Assignment will be chosen related to clinical assignment. Each student will choose a client that you had had your clinical rotation for a case study that you want to investigate. The case study must be approved by your course instructor by the end of your third clinical rotation.
The student will research their issue and find current evidence, at least three (3) peer-reviewed nursing research articles related to their condition/issue.
Two weeks prior to the due date of the paper as indicated on the course outline, the student will submit an outline of their paper to their course instructor that includes the student name, case study overview, nursing practice issue, and references in APA format.
The paper must include the following items:
1. Title Page with student's name
2. Client HPI/PMH
3. Client FMH/ROS
5 revised 12/28/16; 1/4/17
4. Client Medications/Allergies
5. Client PE that you completed
6. Client Laboratory/Diagnostic Test results
7. Nursing Practice Issue related to client situation
8. How the RN has assigned/delegate/supervised LPN, Certificated Nurse Aide, Medication
Aide, and the Unlicensed Personnel
1. Short summary of the three research articles related to condition/issue
2. References
The paper is to be 3-5 pages in length, not including the title paper and reference page, written in APA format. A title page and reference page are required.
PATIENT PROFILE
Mrs. AJ is an 82 yrs. old, female who was admitted for GI bleeding at VHC. Patient was then put on NPO due to her GI bleeding and oropharyngeal dysphagia and is been fed through a J-tube. Patient was transferred to Regency Care Facility, on transfer patient presented with a stage 2 sacral decubitus ulcer, was having multiple loose stools and was later tested positive for clostridium difficile.
She is currently taking Vancomycin for the C-diff and is on contact isolation precaution. Patient is currently bedridden and on dialysis 3 days a week for chronic kidney disease.
On Assessment, patient is alert and oriented *2 (person and time), her mucous membranes were dry and tongue was pale. Patient states "my mouth feels dry and my throat hurts." Skin was dry, scaly and warm to touch. Eyes were pale. She is unable to carry out her ADL's independently. Patient had 3 loose stools within 6hrs. Her vitals read: BP (121/57), Temp (97.2), Pulse (77), O2 (98%) on 2L nasal cannula, RR (17). RBC's was 2.67, Hemoglobin 7.9, and Hematocrit 24.9.
PATIENT HISTORY OF PAST ILLNESS
END STAGE RENAL DISEASE, MUSCLE WEAKNESS, HYPOTENSION, ANEMIA IN CHRONIC KIDNEY DISEASE, CARDIOMYOPATHY, OROPHARYNGEAL DYSPHAGIA, HEART FAILURE, ENDOMETRIA CANCER AND DEPENDENCE ON RENAL DIALYSIS.
PATIENT FAMILY HISTORY
HYPERTENSION
PATIENT MEDICATION/ALLERGIES
--VANCOMYCIN: for C-diff
--TRAMADOL: PRN for pain
--THIAMINE HCL TAB 1 TAB VIA J-TUBE 1*/DAY: supplement
--CHOLESTYRAMINE 4MG VIA J-TUBE 2*/DAY: HLD
--FLUSH J-TUBE WITH 100ML of water every 8hrs: FOR J-TUBE PATENCY
--FLORASTOR CAP 250MG: GIVE 1 CAP VIA J-TUBE 1*/DAY FOR PROBIOTIC
--PANTOPRAZOLE SODIUM TAB DELAYED RELEASE 40MG: GIVE 1 TAB 2*/DAY: FOR GI ULCER.
--SANTYL OINTMENT 250 UNIT/GRAM: APPLY TO SACRUM TOPICALLY 1*/DAY: FOR WOUND HEALING
ALLERGIES: AMOXICILLIN, ENOXAPRIN, ERYTHROMYCIN, HYDROCOSONE, HYDRALAZINE, OXYCODONE, NEOMYCIN, PENICILLIN, SULFA ANTIBIOTICS.
PATIENT PHYSICAL EXAM/ASSESMENT
On Assessment, patient is alert and oriented *2 (person and time), her mucous membranes were dry and tongue was pale. Patient states "my mouth feels dry and my throat hurts." Skin was dry, scaly and warm to touch. Eyes were pale. She is unable to carry out her ADL's independently. Patient had 3 loose stools within 6hrs. Her vitals read: BP (121/57), Temp (97.2), Pulse (77), O2 (98%) on 2L nasal cannula, RR (17). RBC's was 2.67, Hemoglobin 7.9, and Hematocrit 24.9.
PATIENT'S LABS/DIAGONOSITC TEST RESULTS
C-DIFF TOXIN A/B:
RESULT: POSITIVE
DATE DONE: 02/26/17
RESULT ON: 02/27/17
CBC W/O DIFFERENTIAL
WBC: 5.9
RBC: 2.67
HEMOGLOBIN: 7.9
HEMATOCRIT: 24.9