Patient Case Studies for Accurate Nursing Assessments

Patient Case Studies for Accurate Nursing Assessments Jon Teegardin Performing accurate nursing assessments on patients establishes a baseline of information regarding a patient’s complaint and history of present illness. The patients represented in this paper are not real, instead they are created to allow for examples of basic nursing assessments. This paper will assess two patients, one with chronic lower back pain and one with psychiatric and substance abuse complaints. Patient one The first patient is a 45 year old female who presents to the emergency room after arriving by private vehicle with a complaint of lower back pain with radiation down the right leg to the foot. My assessment of the patient begins when I go to the lobby and call the patients name. The patient ambulates with an even steady gait to the examination room. The patient does not require assistance ambulating. Once in the examination room, privacy is provided and an interview and full assessment are conducted. After introducing myself, the patient is identified using two identifiers, name and birthdate. The information provided by the patient is verified against the chart and an identifying wristband is applied. The chief complaint is then verified using an open ended question: Can you tell me why you are visiting the emergency room today? The patient’s response is â€Å"Back in 20012 I injured my back when my boyfriend was drunk and he slammed me against a wall. The doctor told me I had several ruptured discs in my back and it hurts so bad tonight I can’t stand it. The pain started about three days ago and has gotten progressively worse. I reassure the patient that she will be treated as soon as we can get the doctor in the room (Jarvis, 2012). The patient then asks for an emesis bag and states â€Å"I’m hurting so bad I think I’m going to throw up†. An emesis bag is provided. The patient retches several times and spits into the bag. No vomitus is noted . I continue with my interview by asking about the patients’ health history (Jarvis, 2012). I ask the patient about medication allergies. The patient states she is allergic to penicillin’s. Next I ask the patient about any medications she currently takes. The patient reports she takes the following medications: Xanax, 1 milligram 3 times per day, Gabapentin, 400 milligrams 3 times per day, Vicodin 10mg-325mg every 4 hours for pain, Lisinopril 20 milligrams, every day, Simvastatin 40 milligrams every day, Cyclobenzaprine, 20 milligrams every 6 hours, Ultram, 50 milligrams every 8 hours as needed for pain. When asked for a primary care physician, the patient states â€Å"I have recently switched doctors and I have an appointment on Wednesday with my new doctor. The patient presents an appointment card for a local physician. The patient is next asked about her medical history. The patient reports a history of hypertension, high cholesterol, anxiety, and ruptured discs in her lower back. The patient reports a surgical history of bilateral breast augmentation, bilateral tubal ligation, appendectomy, total hysterectomy, and tonsillectomy/adenoidectomy. When questioned about any surgical interventions for her back, the patient states â€Å"I don’t have insurance so I can’t afford to get any surgery on my back†. The patient reports a family history of hypertension, anxiety, and depression on her mother’s side. She also reports smoking 1 pack of cigarettes per day for 10 years but quit smoking 15 years ago. With my initial interview complete, the physical assessment begins (Jarvis, 2012). The patient is placed in a hospital gown for the examination. Vital signs are obtained. The blood pressure is 168/109 in the left arm, 166/106 in the right arm, heart rate is 79, oral temperature is 98.5, respirations are 16 per minute, oxygen saturation is 97% on room air, and the patient rates her pain on a numeric scale as a 10 out of 10 in her lower back. She describes the pain as a sharp, constant pain that is aggravated with movement, and helped with medication. She also relates radiation of the pain to her right leg as a burning sensation. The patient has shoulder length hair that is clean and well groomed. She denies any hearing problems, visual problems, congestion or cough. No drainage is noted from her ears, the eyes are clear with no redness or conjunctiva. Pupils are equal and reactive to light. Nares are clear bilaterally without swelling. The patient has good dentition with evidence of d ental intervention with fillings visible in three teeth. The lips, tongue, oral mucosa, and uvula are unremarkable. Facial symmetry is good with no drooping. The patient’s neck is supple with full range of motion and the trachea is midline. Respirations are clear and even bilaterally. The heart is auscultated and is strong and even at 78 beats per minute. Normal S1 and S2 are present. The patient denies any pain or mass in the breasts and reports that she self-examines monthly and her last mammogram was two years ago. Hand grips are strong and equal, radial pulses are strong and equal bilaterally. The abdomen is soft and non-tender to palpation. Bowel sounds are present in all four quadrants. A healed surgical scar is noted in the lower right quadrant. The patient denies any incontinence of bladder or bowel, and reports nausea and vomiting related to her back pain. The back is grossly unremarkable, and is tender to palpation in the area from L1 to L5. The patient denies any b urning or pain on urination, and denies flank pain. The patient reports a burning sensation down the right leg to the foot. Foot strength equal bilaterally, with strong bilateral pedal pulses. A scar is noted on the anterior right lower extremity distal to the patella. The patient reports that she accidently cut herself there as a child and required stitches to close the laceration. The patient’s mood and affect are appropriate for her age and the current situation. Her speech is clear. The patient is reassured that the physician will see her and the bed is verified to be in its lowest position with the wheels locked. The call light button is explained to the patient and placed within easy reach. The patient is reminded to request assistance prior to ambulating. Summary of findings My summary of finding is that the patient appears to be suffering from chronic back pain related to a traumatic injury in her past, and has uncontrolled hypertension related to noncompliance with her medication regimen. SOAP note S: Patient reports excruciating back pain radiating to the right leg, with nausea and vomiting prior to arrival. She also reports being out of her prescription medications which include a blood pressure medication. O: the patients’ blood pressure is elevated at 168/109, the lower back is tender to palpation. The patient ambulates without assistance but appears to be in mild distress. A: Nontoxic appearing white female that appears consistent with her stated age of 45 years old. EENT within normal limits. PERRLA at 3mm. Facial symmetry equal with no facial droop noted. The neck is supple and trachea is midline. Regular apical rate with S1 and S2. No S3 or S4 noted. Hand grips strong and equal bilaterally. Radial pulses strong and equal bilaterally. Respirations are even and unlabored. Lungs clear to auscultation bilaterally. The abdomen is soft and non-tender. Bowel sounds present in all four quadrants. Tender in the lower back region from L1 to L5 with radiation of pain to the right leg. No vomiting noted during assessment. Denies diarrhea. Denies urinary symptoms. Leg strength strong and equal bilaterally. Ambulates without difficulty or assistance. Pedal pulses present with no edema noted in lower extremities. P: Patient placed on non-invasive blood pressure monitoring and positioned for comfort. Expect MD orders for oral anti-hypertensive to reduce blood pressure and intramuscular injection of narcotic pain medication with antiemetic to control nausea and vomiting. Prepare patient for X-ray of lumbar spine region, and possible CT of the same area. A urine pregnancy test is contraindicated because of history of hysterectomy. Potential for admission to hospital for consult with orthopedist and surgical intervention. Patient two The second patient is a 62 year old female who has a chief complaint of alcohol dependence, benzodiazepine dependence, and depression. This patient is called from the lobby and ambulates to the exam room with an even, steady gait. Once in the examination room, privacy is provided and an interview and full assessment are conducted. I identify myself and the patient is identified using two identifiers and an identification band is placed on her wrist. I begin by obtaining a social history of the patient (Jarvis, 2012). She states she has never seen a psychiatrist and has been treated for depression by her primary healthcare provider. The patient is currently employed as a nurse practitioner/midwife with a county health department. She thoroughly enjoys her job and is fearful of losing her position due to chronic absenteeism related to her alcohol abuse. She reports consuming approximately one half gallon of liquor daily and has smoked one pack of cigarettes per day for twenty years. In her spare time she says that she enjoys sewing and gardening. The patient describes childhood as â€Å"normal†, had a â€Å"great relationship† with her father, but states â€Å"my mother loved my brother more than me, and nothing I did was good enough for her, even though I got straight a grades in school, and was active in church and band†. She further states â€Å"my mother used to beat me for waking up in the morning, becau se she said that I would eventually get into some kind of trouble†. †My brother is gay, but very successful working in Atlanta. I don’t see him enough, and I don’t hold what my mother did against him. I wish we saw more of each other. I got divorced over my drinking, so that was that, I could deal with all of it, up until my daughter died. Any other night I would have watched TV with her, but I was so tired that night. I went straight to bed and she decided to drive down to her brothers, 2 miles away. She made it about halfway, and was killed when she went off the road and hit a culvert, causing her car to roll several times. She died instantly†. Having obtained a social history, I begin obtaining medical history from the patient. The patient reports that she is allergic to codeine, Demerol, sulfa drugs, and Zithromax. She reports having a hysterectomy, cholecystectomy, and left foot ORIF. She is currently taking clonazepam, Lexapro, singular, and Xanax. She reports her mother and father had a history of alcohol abuse and are both deceased. My next assessment is a mental status examination. Having built a therapeutic relationship with the patient, I ask the patient if she has considered harming herself or had any command hallucinations (Jarvis, 2012). The patient denies any suicidal ideation or any hallucinations of any sort. The patient is well dressed, clean, pleasant, and cooperative. Her thought process is coherent with no ambivalence. The patients affect is calm and her appropriateness of mood to thought is normal. There is no depersonalization. The patient