CS

The attached document gives a history of the patient and all the information you need

this needs to be about 8 pages and exactly what is being ask in the rubric.

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apa format

 

1. Patient: CS

Has a history of hypertension, diabetes, depression, renal calculi, and cholesterol

Allergic to Jardiance and latex.

Patient lives at home with husband and 2 children (1 boy and 1 girl)

She does have a little financial problem related to her husband who recently lost his job.

She has a great support system and mother and father her care for her as well.

She is Christian but doesn’t really have any spiritual considerations

 

2. Medical diagnoses

Has a brain tumor which turned out to be glioblastoma in the frontal lobe (suggested to be a high-grade tumor.

 

Patient had a seizure in September and was brought to the hospital by her husband and when the doctor did a CT scan on her they found that she had a tumor that was large.

She returned 1 month later for an elective excision of tumor and a craniotomy. At my care she was 3 days post op and had staples from the middle of her forehead to the left side of her cheek bone.

 

She had a hemovac drain with serosanguinous drainage

Her blood sugar was 406

Vital signs were

Heart rate -42

Blood pressure- 187/81

Oxygen level was 95%

Temperate was at 98.2F

Respiratory rate was 20

Weight 175lb

 

Medication list:

Clonidine 0.2 3xper day (blood pressure )

Januvia 25mg 1x/day

Keppra 500mg 1 every 12 hours (for seizures)

Metformin 1000 mgx2/day (blood sugar)

Omeprazole 20mg x1/day (heart burn)

Zoloft 100mg 1x/day (depression)

Zocor 20mg for cholesterol

Lantus solostar pens for blood sugar

Norco 5/325 every 4 hours as needed for pain

 

 

 

 NUR 4820 Holistic Care Immersion

Case Analysis: Scholarly Writing Assignment

Criteria for Evaluation

 

Purpose:

The student will evaluate the nurse’s role in facilitating safe, quality outcomes for patient-centered care. The student will select a patient care assignment from the clinical practicum (not the same patient used for the case presentation) to complete the case analysis using the criteria stated below. The student must use at least 2 professional journal articles to supplement content from other recent nursing textbooks to provide the evidence for the care provided. Unless classic research, all references must be within 5 years of publication. The written assignment will conform to APA style for format of paper and citations of resources. The expected length of the paper is at least 10 pages.

 

Criteria Possible Points Comments/Earned Points
1. Introduce the background of the patient

· Health history

· Economic and social history

· Spiritual and cultural considerations

· Family members and relationships

· Community of residence

10 /10

Comments:

2. Medical diagnoses

· Discuss pathophysiology of disease or symptoms with focus on current health problem(s)

· Analyze the risk factors and patient’s assessment findings that relate to the pathophysiology or disease conditions

30 /30

Comments:

3. Patient assessment

· Discuss physical assessment findings including vital signs and allergies

· Evaluate the medications including the reasons for patient taking each one.

· Evaluate laboratory and diagnostic tests relevant to care of the patient

· Emphasis should be on the analysis of assessment data to care for patient

30 /30

Comments:

4. Analyze the case and progress toward outcomes using the nursing process framework

· Identify one priority diagnosis and two other nursing diagnoses and provide brief plan of care with rationales and interventions that are realistic and individualized to patient.

· Evaluate the care provided to the patient and the patient’s achievement of care outcomes

40 /40

Comments:

5. Examine how a systems approach to collaboration with other members of the interdisciplinary team contributed to safe patient care. 10 /10

Comments:

6. Evaluate discharge planning goals or other long term planning goals for the patient. 15 /15

Comments:

7. Discuss how the nurse provided or could have provided for the spiritual and cultural needs of the patient. 10 /10

Comments:

8. Evaluate one or more of the agency specific policies and the impact on the provision of care for this patient.

· Was policy a barrier or facilitator for care?

· How does nursing leadership advocate for safe, quality care?

10 /10

Comments:

9. Analyze ethical and legal standards that impacted the care of the patient and family. Possible discussion topics include: ethical standards for professional nursing practice, end-of-life decisions and advanced directives, respect for ethical rights of patients (autonomy, beneficence, etc.) 15 /15

Comments:

10. Analyze ethical and legal standards that impacted the care of the patient and family. Possible discussion topics include: ethical standards for professional nursing practice, end-of-life decisions and advanced directives, respect for ethical rights of patients (autonomy, beneficence, etc.)Reflect on additional learning that you need to enhance your care of a similar patient care situation in the future. 10 /10

Comments:

11. Scholarly presentation of work

· Uses textbooks and recent journal articles to support discussion points

· APA format for style, grammar, in-text citations, and references

· Absence of spelling errors

20 /20

Comments:

Total 200 /200

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