Patient history: The patient has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body . A

Patient history: The patient  has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity  / hemiplegia of left side of the body .

Admission diagnosis: altered mental status.

Discharge diagnosis summary: AMS / possible acute toxic encephalopathy, and SIRs.

Ola was 40yrs he presented to the hospital with Altered mental status, he was lethargic and not following commands in hospital. She was admitted for AMS (altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the ICU and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS( Systemic Inflammatory Response Syndrome) criteria with CBC < 4 and heart rate > 90, although upon review of his medical record his leukocytosis is chronic. he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated . TSH elevated normal T4.

Date: ________ Student Name: ____________________________ Clinical Site/Unit: ___________________________

Clinical Site Instructor:__ ____________________________Previous Shift Report: ____________________________

Client Initials: _______ Client age: _______   Gender: _____________ Height: __________ Weight: ______________

Allergies: ______vicodin __________________________ Code Status: _________________ Transfer Status: ______________

Marital Status: _____________ Religion: _________________ Occupation: ___________________________________

Cultural Background: ____________________________     Primary Language: _______________________________

Diet/Nutrition: ____________________________   Activity: _______________________________ Fall Risk: Yes / No

Use of (type/amount/frequency): Alcohol: _____________ Tobacco (pack years): ______________________________

Medical Diagnosis(s):

Admitting Diagnoses to Acute Care Facility

1._____altered mental status _______________________________ 2.______________________________________

Primary Diagnoses for Admission to TCU/LTC

1._____acute toxin encephalopathy ________________________________ 2.____ Systemic Inflammatory Response Syndrome_________________________________

3._____sepsis ______________________________4.______stap.epidermis _______________________________

Secondary Diagnoses

                                                1.____chronic pain __________________________________ 2._______ _____________________________

3.________traumatic brain injury _______________________________ 4._confusion__________________________________

Surgical History 1.______________________________________ 2.___________________________________

                                                3._______________________________________ 4.___________________________________

Treatments: _______________________________  IV/Tubes/Ostomies: ______________________________________

Dressings/Wounds: (type & location) ___________________________________________________________________

Oxygen: (delivery method & amount) _______________________________ Dialysis: ___________________________

Recent LAB Results:

Why is this lab significant for this client’s condition? If the lab result was abnormal, include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column.

Date          Test                     Normal Value                   Client Value                       Significance

          Wbc           4-10                    4.1 ________________________________________________________________________________________________________________________________RBC                    3.80 -5.40            4.95 ____________________________________________________________hematocrict 35.0- 47.0            37.5

Mcv           80-100                76    

______________________________________________________

MCH  2                 7-34 –                                                     22

___________________________________________________________________________________________________

PLT

___________________________________________238________________________________________________________

Recent Diagnostic tests: (list X-rays, CT scans, MRIs, ECGs, Ultrasounds, Cardiac Catheterizations, etc.)

List the test, the test result, and include an explanation of the significance of the results in relation to the medical treatment, other diagnostics, and nursing considerations/interventions for your client. ____________________________________________________________________________________________________________________

PATHOPHYSIOLOGY:

For the primary admitting diagnosis to the acute care facility and primary diagnosis for the TCU/LTC, provide a 3-5 sentence explanation of the pathophysiology of the problem. Then complete an ATI template for the above four diagnoses (4 total).  Use the “Active Learning Template: Systems Disorder” template from ATI Active Learning templates.  Complete, print, and attached to paperwork

PATHOPHYSIOLOGY CONTINUED:

For the top two secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization. 

If your client is post-surgical, what problems or complications could possibly occur? What nursing assessments would you need to include in your post-operative or post-procedure monitoring

PATHOPHYSIOLOGY CONTINUED:

 4 secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization. 

                    Medication

(Include dose, time, route, & frequency)

       Classification

What nursing considerations should

you include with this medications?

Buspar  15mg

Baclofen 20mg

Cymbalta 30mg

Levetiracetam 1000mg

Omeprazole 20mg

Robafen 100mg /5ml

Senna 8.6mg

Tizanidine hcl 2mg

Xarelto 20mg

Oxycodone HCL 5mg

ibuprofen

Medication Data Sheet

List all scheduled medications for your shift

Drug Name and Classification, Normal Adult Dose, Route & Schedule

Indications for Use and Expected Actions

Side Effects/ Adverse Reactions

Drug and Food Interactions

Nursing Administration Considerations

Client education &

Evaluation of Medication Effectiveness

Ticagrelor

Atorvastin

Pantoprazole

HumLIN  insulin regular

Diclofenac

NURSING PROCESS

Write 2 complete Nursing Diagnoses based on your client problems you noted on your assessment for this day.

