SophiaPretty
$14/per page/Negotiable
Click here to download and analyze the case study for this week. Create a wholistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
Click here to access the codes.
Click here to download the care plan template to help you design a holistic patient care plan. The care plan example provided here is meant only as a frame of reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.
Format:Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be 2 to 4 pages double-spaced and in 12pt font.
|
Grading Criteria |
Maximum Points |
|
Care plan demonstrated involvement of the client in the process of recognition, planning, and resolution of the problem. |
15 |
|
Care plan included effective nursing interventions that are customized for the client and appropriate to the goal. |
15 |
|
Care plan included diagnostic work-up, medications, conservative measures, and follow-up plan. |
15 |
|
Care plan provided rationale for choosing a particular treatment modality. |
15 |
|
Care plan demonstrated logical diagnosis that was substantiated with relevant evidence. |
10 |
|
Care plan focused on patient education and maintained a fine balance between major and minor health issues of the patient. |
10 |
|
Care plan included nursing interventions that are specific, appropriate, and free of essential omissions. |
10 |
|
Used APA standards consistently and accurately. |
10 |
|
Total |
100 |
Click here to access the codes.
Care Plan Template
Patient Initials: ______ Age: _______________ Sex: ___________
Subjective Data:
Client Complaints:
HPI (History of Present Illness):
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):
Significant Family History:
Social/Personal History (occupation, lifestyle—diet, exercise, substance use)
Description of Client’s Support System:
Behavioral or Nonverbal Messages:
Client Awareness of Abilities, Disease Process, Health Care Needs:
Objective Data:
Vital Signs including BMI:
Physical Assessment Findings:
Lab Tests and Results:
Client’s Support System:
Client’s Locus of Control and Readiness to Learn:
ICD-10 Diagnoses/Client Problems:
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
References
Pulmonology Case Study
HPI
A65-year-oldCaucasianfemalepresentswithachiefcomplaintofcoughfortwoweeks. Shehasbeencomplainingofdrycoughsincethepasttwoweeksandlowgradefever thatstartedtwodaysago,andwasashighas101orally.Shehashadadecreased appetitebutnonauseaandvomiting.Thecoughoccursduringthenightandsheneeds to situpinachairtobeabletobreatheeasier.Thecoughismainlydry,rarely productive.
Shehadbeenprescribedinhalersinthepast;theyhavebeenhelpfulbutshedoesnot usethemonaroutinebasis.Shehasbeenprescribedantibioticsinthepastaswelland thatseemstohelpwhensheisacutelyill.Shehasbeensufferingfromshortnessof breathforthepasttwoweeksfollowinganykindofactivitymainlybecauseofthedry cough.Shethinksit’spossiblethatthere’ssomeproblemwithher“heart.”Sheisalso complainingofslightsorethroat,especiallyinthemorningandfeelsshemayhavelung cancer.
Thepatient’ssymptomshavebeenworseningoverthepasttwodays.
Shehashadsimilarepisodesinthepast.Thelastwasthreemonthsagowhenshehad to gototheemergencyroomandtheytoldherthatsheneededtobehospitalized.She declinedhospitalizationatthattimeandwastreatedandreleased.Shesaystheygave herantibioticsandaninhalerbeforedischargingher.Shementionedthatthoughittook sometimetofeelbetter,therewasgradualimprovementinherconditionfollowingthat treatment.Accordingtoher,thisistheworstepisodethatshecanremember.She’svery concernedtodaythatshecouldhavepneumoniaandmightrequirehospitalization.
Sheisseekingmedicalattentiontodaybecauseofthefeverandprolongednatureofher illness.
PMH
Thoughshehasbeentreatedforthisprobleminthepastwithantibioticsandinhalers, shehasnotbeenhospitalized.Thepatienthadachestinvestigationthelasttimeshe hadthisproblem.Shestatesthatshedidnothavepneumoniabutdidhave “emphysema.”Thehealthcareprofessionalswantedtodopulmonaryfunctiontests,but shedeclined.
X-rayreport:
X-rayresults:HyperinflationofbothlungswithanincreasedAPdiameter.Thereis evidenceofemphysema. .
Shestatesthatshehadasthmaasachildandisacigarettesmoker.Shealsohada hysterectomywaybackin1970s.Besidesthese,shehasnoknownchronicmedical problems.
ROS
Shortnessofbreathwithactivity.Nodiaphoresis.Shehashadafever.Nonauseaand vomiting.Denieschestpressuresensationwithphysicalactivity.Nopalpitations.
MEDICATIONS
Thepatientdoesnottakeanyprescriptionmedicines.Shetakesoccasionalover-the- counterTylenolforpain.
Tylenol650mg,2POas needed.
ALLERGIES/REACTIONS
Sheisallergictosulfadrugsthatcausearash.
