
Order Day/Time
Description
Category
Last Performed
Discontinue
Wed | 13:00
Admit to medical-surgical
Alerts
—
Wed | 13:00
Start and maintain IV line
IV
—
Wed | 13:00
Pulse oximetry every 4 hour(s)
Respiratory
—
Wed | 13:00
Vital signs every 4 hours
Vital Signs
—
Wed | 13:00
Up as tolerated
Activity/Mobility
—
Wed | 14:00
Diagnosis-Respiratory distress syndrome-ADDED-Disease Process
Patient Teaching
—
Wed | 13:00
Regular/General Diet
Diet
—
Showing 1 to 7 of 7 entries
FirstPrevious1NextLast
PRNDrug Name
Order Start
Order Stop
Dose
Route
Frequency
Dosage Time
Action
Acetaminophen Tablet – (Tylenol, Genapap)
Wed 13:00
Tue 23:59
650 mg
Oral
Every 6 Hours PRN
– –
Levalbuterol Nebulizer Solution – (Xopenex Nebulizer Solution)
Chart:
System Assessments Wed 13:00
Entry Time:
Wed 13:00
Entered By:
C Diaz, RN
Cardiovascular AssessmentPulses
Apical:
Regular
Tissue PerfusionPeripheral vascular, general:
Warm extremities
EdemaNo edema noted
Cardiac AssessmentNo cardiac problems noted
Respiratory AssessmentProductive Cough Secretions Assessment
Color:
Green
Amount:
Scant
CoughCough strength:
Strong
Cough type:
Productive
OxygenationRespiratory/breathing support:
Nebulizer treatment
Lower Right PosteriorAuscultation:
Coarse crackles
Lower Left PosteriorAuscultation:
Diminished
Upper Right PosteriorWheeze Description:
Expiratory
Auscultation:
Wheeze
Upper Left PosteriorWheeze Description:
Expiratory
Auscultation:
Wheeze
Productive Cough Secretions AssessmentConsistency:
Thick
Secretion odor:
None
Upper Left AnteriorAuscultation:
Clear
Upper Right AnteriorAuscultation:
Clear
Respiratory EffortDyspnea/shortness of breath
Shortness of breath on exertion
Respiratory PatternLabored
Neurological AssessmentLevel of Consciousness/Orientation
Oriented to person, place, time, and situation
Emotional StateCalm
Cooperative
Central Nervous System Assessment (CNS)No CNS problems evident
Integumentary AssessmentIntegumentary Assessment
No assessment required at this time
Sensory AssessmentVision Assessment
Wears glasses
Wears contacts
Musculoskeletal AssessmentRange of Motion (ROM)
Moves all extremities with full range of motion
Gastrointestinal AssessmentAbdomen
Abdominal assessment:
Soft to palpation
GastrointestinalNo gastric problems noted
IntestinalDate of last bowel movement:
Monday
Continence of bowel:
Continent
Intestinal assessment:
No bowel problems noted
Bowel sounds:
Active x 4 quadrants
Rectum:
No reported rectal problems
Pain AssessmentDo You Have Pain Now?
No
Genitourinary AssessmentGenitourinary Assessment
No assessment required at this time
Psychosocial AssessmentPsychosocial Assessment
No assessment required at this time
Safety AssessmentOrientation
Oriented to time, person, place
Fall Risk30
Bracelet CheckHospital ID bracelet
Safety NotesLow fall risk
Morse Fall ScaleHistory of Falling
No=0
Secondary DiagnosisNo=0
Ambulatory AidNone/Bedrest/Nurse Assist=0
IV or IV AccessYes=20
GaitWeak=10
Mental StatusOriented to Own Ability=0
Total Fall Risk ScoreRisk Score:
30
Fall Risk Score and Preventative Measures ImplementedFall Risk Level:
Medium Risk
Fall Risk Measures:
Implement Medium Risk Fall Prevention Interventions:
All items in low prevention plus post fall program sign indicating risk, wrist band identification, ambulate with assistance, do not leave patient unattended in diagnostic or treatment area, make comfort rounds every 2 hours for toileting.
Special Precautions/Isolation AssessmentStandard Precautions
Vision AssessmentWears glasses
Wears contacts
Musculoskeletal Assessment
You are currently working on Phase 2. You have completed Phase 1 of this scenario.
Patient Details:
Print Phase Info
|
Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
Female
Phase
0Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physicians office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.
You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:
1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?
2). What was the last documented temperature for Karen?
3). Does Ms. James use any sensory aides?
4) What does she rate her pain?
5) What is her MORSE Fall Risk Score?Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?
[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]
When you are finished with this task, you may click Complete this Phase.
Phase
2,
Wednesday
16:20You enter Ms. James room to take her vital signs and obtain the following results:
Temperature: 101.5 degrees Fahrenheit, oral
Pulse: 110, radial
Respirations: 20
Blood pressure: 144/68 left arm, sitting
Oxygen saturation: 99%, finger probe, room airDocument the vital signs in the vital signs tab on the Info Panel on the left (do not document in a misc. note). When compared to the patients admission vital signs, how is the patients temperature trending? Document your answer in a Miscellaneous Nursing Note.
Under Basic Nursing Care: Choose 5 interventions you will perform at this time to make this client to increase safety. Only 5 as you will need to prioritize your cares. Try to find 5 related to Impaired Mobility.When you are finished with these tasks, you may click Complete this Phase.
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
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