Nursing Diagnosis #1:

___________________________________________________________________________________________________

Client Goal: ________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1.       _______________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

2: _________________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

Nursing Diagnosis #2:

__________________________________________________________________________________________________

Client Goal: ________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1.       ______________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

2. ________________________________________________________________________________________________

Rationale: ________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

Post-Clinical Education:

Provide the group with education on a topic you learned about preparing for your client/clinical packet.  For example a medical diagnosis, intervention, medication, lab value, treatment method, etc.  Use this space to write your speaking notes and reference(s).

you must now identify and discuss some of the legal and ethical considerations that must be taken into account in constructing your proposed healthcare facility. You are required to include the follow

you must now identify and discuss some of the legal and ethical considerations that must be taken into account in constructing your proposed healthcare facility. You are required to include the following:

• Define and discuss the differences between licensure, certification, and accreditation as they relate to health care facilities.
• Discuss the ethical or legal requirements and responsibilities that a health care organization has in ensuring its facility is licensed, certified, and accredited. When discussing licensure requirements, ensure that you research requirements based on the state in which you reside.
• Define and discuss the differences between the licensure and certification as they relate to healthcare providers or professionals.
• Discuss the ethical or legal requirements and responsibilities that a health care organization has in ensuring its staff members are licensed and certified.
• Research and discuss an accrediting body that will provide accreditation to the facility you are proposing. Ensure that you provide a history of the organization, what types of facilities they accredit, and how the organization has impacted the quality of health care in the United States.

Note: You must include a minimum of 3 scholarly references.

Patient care hinges in part on adequate and timely information exchange between treating providers. Referral and reply letters are common means by which doctors and nurse practitioners exchange inform

Patient care hinges in part on adequate and timely information exchange between treating providers. Referral and reply letters are common means by which doctors and nurse practitioners exchange information pertinent to patient care. Ensuring that letters meet the needs of letter recipients saves time for clinicians and patients, reduces unnecessary repetition of diagnostic investigations, and helps to avoid patient dissatisfaction and loss of confidence in medical practitioners.

As a Nurse Practitioner (NP) you will need to know the difference between a consultation and a referral for treatment, when ordering and when carrying out consultations or referrals.

Consultations

A consultation is a request for opinion or advice, so that the requestor can manage the patient. A consultation is billed under one of the consultation codes listed in Physicians’ Current Procedural Terminology (CPT) (99241-99245 for outpatient of office consultations). If the NP is the consultant, the NP should document the request for a consultation, the reason for the consult, and the NP’s evaluation and recommendations.

When an NP requests a consultation from another provider, the N P should request “consultation” on the referral form, rather than “referring.”

Referrals:

A referral is made when the referring provider wants to turn the management of the patient over to the referred-to provider, at least for the current complaint.

When a NP refers a patient, the NP should state on the referral form that the NP is “referring the patient for evaluation and treatment.” The referred-to provider will bill an evaluation and management code, rather than a consultation code.

Writing Assignment: Consult: Write up a consult request and include all key elements.

Ms. Perez has been referred to Ms. Wilson FNP-C,APRN, MSN  for consultation regarding eczema unresponsive to treatment in the past six months.

Document the evaluation and recommendations for how Ms. Wilson FNP-C,APRN,MSN should deal with the consultation request and bill a consultation code.

Writing Assignment: Referral: Write up a referral request and include all key elements.

As an NP and Ms. Perez primary care provider, you decide to refer her to Dr. Owens a dermatologist for evaluation and treatment regarding eczema unresponsive to treatment in the past six months.

1. Document your referral to Dr. Owens

2. Document the evaluation and recommendations for how Dr. Owens should deal with the referral and bill a referral code.

The use of health information technology (HIT) has increased dramatically over the past decade, resulting in the federal government enacting several pieces of legislation such as the Health Insurance

The use of health information technology (HIT) has increased dramatically over the past decade, resulting in the federal government enacting several pieces of legislation such as the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Continuing to build on your proposal for a healthcare facility from Weeks 1 and 2, you are assigned to research and discuss the following: •Discuss the financial and health benefits that can be realized by implementing an electronic health record (EHR). •Research and explain the estimated cost of implementing an EHR and the estimated cost of managing an EHR over the long run. •Discuss current security concerns surrounding HIT and the EHR. •Discuss how electronic health records can be used for decision-making and problem-solving. •Choose 1 piece of federal legislation (e.g., HIPAA, HITECH Act, Meaningful Use), and discuss the requirements that legislation imposes on the use of HIT and the EHR. Note: You must use at least 3 scholarly references. IP3

In response to federal policy and service requirements, health insurance plans are increasingly developing high-deductible insurance policies and narrow networks. These types of policies require the c

In response to federal policy and service requirements, health insurance plans are increasingly developing high-deductible insurance policies and narrow networks. These types of policies require the consumer to pay more out-of-pocket. To portray this in a positive light, this trend has been labeled as “consumer-based” to suggest that the consumer must pay more from their own funds and, thus, encourage consumers to make better health care choices. However, this could be labeled as a burden on the consumer.

Write a 350- to 525-word article that identifies and evaluates the impact that federal or state health care policies are having on consumer costs. Explore both positive and negative effects.

Include a citation of your article in your assignment.

Cite 3 reputable references to support your assignment (e.g., trade or industry publications, government or agency websites, scholarly works, or other sources of similar quality).