Nursing Case Study Joshua

Ms. Le is a 25 year-old female, with a height of 5’0” and weights 160 lbs. She described herself as not very active who does not regularly exercise and consumes a high amount of fast food and a few alcoholic beverages weekly. She is currently taking prescription medication called Caziant as a contraceptive and moderately takes ibuprofen for headaches and heartburns. She has a medical history of vomiting, heartburn, chest pains, and sever tooth erosion. Due to the many examinations that Ms. Le underwent such as the endoscopy and ph-monitoring test, she was diagnosed with gastroesophageal reflux disease also known as GERD.

Nursing care is a dynamic field of practice. The way it looks today is far out greater intense and very structured. It advances itself by the use of nursing theories and evidence based practice. Policies and procedures constantly change with the advancement of technology and science. While caring for the patient in the given case studies, a nurse involved utilizes practical knowledge, a culture care model and transpersonal caring relationship to attain a caring environment (Smith & Parker, 2015).

The aim of this study is to provide a detailed account of the nursing care for a patient who is experiencing a breakdown in health. One aspect of their care will be discussed in relation to the nursing process. The model used to provide an individualised programme of care will be discussed and critically analysed.

1. The nurse is asked to implement a new, complex, and invasive procedure and is concerned that this may violate the state’s nurse practice act.

CHIEF COMPLAINT: This is a post op note from a procedure performed July 21, 2015 by David Lin, MD.

The Indiana State Board of Nursing is a body of nine selected members, comprised of a mixture of RNs and LPNs. This board listens to cases regarding university nursing programs, certified RNs fighting for their license, and individuals who are trying to obtain a nursing license. It is up to their discretion whether certain actions of a nurse are permissible or not. They also make adjustments to the curriculums or higher education schools to ensure that they are producing good quality nurses.

Waters, Renita Apr 4 2017 12:21PM Waters, Renita April 4,2017 10:05 AM TC Beth Orrick RN nurse from Bent Wood Nursing for information on Mr.Allen Union who was in Bent Wood for a wound on his feet. Ms. Beth explained Allen was getting OT, and PT and was on a walker. Beth stated Mr. Allen wanted to leave and go pay his rent and other bills yesterday he didn't return back. Beth stated she TC Mr. Allen at home and he refuse to come back for any more therapy. Beth explained to Allen he must have more treatment on the wound on his feet to heal and he did take Bent Wood walker back he took. I asked Beth was Allen on any medicine she commented he left all his medication. Beth stated Allen is a diabetic and has high blood pressure including a open

Keia is a 31yo, G2 P0100, who is currently 9 weeks 6 days as dated by a 6-week scan that was off from her LMP. She has a history of an IUFD at 29 weeks. She reports that she had decreased fetal movement prior to coming in and there being no fetal heart tones on examination, but other than that there were no other significant precipitating events. She did have an increased risk for Down syndrome at 1:140 but per the old reports all of her analytes were within normal limits. At the time of delivery, the baby did appear to be appropriate weight and there were no obvious causes at the time of delivery. She reports that she had chromosomes performed after and the chromosomes were negative. She also thinks she had a full autopsy that was unremarkable. She did have a work-up for clotting disorders due to the history of loss and according to the chart everything is relatively within normal limits except for MTHFR which was heterozygous for C677T and A1298C. I did not see beta-2 glycoprotein or antithrombin III. Because of the relatively normal work-up she is on a baby aspirin and Metanx. She is here today to discuss her history and plans for this pregnancy.

Mrs. Wilson is seen in her room at Glenbridge Nursing Home on 02/28/2018. She had an episode last night of chest pain. She is so ebullient and distracted that it is hard to get a straight history, it came on when she was asleep but she may been sitting up. She was seen by a nurse, a sat was taken. I am not sure if there were other orders taken, but there is none on the chart. She says that she spent most of this morning in the bed and still feels tired, but she does not think she broke out in a sweat. She was more short of breath. She is calling it is a "stroke." I had tried to begin tapering her diazepam by discontinuing the morning dose and apparently all daytime clorazepate was discontinued by error and she gets it only at night.

Pt is a 15 y/o biracial female that presented at NNBHC by her father with a dx of persistent depressive disorder with intermittent major depsressive episode, with current episode, severe; rule out PTSD, chronice; marijuana use disorder, mild; and parent child relational problems. Pt presents appropriately dress, pt eye contact was poor. Throughout the assessment the pt demonstrated intermittent of tearfulness. Pt expressed that she have been feeling worthless, helplessness, and hoplessness. Pt describe that since her mother died she has not seen any motivation for living. Pt states that she has been feeling suicidal for weeks, however lately it has became more intrusive. Pt states that she has a plan to either overdose

1. Monitor the patient's oxygen saturation frequently (once per hour) at rest and after exertion on room air

Naomi Louise Lungstrom, is a 59 year old nurse. She is married and has 3 sons. She has a great husband and works at Washington State University school of Nursing. Both her husband and colleagues act as a great support system. Her religion is Lutheran and would like a Chaplin regardless if they are a priest or not.

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., Camera, I.M. (2011). Medical-surgical nursing: Assessment and management of clinical problems (8th ed). St. Louis, MO: Elsevier.

According to Murray and McKinney (2014), parents should call the pediatrician any time the in-fant appears sick or they believe something is wrong with the infant. The office staff can deter-mine if the baby needs an appointment with the problems explained. The parents should write down all symptoms to avoid leaving something out. Parents will want to take their infant to the doctor if the temperature is above 100.4 F (38 C). If the infant vomits the entire feeding more than once or twice a day. A significant increase in stools or watery stools. The infant has blisters, sores, or rashes that are unusual. Changes in behavior like listlessness or sleeping more than usual, irritability or crying more than normal. If the infant starts coughing,

1. When a nurse performs a physical examination on a newborn, which of the following nursing assessments should be reported to the physician?