This is a Unfolding Case Study | Name: James, Karen Age: 57 Years Gender: Female Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her

This is a Unfolding Case Study | Name: James, Karen Age: 57  Years Gender: Female Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s 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. | Name: James, Karen Age: 57  Years Gender: Female 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. was documented for the respiratory effort? was auscultated in the Lower Right Posterior lobe of the lungs? was documented related to tissue perfusion? 2). was the last documented temperature for Karen? 3). Does Ms. James use any sensory aides? 4) does she rate her pain? 5) is her MORSE Fall Risk Score? Review the client’s story 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. Chief Informant: Patient Chief Complaint: Shortness of breath, productive cough story 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 story: Mother died at age of 72 with breast cancer. Father is alive at the age of 79 and has congestive heart failure. Previous Illnesses: Patient has asthma. Also states she gets bronchitis every 1-2 years. Contagious Diseases: None Injuries or Trauma: None Surgical story: Tonsillectomy and adenoidectomy as a child. Dietary story: Regular diet. Patient is 5’1″ and 140 pounds. Has recently lost 20 pounds on Weight Watchers diet. Other: — Social story: 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 Integument: 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. General: 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. Pneumonia 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/dL She is also febrile at 102.7. Nursing will initiate IV antibiotics. Showing 1 to 1 of 1 entries Wed 12:45 102.7 22 112 142/77 98 C Diaz, RN Select and drag to zoom in on a date range 102.7F/39.3C Wed | 13:00 Admit   to medical-surgical Alerts — Wed | 13:00 IV — Wed | 13:00 Respiratory — Wed | 13:00 Vital Signs — Wed | 13:00 Activity/Mobility — Wed | 14:00 Patient Teaching — Wed | 13:00 Regular/General   Diet Diet — Showing 1 to 7 of 7 entries Wed   13:00 Tue   23:59 650   mg Oral Every   6 Hours PRN –   – System Assessments Wed 13:00 Wed 13:00 C Diaz, RN Apical: Regular Peripheral vascular, general: Warm extremities No edema noted No cardiac problems noted Color: Green Amount: Scant Cough strength: Strong Cough type: Productive Respiratory/breathing support: Nebulizer treatment Auscultation: Coarse crackles Auscultation: Diminished Wheeze Description: Expiratory Auscultation: Wheeze Wheeze Description: Expiratory Auscultation: Wheeze Consistency: Thick Secretion odor: None Auscultation: Clear Auscultation: Clear Dyspnea/shortness of breath Shortness of breath on exertion Labored Oriented to person, place, time, and situation Calm Cooperative No CNS problems evident No assessment required at this time Wears glasses Wears contacts Moves all extremities with full range of motion Abdominal assessment: Soft to palpation No gastric problems noted Date 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 No No assessment required at this time No assessment required at this time Oriented to time, person, place 30 Hospital ID bracelet Low fall risk No=0 No=0 None/Bedrest/Nurse Assist=0 Yes=20 Weak=10 Oriented to Own Ability=0 Risk Score: 30 Fall 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. Wears glasses Wears contacts You are currently working on Phase 2. You have completed Phase 1 of this scenario. | Name: James, Karen Age: 57  Years Gender: Female Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s 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. was documented for the respiratory effort? was auscultated in the Lower Right Posterior lobe of the lungs? was documented related to tissue perfusion? 2). was the last documented temperature for Karen? 3). Does Ms. James use any sensory aides? 4) does she rate her pain? 5) is her MORSE Fall Risk Score? Review the client’s story 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. You 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 air… Document 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 patient’s admission vital signs, how is the patient’s 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. submit your post work to Canvas within 24 hours of the completion of your VCBC Experience.   refer to the Experiential Learning Orientation for further questions and a reminder on how to ensure your assignment is properly saved. complete the Concept Notebook (Map) for the concept of Mobility linked to your clients for the day. This assignment is due within 24 hours of completing your VCBC. refer to the Experiential Learning Orientation for further questions and a reminder on how to ensure your assignment is properly saved. 205/225 Concept Notebook RubricCriteriaRatingsPtsThis criterion is linked to a Learning OutcomeRelated Concept 1 pts This criterion is linked to a Learning OutcomeExemplar 1 pts This criterion is linked to a Learning OutcomeAssessment 1 pts This criterion is linked to a Learning OutcomeLab & Diagnostic 1 pts This criterion is linked to a Learning OutcomeInterventions 1 pts This criterion is linked to a Learning OutcomeMedications 1 pts This criterion is linked to a Learning OutcomePotential Complications 1 pts This criterion is linked to a Learning OutcomeCollaborative Care 1 pts This criterion is linked to a Learning OutcomeSpelling and Grammar 1 pts This criterion is linked to a Learning OutcomeReferencesCorrect APA references. 1 pts Total Points: 10

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