Mr. Smith is a 58 year old African American male who is a married stock broker with five children. Three of his children are in college while the other two live at home. His normal workday consists of working 10 hour days with an hour drive time to and from his office. This means Mr. Smith has little time to dedicate to exercising. Mr. Smith often experiences headaches, fatigue, malaise, dizziness, vision changes, nausea, and dyspnea.…
G.S. is a very pleasant 83 year old white female admitted to the unit on 10/29/15 for congestive heart failure and shortness of breath. This is her second time being admitted within a week of discharge for the same diagnosis. G.S. is a widow who lives along at home. She has never smoked and does not drink alcohol. She is, however, a little on the obese side.…
The resident skin upper and lower limbs are pink, warm, and dry with a soft texture. Her skin turgor is less than 2 seconds with no wounds or lesions noted. There are pressure ulcers located on left and right buttocks. Resident scored a 13 which means she is at high risk for pressure ulcers on the Braden scale. The resident’s hair is straight, gray, fine with no appearance of balding.…
Define the Problem New patient has no records/radiographs and is refusing radiographs. The hygienist continued with the appointment without obtaining the necessary radiographs. The patient denies using any tobacco products or recreational drugs when asked during the medical history but admits to it at the end of the appointment.…
Mr. DeRodes is Executive Vice President and Chief Information Officer (CIO) at Target. His areas of responsibility include oversight of the Target technology team and operations, with responsibility for the ongoing data security enhancement efforts as well as the development of Target’s long-term information technology roadmap. Bob has significant experience leading information technology and business operations with an emphasis on transformational change, innovation, and execution inside large corporations. Most recently, he led DeRodes Enterprises, LLC an information technology and business operations advisory firm. Prior to DeRodes Enterprises, Bob served as First Data’s executive vice president, global operations and technology, where…
Database and Assessment Table 1 – Physical Nursing Assessment Data GENERAL: Patient is an 88 year-old Caucasian male. Vital signs stable at 97.3°F, 82BPM, 22 breaths/min, 84/54mmHg, 100% on 1.5lL O2, 0/10 pain, patient weight 58kg. SKIN/HAIR/NAILS: Skin was thin and fragile, warm and moist, skin color slightly pale, skin tear on left upper arm measuring 3 inches, no bleeding or pain.…
Henry Williams is a 74 year old African American male. Mr. Williams was admitted to the hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Mr. Williams has a past medical history of COPD, cardiovascular disease (CVD), asthma, hearing loss with use of hearing aids, hypertension (HTN), and hyperlipidemia. He smoked one pack per day for 50 years. He quit smoking about 6 years ago.…
The 52-year-old African American has insufficient personal medical and family history because his father died in an automobile accident when he was a child, and he has not seen a doctor in the last 10 years. I will ask the patient if his mother told him about any concerning health issue regarding his late father, and if any of his uncle on his father side has any health issue and what type. Also, when he had his last routine physical and was there any abnormal findings, again why he decided not continue routine physical in the last 10 years. Although obtaining a correct diagnosis could be challenging, but a thorough history, physical assessment and conducting required test such as urinalysis, serum creatinine, postvoid residue and prostatic…
Client History A.O. is an 89 year old Catholic female of Japanese background. Past marital status is unknown, currently unmarried. Currently on medication for hypertension which initially caused bradycardia until the dosage was lowered. A.O. was immunized as a child, did protract chicken pox. Measles, and mumps.…
He is not taking any medication and currently practicing conservative management due to financial problems. The patient is not working. He is an immigrant and married to the locals The patient is alert, conscious and tacypnic. He…
Primary diagnosis: Affective disorders. Secondary diagnosis: Chronic pain. Code 2480- but that code is “Diagnosis established – no predetermined list code of medical nature applicable. Did not find code for pain or chronic pain.…
Abnormal assessments included respiratory, cardiovascular, peripheral vascular, neurological, urinary, gastrointestinal, musculoskeletal, hematologic, and endocrine. The patient also had an abnormal dietary and eating habits. Objective data was obtained through vital signs and intake and output measurements. Assessment of blood pressures and looking at previously documented blood pressure readings in his chart led to the assumption of hypertension. His primary care physician further confirmed this as a medical diagnosis.…
This paper is going to talk about my client’s diagnosis and his secondary diagnosis, my assessment and nursing care that was done and could be done along with my evaluation. History and Priority Nursing Problem Mr. X is a 49-year-old male who came in with shortness of breath from a nursing home. His secondary diagnosis ae HIV, AIDS, syphilis, respiratory failure and Kaposi sarcoma. He has an allergy to ciproflaxin.…
Discharge Planning Discharge planning is a very important component in patient care. According to Gholizadeh, Delgoshaei, & Gorji (2016), “Discharge planning is a main concept for quality patient care and sustainability of health system”, (p. 168). It consists of making sure the patient is discharged with the proper care and resources before leaving the hospital. “Discharge planning is a complicated process which is composed of assessment of patient during admission in the hospital, training the patient and their family, post-discharge follow-up and evaluation”, (Gholizadeh, Delgoshaei, & Gorji, p.g 168). According to Horwitz, Moriarty, & Chen, “safely transitioning patients from hospital to home is a complex process that requires successfully…
Case Study Two: A Complete Physical Assessment Shannon A. Lewis University of Mississippi Medical Center N 610 A 52-year-old female comes to your office today for a physical exam. She states that she enjoys good health and believes she is active for her age. She states she has been feeling well but just decided it was time for a complete check-up. She sees a local health care provider annually at the health department for refills on her prescriptions but has not had a “real” physical in many years. She is a WDWNWFNAD (well-developed, well-nourished, white female, no acute distress.…