SOCIALHISTORY
Thepatienthasbeenwidowedfor20years.Sheisreceivinganannualpensionof
$40,000.00andhassomemoneythatshehassavedinthebank.Shehasahighschool diplomaandownsherhouse.Thoughshehaslittledisposableincome,herfinancesare essentiallystable.Shehaslittleknowledgeofcommunityresourcesthatareather disposal.
Shehasa primarycareprovider,whomsheseesthreetofourtimeseveryyearfora physicalexamination.Thephysicianisverybusyanddoesnotspendmuchtimewith her.Shehasinsurancebutitdoesnotcoverallherprescriptionmedications.Sherelies onalotonsamples.
Shehastwogrown-updaughterswholiveinthenearbycommunity.Theyarebothin theirfortiesandarealiveandwell.Thepatientwouldlikeherdaughterstobemore involvedinherlife,butsheisnotsurehowtoapproachthemaboutthis.Thepatient’s perceptionofself-efficacyhasbeendecliningoverthepasttenyears.Shefeelsthatshe couldbefeelingdepressedbecauseshedoesnotgetoutofthehouseveryoftenand this depressionisonlygettingworsewitheachpassingyear.
Thepatienthasverylowlevelofday-to-daystress.However,sherealizesthather depressivesymptomsmaybecausingsomeofherphysicalsymptoms.
Shegoestochurchandhassomecontactsthere.Sheseesherdaughtersoncea month.Thesepeoplearehersupportsystem,butshehasnoonetotalktoonaroutine basis.
HABITS
• Diethabits
Shehasa healthydietandherdietaryintakeisadequate.Thepatienthaspositive healthbeliefsandknowsthatsheshouldbedoingmoretomaintainahealthylifestyle. Shedoesnotgetadequateexercisebecauseofhershortnessofbreath.Sheenjoys visitingherphysician.
Smoking:Shehassmokedonepackperdayfor40years. Alcohol:Shedeniesalcoholuse
SubstanceUse:Shedeniesanystreetdruguse
WORKHABITS
Shehasalwaysbeenahairdresser;isretirednow.Shegoestochurchandoccasionally attendssomeoftheirfunctions.Herhobbiesincludesewing.SheisfromtheUnited Statesandlivesinasuburbansetting.Crimerateinherlocalityislowwitheasyaccess
topublictransportation.Thereareavarietyofcommunitygroups,butsheisnotawareof theseresources.
FAMILYHISTORY
Hertwooldersistersarealiveandwell,onewithosteoporosisandonewithbreast cancer. Her75-year-oldsisterwasdiagnosedwithosteoporosisattheageof55.Her72- year-oldsisterwasdiagnosedwithbreastcancerat60yearsofage.
PHYSICALEXAMINATION
VitalSigns:BP:130/72leftarmsittingregularcuff;T:101po;P:100andregular;R:20, non-labored;Wt:130#;Ht:55”.
HEENT:Whitematerialonthebuccalmucosa;doesnotwipeoffwithtongueblade. LymphNodes:None
Lungs:Decreasedbreathsounds,dulltopercussionrightlowerlobe.Endexpiratory wheezeinrightlowerlobe.Noralesorrhonchi.Increasedanterior-posteriordiameterto chestwall.
Heart:RRRwithoutmurmur Carotids:Nobruits Abdomen:Benign
Rectum:Notexamined
Genital/Pelvic:Notexamined
Extremities,IncludingPulses:2+pulsesthroughout,noedema
Neurologic:Notexamined
LABRESULTS/RADIOLOGICALSTUDIES/EKGINTERPRETATION
CBC-WBCs15,000with+leftshift
Pulseoximeterreading:SAO2:98%
RadiologicalStudies
CXR–SameasX-ray
EKG
Normalsinusrhythm
Please watch this link for how to set up your APA format paper.
http://www.youtube.com/watch?v=9pbUoNa5tyY
Title in Upper and Lower Case
Your Name
Your University
Please do not exceed 23% plagiarism
Abstract
What is an abstract? It should be between 100–250 words. Abstract needs to be clear, concise and it must deliver the entire of your paper in just a few words. You also need to include “keywords” as well.
Keywords: Enter key words that describe the main themes in your paper. It needs to be in “double spaced manuscript, times Roman typeface, 1 inch margins.” (APA, 2010, p. 41)
For further information on how to write abstract paper please click on the links below:
1. https://owl.english.purdue.edu/owl/resource/656/1/
2. http://grammar.yourdictionary.com/grammar-rules-and-tips/helpful-tips-for-writing-an-abstract.html
3. http://www.csus.edu/org/swaa/student_abstract_guide/
4. http://academictips.org/mla-format/apa-format-abstract-page/
(this is how abstract APA should look like)
Title of Paper in Upper and Lower Case (Centered, Not Bold)
Introduction (only if required to be a Heading)
Paragraph one is the introduction to the paper. It should begin with something that will take hold of the reader’s attention and provide a citation to support your opening sentence (Amanda, 2013). You need to include citations in all your scholarly paper (APA) paper. You will include page number only if it is a direct quote (i.e. Amanda, 2013, p. 6).Next, support that opening sentence with discussion or explanation with one or multiple sentences which will make up the body of the introductory paragraph. The last sentence of the introduction should highlight areas to be covered in the paper. APA success requires understanding of the format and skill in concise, clear written communication.
