nursing case study
I will be providing the documents that need to be filled out correctly and completely! Later once a bid has been selected, I will sent you the needed information to complete these documents because Studypool is not letting me sent them all together due to the maximum number of files. The documents that need to be filled out are the “SBAR form”, the “Case study worksheets”, the “documentation assignments” and the “Guided Reflection Questions”. Assignment needs to be done within time frame! No later at all!
Rashid Ahmed Guided Reflection Questions Opening Questions How did the simulated experience of Rashid Ahmeds case make you feel? Talk about what went well in the scenario. Reflecting on Rashid Ahmeds case, were there any actions you would do differently if you were to repeat this scenario? If so, how would your patient care change? Scenario Analysis Questions? PCC What priority problem(s) did you identify for Rashid Ahmed? What information led to identification of the priority problems? PCC Complete the following table related to the causes and assessment findings specific to Rashid Ahmeds fluid imbalance. Cause of fluid deficit Assessment Findings Cause of assessment changes Vomiting and Diarrhea PCC What potential problems could arise if the identified fluid and electrolyte imbalances are not corrected?
EBP Identify the rationale for weighing Rashid Ahmed at the same time each day wearing the same clothing. EBP Discuss the rationale for infusion of 0.9% normal saline. S Identify potential patient safety issues T&C What other interprofessional team members should be involved in Rashid Ahmeds care? Concluding Questions Describe how you would apply the knowledge and skills that you obtained in Rashid Ahmeds case to an actual patient care situation.
Rashid Ahmed Documentation Assignments 1. Document your findings related to the focused assessment regarding Mr. Ahmed’s fluid and electrolyte status. 2. Recognize and report clinical manifestations of hypokalemia and hyponatremia. 3. Referring to your feedback log, document all nursing care provided, including management of fluid balance with IV therapy, and Mr. Ahmed’s response to this care. 4. Document all patient teaching regarding care, medications, and safety issues provided to Mr. Ahmed, and his response to the education.
CASE STUDY WORSHEET Students Name: Date: Admit Date: Patient Initials: Age/Gender: Room #: Code Status: Allergies: Isolation: Surgery: POD#: a. Synthesis of the Disease 1. CHIEF COMPLAINT (patients own words) and Medical Diagnosis on admission? Refer to MD H&P and initial notes for Medical Diagnosis. -The reason that this patient is admitted to the hospital, more specifically to the Emergency Department is because he was experiencing dehydration as well a hypokalemia. 2. What is the current problem, signs and symptoms the patient is manifesting (Pathophysiology)? Refer to the latest progress note. Provide a brief synthesis of the disease condition as it applies to your patient (cite reference). b. Past Medical History (e.g. HTN, Diabetes, Asthma) Clinical Significance c. Socio/Economic History (Family support, living situation, occupation) Clinical Significance
d. Diagnostic Tests and Procedures Findings Clinical Significance and Indication (for this patient) *You may add rows as needed
e. RELEVANT Lab(s) Normal range Admission Date/Result Today Date/Result Clinical Significance for abnormal results only (this patient)
*replicate table as needed to avoid major tables running several pages when submitting care plan for grading. I. Nursing Assessment: 1. Vital Signs Trend Vital Signs Admission Date/Time Today Date/Time Today Date/Time Clinical Significance (for this patient) T: P: R: BP: O2 sat: 2. Pain Pain Assessment Admission Date/Time Today Date/Time Today Date/Time Clinical Significance (for this patient) Assessment Tool Pain Level Location Quality of pain: 3. Intake and Output Last 24 Date/Time Today Date/Time Clinical Significance (for this patient) Intake Output I/O Net Balance Physical Examination: Date and Time of Assessment: Head-to-Toe Assessment (Student should provide their complete head-to-toe assessment of all the body systems) GENERAL APPEARANCE:
NEUROLOGICAL: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: GENITOURINARY: MUSCULOSKELETAL/EXTREMITIES: INTEGUMENTARY: II. Patient Care 1. Summary of medical treatment plan (Review Progress notes and H&P, outline problems identified by provider with corresponding treatment plan with interdisciplinary practice e.g. Infection: continue antibiotics and wound consult. Pain- continue analgesia per pain pharmacy service)
2. Surgical Management: Name and Type of Surgery Indication and Clinical Significance (for this patient) Priority Nursing Considerations During the Perioperative Period 3. Current Medication List: Medications Generic/Trade Name Dose/Route/Frequency Classification and Mechanism of Action Side Effect and Adverse Reactions Nursing Considerations Indication (for this patient) *Do not copy paste from PDR only use the information as it applies to your patient. *Before and after administering *You may replicate this table as needed to avoid one major table running several pages.
