Posted: March 8th, 2016
1. Introduce the client by describing why he or she presented to the facility and include their reason for admission (primary diagnosis). Use the literature to define ALL the client’s primary & secondary diagnoses and describe how these secondary diagnoses relate to the client’s primary reason for seeking care. Summarize the well-researched history of the client including the client’s age, current health status, health history, family dynamic, support groups, community environment, occupation and how he or she uses the health care system (Please remember client confidentiality). This question is to be answered in APA sentence format. (20 marks)
2. Using the templates provided (pg. 7&8), identify ALL of the medical treatments for the client. Identify each of the diagnostic tests and medical treatments involved in the client’s plan of care. Analyze and interpret a minimum of 1 result for each test or procedure. Even if tests are normal, please describe what the test is, what it measures, & why it is being done. Remember to include ALL of the following:
• All current medications (regular and prn)
• All procedures & diagnostic tests
• All current laboratory tests (exclude MRSA/VRE and urinalysis results)
o Analysis of laboratory values must include a complete blood count, electrolytes, blood glucose, urea and creatinine. Other laboratory studies may also be included based on the patient’s diagnoses.
The template for medical treatments will become part of the appendices. Please see the rubric for a breakdown of marks related to this section of the paper. (25 marks)
3. Evaluate and interpret the findings of the head to toe (systematic) assessment of the client. Integrate assessment findings to the admitting diagnosis (primary) and any other diagnoses (secondary) that may be applicable. This is known as a focused based assessment. All abnormal physical assessment findings must be interpreted in relation to the patient’s health status. Include both subjective and objective data. (Hint: Divide the body into systems and speak to each system in your paper). A template for gathering this information will be available for use on Bb. Please do not include the template in this paper; it is only used as a tool to help keep the information sequenced. This question is to be answered in APA sentence format. (For additional help, ask your clinical mentor to go over the head to toe assessment in practicum). (20 marks)
4. Describe 1 nursing problem of high priority that you identified while caring for the client. Then provide 2 nursing interventions or ways you did help to or could help to teach or resolve the identified problem. Make sure to link the nursing problem and the 2 nursing interventions to the client’s assessment and medical diagnoses. Ask yourself: How did I, or could I provide health teaching or promote health for each of the interventions? What strategies or nursing care did I use or could I use in this situation? Be specific and use supporting evidence from the literature to rationalize your choices. (Some examples of nursing problems are: pain management, skin integrity, infection, mobility, nutrition, GI/ GU problems, oxygenation, fluid volume deficit or excess, electrolyte imbalance, anxiety, ineffective coping, or knowledge deficit around a particular disease process, to name a few).This question is to be answered in APA sentence format. (20 marks)
5. CONCLUSION: Write a conclusion to the paper outlining how your care was effective and the client’s response to your care. In this description, identify what you said and did that made your nursing care unique and individual. Give examples of how this experience has changed your nursing practice moving forward. (5 marks) (There is an another 10 marks attributed to APA & referencing for this paper – please refer to the rubric on page 9 & 10)
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