First Paper Subheading first level (Bold and Centered)
Care Plan for Week 2: Pulmonology Clinic Case
Patient Initials: ______ Age: __63_____________ Sex: __F_________
Subjective Data:
Client Complaints: enter the information here
HPI:
Type content of paper here. Please utilize as many paragraphs as needed to cover the content properly. Students can use the grading criteria components in the rubric as the subheading. From here, students need to answer the questions. Please be sure that the length of the paper should be within 3-4 pages long so answer the questions in a concise and direct. BACABAVAUJEGFK…….etc…………………………………………….
It is the same in this new paragraph. Please be sure to indent in all new paragraphs. Please be sure to include citations where you obtain information that does not belong to you. If not, it is considered plagiarism and the assignment will be zero. This includes information from the case scenario. It is important to include only important information from the case scenario in the body of the paper.
PMH:
Enter the information in complete sentences in paragraph here ……
ROS:
Enter the information in complete sentences in paragraph here ……
Social/Personal History: (occupation, lifestyle—diet, exercise, substance use)
Do the same …..Remember that it needs to be written in scholarly format.
Description of Client’s Support System:
Write in new paragraph here…
Behavioral or Nonverbal Messages:
Do the same here in paragraph….Remember to include citations in your paper to support your writing.
Client Awareness of Abilities, Disease Process, Health Care Needs:
Objective Data:
Use as many headings as necessary to organize your paper. Short papers may only have first level headings. Longer papers may require more organizational detail. See your APA Manual page 62 for instructions on formatting multiple levels of headings.
Vital Signs including BMI:
Continue to write and answer in paragraph format. Please do not include anything that is not needed in the paper unless it will support your points in the paper.
Physical Assessment Findings:
Lab Tests and Results:
Client’s Support System:
Client’s Locus of Control and Readiness to Learn:
ICD-9 Diagnoses/Client Problems:
Please use the links listed in the course to help you in this section. Remember to include citations.
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
Please do not use the information from the careplan book that you learned in ADN program as you are NP student. This means that students will need to do extensive research information for the paper.
Conclusion
Most papers should end with a conclusion or summary which consist a short description of the key points of the paper. It should be brief and contain little or no detail. In other words, it needs to be general. No matter how much space is left on the page, the References are always on the next page. (Please notice that all font size (12pt) and face (Times New Roman) is the same throughout the entire paper.)
http://www.youtube.com/watch?v=9pbUoNa5tyY
Watch this link and it will show you how to write citation!
Go to p. 41, 229 (cover page), 62-63 for (subheadings), 171-177 for (citations), 198-225 for (reference page) in your APA 6th ed. manual format book.
APA Tips:
There are a few things that you can do that will help you to avoid being charged with academic dishonesty. Please note the following:
1) Anytime that you use the words or ideas of another person without giving credit, it is considered plagiarism, WHETHER YOUR ACTIONS ARE INTENTIONAL OR NOT!
2) Differences between direct and indirect quotes:
a) Direct Quotes: Includes the exact wording from the source.
b) Indirect Quotes: Summarizes or paraphrases the content from the source.
3) APA in-text requirements:
a) Direct Quote: Author’s last name, publication date, and page number.
b) Indirect Quote: Author’s last name, publication date.
When you write your paper, be sure to answer the criteria listed in the rubric because you are graded according to the info. below.
|
Grading Criteria |
Maximum Points |
|
Care plan demonstrated involvement of the client in the process of recognition, planning, and resolution of the problem. |
15 |
|
Care plan included effective nursing interventions that are customized for the client and appropriate to the goal. |
15 |
|
Care plan included diagnostic work-up, medications, conservative measures, and follow-up plan. |
15 |
|
Care plan provided rationale for choosing a particular treatment modality. |
15 |
|
Care plan demonstrated logical diagnosis that was substantiated with relevant evidence. |
10 |
|
Care plan focused on patient education and maintained a fine balance between major and minor health issues of the patient. |
10 |
|
Care plan included nursing interventions that are specific, appropriate, and free of essential omissions. |
10 |
|
Used APA standards consistently and accurately. |
10 |
|
Total |
100 |
See below for reference page….
References (centered, not bold)
American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.
Attachments: