a summary of this health assessment

https://nursingpapersmarket.com/product/comprehensive-assessment-of-tina-jones/

 

Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount!
Use Discount Code "Newclient" for a 15% Discount!

NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.

SOAP NOTE: Asthma Exacerbation 3

 

Patient name: A.A

Sex: Female DOB: 9/04/1995 Age: 25 years-old

Ethnicity: Hispanic.

Language: Spanish.

Marital Status: Married

Religion: Christian

SUBJECTIVE:

Chief Complaint: “I can’t cash my breath since this morning when I finished my exercise routine at gym”

History of Present Illness: 

Patient is a 25-years-old that presents to the office with a chief complain of Shortness of breath, since this morning after finished workout at gym, patient with wheezing upon auscultation. Patient denied any other symptoms related.

Past Medical History:

Surgeries: N/A ( if any add it)

Hospitalizations: N/A if any add it

Chronic Medical conditions: Asthma as per records and patient statement.

Psychiatric Illnesses: None.

Injuries: None

Childhood Illnesses: Asthma since 5 years old.

Preventive Care:

Pap smear: 12/2019( Negative)

Family History: 

Mother is alive: Asthma

Father is alive: Cancer and Diabetes.

Sister is alive: Diabetes

Brother: No brother

Children: No Children

Additional History:

Immunizations: All vaccines current/ Flu vaccine: 9/15/2020

Nutritional Status: Regular Diet.

Physical Trauma/ Accident: Denied

BEHAVIOR/HABIT:

Caffeine: Yes

Smoke: No

Alcohol:No

Drug: No using illicit drugs

Exercises: Moderate exercise habit

Legal Document: Patient does not have a living will and livings will/advanced not directives on records.

FUNCTIONAL STATUS:

Normal/ Independent ADL’s.

Allergies: Not Known Drug Allergies. Or what the patient has.

 

Medications:  currently taking:

Albuterol 2.5 mg 3 or 4 times a day by nebulization, over approximately 5 to 15 minutes.

Advair Diskus 2 puff twice a day.

 

HEALTH CARE MAINTENANCE: She has received the influenza vaccine recently. Annual check up with primary care provider. Review of physical health, well being, and psychosocial concerns, nutritional education and guidance, and health education, guidance annually by patient chart.

OBJECTIVE: APPEARANCE: Well nourished, developed and dressed/groomed, pleasant demeanor, speech clear. Appears to be without discomfort, does not look distressed.

 

VITALS SIGNS:

-Blood Pressure: 100/58

-Pulse: 99 bpm

-Respiration: 24 rpm ) Not Regular)

-Temperature: 98.3 degrees Fahrenheit

-O2 saturation: 100% at room air.

-Weight: 130 lbs

-Height: 5’2”

-BMI: 22

-Pain level 0/10 on scale of pain. (If is a case with pain put scale from 0-10 and describe it) OLDCART Onset-Location-Duration-Characteristics-Aggravating-Factors-Relieving-FactoTreatment.

 

Respiratory: Shortness of breath, with rapid respiration, on auscultation wheezing through all

ASSESSMENT:

DIAGNOSIS:

Asthma exacerbation diagnosis due clinical presentation and physical exam.

1. Asthma exacerbation (ICD 10: J45.901).

Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible broncho constriction. Symptoms and signs include dyspnea, chest tightness, cough, and wheezing. The diagnosis is based on history, physical examination, and pulmonary function tests.

DIFFERENTIAL DIAGNOSTIC:

Wheezing is a relatively high-pitched whistling noise produced by movement of air through narrowed or compressed small airways. It is common in the first few years of life and is typically caused by viral respiratory tract infection or asthma, but other possible causes include inhaled irritants or allergens, esophageal reflux, and heart failure.

Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational exposures are less common causes in nonsmokers. Symptoms are productive cough and dyspnea that develop over years; common signs include decreased breath sounds, prolonged expiratory phase of respiration, and wheezing. Severe cases may be complicated by weight loss, pneumothorax, frequent acute decompensation episodes, right heart failure, and/or acute or chronic respiratory failure.

Hypersensitivity pneumonitis is a syndrome of cough, dyspnea, and fatigue caused by sensitization and subsequent hypersensitivity to environmental (frequently occupational) antigens. Acute, subacute, and chronic forms exist; all are characterized by acute interstitial inflammation and development of granulomas and fibrosis with long-term exposure.

Plan:

Lab test:Chest X-ray Posterior/Anterior and Lateral.

Pulse Oximetry.

Pharmacologic treatment: 1. Dry Powder Inhaler: 90 mcg/puff 2 puffs q 4–6 h as needed and 2 puffs 15–30 minutes before exercise.

2. Mometasone Dry Powder Inhaler: 110 or 220 mcg/puff 220 mcg once/day in the evening (maximum 220 mcg twice a day or 440 mcg once/day in the evening).

3. Prednisolone Short-course burst: 40–60 mg once/day (or 20–30 mg bid) for 3–10 days.

Non- Pharmacological Treatment:

1) Relaxation and breathing techniques such as yoga that help to prevent asthma symptoms and improve your overall wellbeing.

2) Continue with Regular physical activity, that help improving the performance of your heart and lungs.

3) Avoiding allergy triggers.

4) Not start smoking

Education Plans:

Increase intake of water. (2 liters/day).

High fiber diet (more than 30 g/day).

Patient educated on management of Asthma exacerbation in dietary measures and preventions of further complications of her new medications treatment, also to contact the provider if an abnormally or knew symptoms occurs.

Return to the Clinic after more Labs and Test was done to review results.

Follow-ups/Referrals: -Referrals to Pulmonologist for follow up and further treatments.

-Follow up in two weeks to evaluated patient and other laboratory testing results.

 

Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount!
Use Discount Code "Newclient" for a 15% Discount!

NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.

The paper must be in APA style and all in-text citations should be in APA format, with a minimum of 6 pages  in double spaces not including the cover and reference pages.  All paper submitted must be in APA format according to Publication Manual American Psychological Association (APA) (6th ed.). 2009. The paper must include:

– Introduction: Clearly identifies the topic, Establishes goals and objectives of presentation. Introduce clearly the topic.

– Population at Risks Factor. The population is clearly stated including possible risks factors and medical history

– Research Content EBP. Excellent EBP provided. Followed the CDC recommendations and Evidence

– Education. Excellent education provided including strategic tools methods by following the EBP guidelines

– Body and Content. Excellent body content and well chosen topic. Easy to read with the essential information throughout without mistakes Adequate length 5 pages.

Conclusion. Excellent Conclusion clearly supported by the information presented at the end of the paper

References within five (5) years  in APA format

 

Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount!
Use Discount Code "Newclient" for a 15% Discount!

NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.

Required Readings

Marshall, E., & Broome, M. (2017). Transformational leadership in nursing: From expert clinician to influential leader (2nd ed.). New York, NY: Springer.

• Chapter 5, “Collaborative      Leadership Contexts: Networks, Communication, Decision Making, and      Motivation” (pp. 121–144)
• Chapter 9, “Creating and Shaping      the Organizational Environment and Culture to Support Practice Excellence”      (pp. 247–278)
• Chapter 10, “Building Cohesive and      Effective Teams” (pp. 279–298)

Select at least ONE of the following:

Clark, C. M., Olender, L., Cardoni, C., & Kenski, D. (2011). Fostering civility in nursing education and practice: Nurse leader perspectives. Journal of Nursing Administration, 41(7/8), 324–330. doi:10.1097/NNA.0b013e31822509c4

Note: You will access this article from the Walden Library databases.

Clark, C. M. (2018). Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility. Nurse Educator. doi:10.1097/NNE.0000000000000563

Note: You will access this article from the Walden Library databases.

Clark, C. M. (2015). Conversations to inspire and promote a more civil workplace. American Nurse Today, 10(11), 18–23. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2015/11/ant11-CE-Civility-1023.pdf

Griffin, M., & Clark, C. M. (2014). Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. Journal of Continuing Education in Nursing, 45(12), 535–542. doi:10.3928/00220124-20141122-02

Note: You will access this article from the Walden Library databases.

Document: Work Environment Assessment Template (Word document)

Required Media

TEDx. (2017, April). Jody Hoffer Gittell: The power of a simple idea [Video file]. Retrieved from https://www.youtube.com/watch

Discussion: Workplace Environment Assessment

How healthy is your workplace?

You may think your current organization operates seamlessly, or you may feel it has many issues. You may experience or even observe things that give you pause. Yet, much as you wouldn’t try to determine the health of a patient through mere observation, you should not attempt to gauge the health of your work environment based on observation and opinion. Often, there are issues you perceive as problems that others do not; similarly, issues may run much deeper than leadership recognizes.

There are many factors and measures that may impact organizational health. Among these is civility. While an organization can institute policies designed to promote such things as civility, how can it be sure these are managed effectively? In this Discussion, you will examine the use of tools in measuring workplace civility.

To Prepare:

· Review the Resources and examine the Clark Healthy Workplace Inventory, found on page 20 of Clark (2015).

· Review and complete the Work Environment Assessment Template in the Resources.

·

Post a brief description of the results of your Work Environment Assessment. Based on the results, how civil is your workplace? Explain why your workplace is or is not civil. Then, describe a situation where you have experienced incivility in the workplace. How was this addressed? Be specific and provide examples.

Assignment: Workplace Environment Assessment

Clearly, diagnosis is a critical aspect of healthcare. However, the ultimate purpose of a diagnosis is the development and application of a series of treatments or protocols. Isolated recognition of a health issue does little to resolve it.

In this module’s Discussion, you applied the Clark Healthy Workplace Inventory to diagnose potential problems with the civility of your organization. In this Portfolio Assignment, you will continue to analyze the results and apply published research to the development of a proposed treatment for any issues uncovered by the assessment.

To Prepare:

· Review the Resources and examine the Clark Healthy Workplace Inventory, found on page 20 of Clark (2015).

· Review the Work Environment Assessment Template.

· Reflect on the output of your Discussion post regarding your evaluation of workplace civility and the feedback received from colleagues.

· Select and review one or more of the following articles found in the Resources:

o Clark, Olender, Cardoni, and Kenski (2011)

o Clark (2018)

o Clark (2015)

o Griffin and Clark (2014)

The Assignment (6 pages total):

Part 1: Work Environment Assessment (2 pages)

· Review the Work Environment Assessment Template you completed for this Module’s Discussion.

· Describe the results of the Work Environment Assessment you completed on your workplace.

· Identify two things that surprised you about the results and one idea you believed prior to conducting the Assessment that was confirmed.

· Explain what the results of the Assessment suggest about the health and civility of your workplace.

Part 2: Reviewing the Literature (2 pages)

· Briefly describe the theory or concept presented in the article(s) you selected.

· Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment.

· Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples.

Part 3: Evidence-Based Strategies to Create High-Performance Interprofessional Teams (2 pages)

· Recommend at least two strategies, supported in the literature, that can be implemented to address any shortcomings revealed in your Work Environment Assessment.

· Recommend at least two strategies that can be implemented to bolster successful practices revealed in your Work Environment Assessment.

 

Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount!
Use Discount Code "Newclient" for a 15% Discount!

NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.