4. Intravenous Therapy: Type of IV Access (PIV, Port, PICC, Midline) Type of IVF and Rate Indication and Clinical Significance (for this patient) Patient Response 5. Diet therapy/ Nutrition Diet Indication and Clinical Significance (for this patient) 6. Activity/ Exercise Activity Indication and Clinical Significance (for this patient)
7. Nursing Management #1 Nursing Diagnosis (ND) Cluster ALL relevant data that supports this priority ND: Desired Patient Outcomes/Goals (SMART goal) What interventions will you initiate based on these goals? Rationale (cite reference) Actual Patient Outcome 1. 1. 1. 2. 2. 2. 3. 3. 3. #2 Nursing Diagnosis (ND) Cluster ALL relevant data that supports this priority ND: Desired Patient Outcome/Goal (SMART goal) What interventions will you initiate based on these goals? Rationale (cite reference) Actual Patient Outcome 1. 1. 1. 2. 2. 2.
3. 3. 3. #3 Nursing Diagnosis (ND) Cluster ALL relevant data that supports this priority ND: Desired Patient Outcome/Goal (SMART goal) What interventions will you initiate based on these goals? Rationale (cite reference) Actual Patient Outcome 1. 1. 1. 2. 2. 2. 3. 3. 3. III. Education and Discharge Planning (Responses must be detailed and thorough) 1. What educational/discharge priorities have you identified and how did you address them? 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
3. What long term and rehabilitative needs can be foreseen for this patient? Give at least 3 priority needs. IV. Evaluation (Responses must be detailed and thorough) 1. Has the patient status improved? Why or why not? 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? V. Post-Clinical Reflections (Responses must be detailed and thorough) 1. What did you learn or demonstrate growth in as a result of this clinical experience? 2. Share an example of good clinical judgment used today in the clinical setting? References (APA format)
SBAR REPORT FORM S SITUATION Admitting Diagnosis: Code Status Allergies History of Present Illness B BACKGROUND Medical History Recent Procedures/Results/Prep A ASSESSMENT HEENT Neuro Resp Lung sounds O2 ______liters/________ RA Cardio Rhythm Rate GI Bowel Sounds GU Foley Voiding Musculoskeletal Skin (Braden)_________ Fall Risk score (Morse or Schmidt): __________ Pain Assessment (Baseline/Scale): Isolation (Type) Activity: Precautions Diet: Nutrition Status IV (location, size, date) IV fluids (purpose) MEDICATION LIST (Med Dose/Classification/Purpose) PNA VAC FLU VAC Vital Signs/Rhythm/Pain Level ___________________________ ___________________________ ___________________________ MEDICATION ADMINISTRATION TIMES 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07 ACCUCHECK: qAC q ACHS Q 4 NPO scale 06: _______ 1130: _______ 1630: _______ 2200: ________ ____________________________________________________ LAB DATE/TIME: R RECOMMENDATION(S) TRANSFER/DISCHARGE PLAN: CA PTT PT/INR CK/TROP BNP WBC HGB HCT PLT GLUUUNa+ K+ Cl- Mg+ BUN Crea
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