karen james case study
Order ID: 89JHGSJE83839 Style: APA/MLA/Harvard/Chicago Pages: 5-10 Instructions:
This is an Unfolding Case Study
Patient Details:
Print Phase Info
|
Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
FemaleKaren James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physicians office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.
You are currently working on Phase 1. You have completed Phase 0 of this scenario.
Patient Details:
Print Phase Info
|
Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
Female
Phase
1,
Wednesday
16:00You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.
Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:
1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?
2). What was the last documented temperature for Karen?
3). Does Ms. James use any sensory aides?
4) What does she rate her pain?
5) What is her MORSE Fall Risk Score?
Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?
[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]
When you are finished with this task, you may click Complete this Phase.
Patient InformationChief Informant:
Patient
Chief Complaint:
Shortness of breath, productive cough
History of Current Problem:
Patient states she has had 3-week history of influenza. Has now developed a severe cough approximately 3 days ago with shortness of breath. Unable to sleep due to cough, which often causes bronchospasms. Patient also complains of fever, fatigue, and right-sided chest pain. Seen in urgent care 3 days ago and given Z-pack. No improvement in symptoms.
Allergies:
None known
Family History:
Mother died at age of 72 with breast cancer. Father is alive at the age of 79 and has congestive heart failure.
Past Medical HistoryPrevious Illnesses:
Patient has asthma. Also states she gets bronchitis every 1-2 years.
Contagious Diseases:
None
Injuries or Trauma:
None
Surgical History:
Tonsillectomy and adenoidectomy as a child.
Dietary History:
Regular diet. Patient is 5’1″ and 140 pounds. Has recently lost 20 pounds on Weight Watchers diet.
Other:
—
Social History:
No smoking, no drugs. Uses alcohol in social situations.
Current Medications:
Tylenol 650 mg PO every 4 hours PRN pain or fever
Prozac 20 mg PO every day
Xanax 0.25 mg PO every 8 hours PRN
Xopenex HFA 2 puffs every 6 hours PRN
Review of SystemsIntegument:
Denies complaints.
HEENT:
States she had neck soreness related to influenza, with “swollen glands.”
Cardiovascular:
No complaints.
Respiratory:
Complains of shortness of breath, frequent productive cough. States her cough often turns into bronchospasms. Uses inhaler, peppermint tea, lozenges, and Vicks VapoRub.
Gastrointestinal:
Complains of decreased appetite.
Genitourinary:
No complaints.
Musculoskeletal:
Complains of generalized body aches.
Neurologic:
Alert and oriented.
Developmental:
Denies complaints.
Endocrine:
No complaints.
Genitalia:
No complaints.
Lymphatic:
No complaints.
Physical ExamGeneral:
57-year-old female in mild distress. Appears weak.
Vital Signs:
Temp: 103.2 F, Pulse: 114, Resp: 28, Blood pressure: 154/78 in office this morning
Integument:
Skin clear of rash.
HEENT:
Pupils equal and reactive. Nasal congestion. Neck supple.
Cardiovascular:
S1, S2, no murmur.
Respiratory:
Lungs clear with crepitation in right base.
Gastrointestinal:
Abdomen soft, active bowel sounds.
Genitourinary:
—
Musculoskeletal:
Moves all extremities well.
Neurologic:
Alert and oriented.
Developmental:
—
Endocrine:
—
Genitalia:
Not assessed. Seen by gynecologist recently. Negative pap smear and negative mammogram.
Lymphatic:
No lymph node swelling at this time.
Impressions:
Pneumonia
Plan:
The patient is admitted for IV antibiotics and close observation of respiratory status. Patient will need influenza and pneumonia vaccines.
Provider Signature:
Michael Foster, MD
Day:
Wednesday
Time:
12:45
Chief Complaint:
The patient is a 57-year-old female admitted today for chief complaint of shortness of breath.Patient’s labs were completed in the primary care provider’s office prior to admission and results include the following:
WBC: 20.2 x 109/L
RBC: 4.51 RBC x 106/ul
Hemoglobin: 14.0 g/dL
Hematocrit: 40.2%
Sodium: 139 mEq/L
Potassium: 4.2 mEq/L
Chloride: 105 mEq/L
CO2: 26 mEq/L
Glucose: 91 mg/dL
BUN: 17 mg/dL
Creatinine: 0.5 mg/dLShe is also febrile at 102.7.
Nursing will initiate IV antibiotics.
