Gathering Cues And Coming For Know The Patient

DIAGNOSTIC DATA: White count was 13.4, hemoglobin and hematocrit 15.4 and 45.8, platelets 206, with an 89% shift. Sodium 133, potassium 3.7, chloride 99, bicarb 24, BUN and creatinine are 18 and 1.1, respectively. Glucose 146, albumin 4.3, total bilirubin 1.7. The remainder of the LFTs is within normal limits. Urinalysis reveals trace ketones with 100mg per decilitre protein and a small amount of blood. CT scan was performed revealing evidence of acute appendicitis with pericecal inflammation, as well as, dilatation of the appendix and

He was able to tolerate PO earlier around 6am. but now denies having an appetite. Patient had very small bowel movement earlier this morning that was not normal for him. He has not passes has the morning. 'he is voiding well. Denies fevers, chills or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy.

These are critical pieces of information to understand as they are what direct the patient in how he or she will respond in certain situations and interpret what the physician is saying or doing.

Susan is a 78 year old widowed lady who was admitted to a medical ward following an episode of coffee brown vomiting and breathlessness. Susan has a past medical history of chronic

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

Write one goal and one measurable expected outcome related to your nursing diagnosis. Explain why this goal and outcome is a priority. Include cultural considerations for this client.

Patient was in the ER room when first seen. PT was with her family members and family states that she speaks little English and that she has had abdominal pain for the past day along with bloody stools. Family states that she is on calcium supplements and no other medications. Last oral intake is 24 hours ago. Family states no known past medical history. Pt is in the hospital bed in the fetal position and towards the right side. Patient's airway is clear and breathing is normal. Skin is warm and dry. Patent is AAOx4. Assessment of head, neck, and chest show no signs of deformities. Abdominal area not assessed due to severe pain. Back is without deformity. The upper extremity shows no sign of deformities or trauma. The lower extremity shows

3. Q) What type of information is gathered when obtaining the Social History of the patient? Why is this important?

The spouse explained to us that up to two day ago, that patient was able to sit in a wheelchair, ate pureed foods and was awake and alert. What was presented the day in the ER was a patient with multiple fractures, nonverbal and very lethargic. The husband was not aware of any falls, or medical conditions that would cause her symptoms. He also chose not to follow up with exams looking for a reason, such as a stroke. We accepted his wishes and returned his wife back to the nursing home with no treatment. The decision was made as a team effort between the spouse, medical staff, and the patient, with her advance directives.

The patient is a 44-year-old female who I saw for her physical in June 18, 2015. At that point, she was complaining of epigastric pain that radiated into her back. I did ask her to start Prilosec over the counter, daily. Initially, we had called her and she reported that this was helpful, although now, she reports that at the same time, she had a cold and she was more focused on the cold than the epigastric pain. Subsequently, she states her pain really has not changed and she continues to have epigastric pain, which does radiate to her mid-back. Her bowel movements have been soft, she has been somewhat nauseous, but no vomiting. She has not see any blood in her stools. She does think

Clinical reasoning is concerned with relationships and has concern for those they are caring for (Benner et al., 2008). It is a term used synonymously with decision making and clinical judgement (Simmons, 2010).

The patient is a 99-year-old female who is brought to the emergency room by BLS from her home. It is unclear from the emergency room record as to the reason for her being brought from home and there is some question of possible abuse. The EMS stated that the Adult Protective Services had been visiting the patient's home and they found the home in disarray. Perhaps they were called. She came at 11:40 in the morning of the 9th. She also on presentation was found to have bedbugs and was cleared the bedbugs in the ED. Her medical history is probably just hypothyroidism she is only on Levothyroxide. and that is the only medication. Her laboratory work showed to have her urinary tract infection. She also was anemic. Her hemoglobin dropped

1. Choose one patient (new mother, newborn, or pregnant/laboring woman) and identify the priority problem. What did you contribute toward resolving or easing the problem?

Interpretation is a very important factor that usually comes first when it comes to taking care of a patient. When I think of interpretation in patient care, I think of interpreting what the patient is telling. Taking the symptoms that they are describing that they have and going through and thinking of what the diagnosis might be. Another sense that interpretation could come into play would be interpreting a diagnosis or even a medication to a patient. It might be easy to tell the patient, “I am going to give you a bronchodilator” but that person might not have a clue what that means. In cases like this it would just be easier to explain to plain detail to the patient what you are giving them or what their diagnosis might be rather then throwing