Ns1211 2009 Week 4 Part 8

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The document summarizes a lecture on vital signs. It discusses an overview of vital signs, and specific signs including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain. It outlines an assignment on these topics with three questions, due dates, and referencing guidelines. Key vital signs and the assignment are to be covered.

Saúde e medicina

Today’s Lecture  Vital Signs Overview/Context  Temperature  Pulse  Blood Pressure  Respiratory Rate  Oxygen Saturation  Pain  Assignment

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Today’s Lecture  Vital Signs Overview/Context  Temperature  Pulse  Blood Pressure  Respiratory Rate  Oxygen Saturation  Pain  Assignment

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Episodic Note Case Study: Assessment of the Abdomen and Gastrointestinal System ABDOMINAL ASSESSMENT Subjective: • CC: “My stomach hurts, I have diarrhea and nothing seems to help.” • HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards. • PMH: HTN, Diabetes, hx of GI bleed 4 years ago • Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs • Allergies: NKDA • FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD • Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys) Objective: • VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs • Heart: RRR, no murmurs • Lungs: CTA, chest wall symmetrical • Skin: Intact without lesions, no urticaria • Abd: soft, hyperactive bowel sounds, pos pain in the LLQ • Diagnostics: None Assessment: • Left lower quadrant pain • Gastroenteritis PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. Assignment: Assessing the Abdomen A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping. Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen. In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions To Prepare Review the Episodic note case study your instructor provides you for this week’s Assignment. · With regard to the Episodic note case study provided: o Review this week’s Learning Resources, and consider the insights they provide about the case study. o Consider what history would be necessary to collect from the patient in the case study. o Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. The Assignment 1. Analyze the subjective portion of the note. List additional information that should be included in the documentatio.

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Assessing the Ears, Nose, and Throat Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes, but would probably perform a simple strep test. In this Discussion, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions. Note: By Day 1 of this week, your instructor will have assigned you to one of the following case studies to review for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case. Case 2: Focused Throat Exam Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus over the past two weeks, Lily figured she shouldn't take her three-day sore throat lightly. Your clinic has treated a few cases similar to Lily's. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn't sound congested. . To prepare: With regard to the case study you were assigned: Review this week's Learning Resources and consider the insights they provide. Consider what history would be necessary to collect from the patient. Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis? Identify at least 10 possible conditions that may be considered in a differential diagnosis for the patient . Note: Before you submit your initial post, replace the subject line (“Week 5 Discussion”) with “Review of Case Study ___,” identifying the number of the case study you were assigned. Post on or before Day 3 a description of the health history you would need to collect from the patient in the case study to.

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Make a SOAP Note: Assessing Ear, Nose, and Throat Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes, but would probably perform a simple strep test. In this Discussion, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions. Note: By Day 1 of this week, your instructor will have assigned you to one of the following case studies to review for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case. Case 1: Nose Focused Exam Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he's taken Mucinex OTC the past two nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous. Case 2: Focused Throat Exam Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus over the past two weeks, Lily figured she shouldn't take her three-day sore throat lightly. Your clinic has treated a few cases similar to Lily's. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn't sound congested. Case.

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Assignment: ABDOMINAL ASSESSMENT Subjective: CC: “My stomach hurts, I have diarrhea and nothing seems to help.” HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards. PMH: HTN, Diabetes, hx of GI bleed 4 years ago Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs Allergies: NKDA FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD Assignment 1: Lab Assignment: Assessing the Abdomen Photo Credit: Getty Images/Hero Images A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping. Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen. In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. To Prepare Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study. With regard to the Episodic note case study provided: Review this week’s Learning Resources, and consider the insights they provide about the case study. Consider what history would be necessary to collect from the patient in the case study. Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. The Assignment Analyze the subjective portion of the note. List additional information that should be included in the documentation. Analyze the objective portion of the note. List additional information that should be included in the documentation. Is the assessment supported by the subjective and objective information? Why or why not? What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be con.

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Assignment topic : Rapid Influenza Testing in Children and Adults. When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors in order to select the most appropriate test or tool and to accurately interpret the results. Not only do these diagnostic tests affect adults, body measurements can provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process. For this Assignment, you will consider the validity and reliability of different assessment tools and diagnostic tests. You will explore issues such as sensitivity, specificity, and positive and negative predictive values . You will also consider examples of children with various weight issues. You will explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight. To Prepare · Review this week’s Learning Resources and consider factors that impact the validity and reliability of various assessment tools and diagnostic tests. You also will review examples of pediatric patients and their families as it relates to BMI. · Search the Library and credible sources for resources explaining the tool or test you were assigned. What is its purpose, how is it conducted, and what information does it gather? · Also, as you search the library and credible sources, consider what the literature discusses regarding the validity, reliability, sensitivity, specificity, predictive values, ethical dilemmas, and controversies related to the test or tool. Assignment (3–4 pages, not including title and reference pages) : For the Adult Assessment Tools or Diagnostic Tests: Include the following: · A description of how the assessment tool or diagnostic test you were assigned is used in healthcare. o What is its purpose? o How is it conducted? o What information does it gather? · Based on your research, evaluate the test or the tool’s validity and reliability, and explain any issues with sensitivity, reliability, and predictive values. Include references in appropriate APA formatting. For the Child : Include the following: · An explanation of the health issues and risks that are relevant to the child you were assigned. · Describe additional information you would need in order to further assess his or her weight-related health. · Identify and describe any risks and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this infor.

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Ns1211 2009 Week 4 Part 8

1. Today’s Lecture  Vital Signs Overview/Context  Temperature  Pulse  Blood Pressure  Respiratory Rate  Oxygen Saturation  Pain  Assignment

2.

5.

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11. Referencing

12. Referencing

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16. Today’s Lecture  Vital Signs Overview/Context  Temperature  Pulse  Blood Pressure  Respiratory Rate  Oxygen Saturation  Pain  Assignment

17.