Showing 1 to 1 of 1 entries
FirstPrevious1NextLastChart Time
Temp
Resp
Pulse
BP
Sat%
Notes
Entry By
Wed 12:45
102.7
22
112
142/77
98
C Diaz, RN
Select Chart Type: Temperature Respiration Pulse Blood Pressure Oxygen Saturation
Select and drag to zoom in on a date range
102.7F/39.3CPatient Card
Order Day/Time
Description
Category
Last Performed
Discontinue
Wed | 13:00
Admit to medical-surgical
Alerts
—
Wed | 13:00
Start and maintain IV line
IV
—
Wed | 13:00
Pulse oximetry every 4 hour(s)
Respiratory
—
Wed | 13:00
Vital signs every 4 hours
Vital Signs
—
Wed | 13:00
Up as tolerated
Activity/Mobility
—
Wed | 14:00
Diagnosis-Respiratory distress syndrome-ADDED-Disease Process
Patient Teaching
—
Wed | 13:00
Regular/General Diet
Diet
—
Showing 1 to 7 of 7 entries
FirstPrevious1NextLast
PRNDrug Name
Order Start
Order Stop
Dose
Route
Frequency
Dosage Time
Action
Acetaminophen Tablet – (Tylenol, Genapap)
Wed 13:00
Tue 23:59
650 mg
Oral
Every 6 Hours PRN
– –
Levalbuterol Nebulizer Solution – (Xopenex Nebulizer Solution)
Chart:
System Assessments Wed 13:00
Entry Time:
Wed 13:00
Entered By:
C Diaz, RN
Cardiovascular AssessmentPulses
Apical:
Regular
Tissue PerfusionPeripheral vascular, general:
Warm extremities
EdemaNo edema noted
Cardiac AssessmentNo cardiac problems noted
Respiratory AssessmentProductive Cough Secretions Assessment
Color:
Green
Amount:
Scant
CoughCough strength:
Strong
Cough type:
Productive
OxygenationRespiratory/breathing support:
Nebulizer treatment
Lower Right PosteriorAuscultation:
Coarse crackles
Lower Left PosteriorAuscultation:
Diminished
Upper Right PosteriorWheeze Description:
Expiratory
Auscultation:
Wheeze
Upper Left PosteriorWheeze Description:
Expiratory
Auscultation:
Wheeze
Productive Cough Secretions AssessmentConsistency:
Thick
Secretion odor:
None
Upper Left AnteriorAuscultation:
Clear
Upper Right AnteriorAuscultation:
Clear
Respiratory EffortDyspnea/shortness of breath
Shortness of breath on exertion
Respiratory PatternLabored
Neurological AssessmentLevel of Consciousness/Orientation
Oriented to person, place, time, and situation
Emotional StateCalm
Cooperative
Central Nervous System Assessment (CNS)No CNS problems evident
Integumentary AssessmentIntegumentary Assessment
No assessment required at this time
Sensory AssessmentVision Assessment
Wears glasses
Wears contacts
Musculoskeletal AssessmentRange of Motion (ROM)
Moves all extremities with full range of motion
Gastrointestinal AssessmentAbdomen
Abdominal assessment:
Soft to palpation
GastrointestinalNo gastric problems noted
IntestinalDate of last bowel movement:
Monday
Continence of bowel:
Continent
Intestinal assessment:
No bowel problems noted
Bowel sounds:
Active x 4 quadrants
Rectum:
No reported rectal problems
Pain AssessmentDo You Have Pain Now?
No
Genitourinary AssessmentGenitourinary Assessment
No assessment required at this time
Psychosocial AssessmentPsychosocial Assessment
No assessment required at this time
Safety AssessmentOrientation
Oriented to time, person, place
Fall Risk30
Bracelet CheckHospital ID bracelet
Safety NotesLow fall risk
Morse Fall ScaleHistory of Falling
No=0
Secondary DiagnosisNo=0
Ambulatory AidNone/Bedrest/Nurse Assist=0
IV or IV AccessYes=20
GaitWeak=10
Mental StatusOriented to Own Ability=0
Total Fall Risk ScoreRisk Score:
30
Fall Risk Score and Preventative Measures ImplementedFall Risk Level:
Medium Risk
Fall Risk Measures:
Implement Medium Risk Fall Prevention Interventions:
All items in low prevention plus post fall program sign indicating risk, wrist band identification, ambulate with assistance, do not leave patient unattended in diagnostic or treatment area, make comfort rounds every 2 hours for toileting.
Special Precautions/Isolation AssessmentStandard Precautions
Vision AssessmentWears glasses
Wears contacts
Musculoskeletal Assessment
You are currently working on Phase 2. You have completed Phase 1 of this scenario.
Patient Details:
Print Phase Info
|
Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
Female
Phase
0Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physicians office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.
You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:
1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?
2). What was the last documented temperature for Karen?
3). Does Ms. James use any sensory aides?
4) What does she rate her pain?
5) What is her MORSE Fall Risk Score?Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?
[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]
When you are finished with this task, you may click Complete this Phase.
Phase
2,
Wednesday
16:20You enter Ms. James room to take her vital signs and obtain the following results:
Temperature: 101.5 degrees Fahrenheit, oral
Pulse: 110, radial
Respirations: 20
Blood pressure: 144/68 left arm, sitting
Oxygen saturation: 99%, finger probe, room airDocument the vital signs in the vital signs tab on the Info Panel on the left (do not document in a misc. note). When compared to the patients admission vital signs, how is the patients temperature trending? Document your answer in a Miscellaneous Nursing Note.
Under Basic Nursing Care: Choose 5 interventions you will perform at this time to make this client to increase safety. Only 5 as you will need to prioritize your cares. Try to find 5 related to Impaired Mobility.When you are finished with these tasks, you may click Complete this Phase.
RUBRIC
Excellent Quality
95-100%
Introduction 45-41 points
The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.
Literature Support
91-84 points
The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.
Methodology
58-53 points
Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met.
Average Score
50-85%
40-38 points
More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided.
83-76 points
Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration.
52-49 points
Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met.
Poor Quality
0-45%
37-1 points
The background and/or significance are missing. No search history information is provided.
75-1 points
Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration.
48-1 points
There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met
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karen james case study