does not appear to be delusional, obsessive, or display ideas of reference. She is oriented to person, place, time, and situation. Vital signs are obtained and are all within normal limits. The patient denies any pain. Summary of finding My summary of finding is that this patient is suffering from depression, related to her divorce and the death of her daughter. Her needs include counseling, detox, and peer support. The patient’s education is an asset to her treatment. She has the support system of two sons. Stressors include her divorce due to her alcoholism and the sudden death of her daughter. Her coping methods include alcohol abuse, benzodiazepine abuse, and social isolation. SOAP note S: The patient reports feeling depressed and abusing alcohol and benzodiazepines. She denies suicidal ideation. O: The patient is well dressed, clean, pleasant, and cooperative. Her thought process is coherent with no ambivalence. The patients affect is calm and her appropriateness of mood to thought is normal. There is no depersonalization. The patient does not appear to be delusional, obsessive, or display ideas of reference. She is oriented to person, place, time, and situation. Vital signs are obtained and are all within normal limits. The patient denies any pain. A: The patient is suffering from depression related to her divorce and the death of her daughter. She could benefit from an inpatient rehab program. P: Prepare patient for lab draws to obtain baseline values, presence of drugs of abuse, and medical clearance. A call to the Georgia Crisis Access Line is anticipated for placement of the patient in an inpatient detoxification/rehabilitation program. Referral to grief counselor is also a possibility. References Jarvis, C. (2012). Physical Examination and Health Assessment [VitalSouce bookshelf version]. Retrieved from http://digitalbookshelf.southuniversity.edu/books/978-1-4377-0151-7/outline/5

Plan For Development Of Human Capital

The staff development and leadership training models and programs of Clark County School District includes various aspects like Specific goals for student achievement, Time-bound goals for student achievement, Strong, internal evaluation practices and Time and Opportunity. (Wiedemann, 2006, 6) But from the perspective of modern Human Resource and development there are still rooms for improvements. The main aim of an able leader is to produce confident, independent learners and support staffs thorough a capacity for self assessment.The first of these factors deals with spiritual dimension of the leaders in the context and perception of their students and support staffs. The second factor deals with physical dimension where the focus is mainly laid down on the classroom environment. The third factor is the instructional dimension where the teaching skills of the teachers are taken into consideration. Lastly there is the factor of managerial dimension which is focused on dealing with ad dressing student behavior. (Finnis, 2003)To maintain standards in educational tolerance and sensitivity, we must learn about each student individually. This would be for their benefit to not only realize their goals and aspirations but to know their potential limitations and help them in the discovery of methods toward surpassing those limitations in order to gain access to their aspirations. Professors must also provide the students the outside methods toward attaining confidence in their ability to learn new skills in forwarding their education.Consistent teaching and learning is managed in order to improve attainment resources for teaching and learning in the form of revision guides, coursework help, lesson plans, worksheets, tasks and links to other sites. (Zimmerman, 2002) This has often resulted in improved consistency in teaching and would also have enabled students’ access to useful materials encouraging independent learning. It should also be mentioned that Leaders a nd the aspect of leadership must be efficient and intelligent.Let us take the example of Peters and Waterman, who in â€Å"In Search of Excellence† thought of â€Å"being visible† and â€Å"management by walkabout†. The dexterity and expertise of managers should support the endeavours of the Staffs. Staffs should feel that they are guided by the managers in perusing their duties. By sound management techniques the ambitions of participative leadership and the human relations school can be achieved. (Wright, 2004)In general it can be stated that strategies followed by the school are to EXPAND its student and staff base and enhance the moral by pursuing multimedia opportunities, DELIVER an award-winning level of excellence, building public interest, trust and pride, PROVIDE vigorous leadership and support in the institution, INSTILL an environment of internal and external excellence in customer service, EMPOWER and recognize each staff's unique contribution, ACHIE VE the highest standards of quality, IMPROVE motivation strength and thus build up a considerable level of human capital.  (Berkowitz, 2000)In conclusion it should be the main aim to produce confident, independent learners thorough a capacity for self assessment. In this manner gaining independence in their education and the capacity to achieve will further their aspirations toward higher goals.Providing a baseline for their understanding and ability to interact with them and then first ascertaining their learning level prior to assigning the individual goals as well as the overall goals for each individual student is an important step toward gaining understanding and the capacity for learning. Taking the steps outlined in the Classroom Strategy and adapting them to the differentials provided by the learning styles of each student is an important aspect for consideration and would in fact manage to be one of the goals set to achieve as a teacher. (Manning, 2003) References: Berkowitz L; (2000); Leadership and Implementations: Findings and Enactment. New Haven and London: Yale University Press. Finnis, J. 2003. Fundamentals of Leadership; Georgetown University Press Manning, Schissler Susan. (2003). Ethical Leadership in Human Services: A Multi-Dimensional Approach, New York: Allyn and Bacon. Wiedemann, Denise; 2006; District School Improvement – Amao Plan; Clark County School District; Las Vegas: Nevada; retrieved on 28.06.2007 from http://ccsd.net/schools/pdf/DSIP2006-full.pdf Wright, Robert; 2004; The Moral Animal: why we are the way we are. Little, Brown & Co Zimmerman, S; (2002); Introduction to Management Principals; National Book Trust

General Education Essay

AUB is committed to offering its students a broad undergraduate liberal arts education that enables them to acquire the analytical skills and habits of life-long learning that they will need to compete successfully in the twenty-first century. The General Education distribution requirements are intended to expose students to a range of intellectual experiences during their time at AUB. We want to give our students the opportunity to make choices and to question and test what they believe are their career goals and their intellectual interests. In addition to courses in their academic majors and the opportunity to take minor concentrations in specific fields, all AUB students must take a minimum of 33-36 credits of general education requirements distributed in the following fields: †¢ †¢ †¢ †¢ †¢ †¢ 3-6 credits in English Communication Skills through English 204 (English 206 in FEA). 3 credits in Arabic Communication Skills (except those formally exempted) 6 credits in Natural Science. 12 credits in Humanities. 6 credits in Social Science. 3 credits in Quantitative Thought. We believe that a student who has chosen to follow a course of study at AUB leading to a degree in a professional field such as engineering should be exposed to the humanities and social sciences. By the same token, a student who plans to major in history should have the opportunity to take science courses and to work in a lab. While being exposed to various fields of knowledge, we also want our students to have the opportunity to experience different modes of learning (lectures, seminars, labs, and independent research projects). Different modes of analysis are designed to enhance students’ verbal and interactive skills (seminars), writing and analytic skills (research projects), and hands-on experimental skills (laboratories). These distribution requirements may be met by either required or elective courses. Humanities and Social Sciences courses are divided into two lists: List I and List II within each domain. Students are required to select their courses as follows: †¢ †¢ †¢ †¢ Two Humanities courses from Humanity List I. (FAS Students are required to select CVSP courses) Two Humanities courses from either Humanities lists I and II. One Social Science course from Social Sciences List I. One Social Science course from either Social Sciences lists. 1 In addition, No more than two courses from the student’s major may fulfill the Humanities requirement, no more than one course from the student’s major may fulfill the Social Science requirement, and no more than one course from the student’s major may fulfill the Natural Science requirement. Students who are exempted from Arabic are required to take a Humanity or a Language course instead, unless their Faculty requires otherwise. Students who cannot fulfill the Arabic Communications Skills requirement will be asked to sit for an Arabic Placement Test. According to the result, they may take ARAB201A in replacement to the Arabic Communications Skills requirement. FAS requires that a minimum of six credits in Humanities must be taken from CVSP courses 201-208. FAS Students must complete one course from each of the two CVSP sequences; that is, one course from Sequence I followed by one course from Sequence II. The list of approved General Education courses will be updated regularly on the Registrar’s Office website. Arabic Communication Skills Courses: ARAB 201A, ARAB 201B, ARAB211, ARAB212, ARAB 221, ARAB225, ARAB 227, ARAB 228, ARAB 229, ARAB230, ARAB 231, ARAB232, ARAB234, ARAB235, ARAB236, ARAB 237, ARAB238, ARAB 243, ARAB 245, ARAB 246, ARAB249, ARAB 251J, ARAB252C, ARAB290. English Communication Skills Courses ENGL 203, ENGL 204, ENGL 206, ENGL 208 Humanities List I: AMST : AMST 215, AMST 230, AMST 240, AMST 275L, AMST 275F, AMST 275M, AMST 275N, AMST 275O, AMST 275R, AMST 275S, AMST276J, AMST276K, AMST276L, AMST276M, AMST276P ARAB 201B, ARAB 230, ARAB 232, ARAB 233, ARAB 234, ARAB 235, ARAB 238, ARAB 239, ARAB 240, ARAB 243, ARAB 247, ARAB 251 ARCH 121, ARCH 122, ARCH 223, ARCH 224 AROL 201, AROL 212, AROL 214, AROL 217, AROL 219, AROL 222, AROL 225, AROL 226, AROL 231, AROL 235I, AROL 235J, AROL235K ARAB : ARCH : AROL : 2 CVSP Sequence I : CVSP 201, CVSP 202, CVSP 205,CVSP 207A, CVSP 207C, CVSP207E, CVSP 207H, CVSP 207R,CVSP207I, CVSP295L CVSP Sequence II: CVSP 203, CVSP 204, CVSP206, CVSP 208C, CVSP 208D, CVSP 208F, CVSP 208G, CVSP 208H, CVSP 208J, CVSP208K, CVSP208L CVSP: CVSP 212, CVSP 215, CVSP 216, CVSP 217, CVSP 250, CVSP251, CVSP295O ENGL: ENGL 201, ENGL 207, ENGL210, ENGL 216, ENGL 217, ENGL219, ENGL 221,ENGL 224, ENGL 225, ENGL226, ENGL 227, ENGL 236, ENGL240, ENGL 244D, ENGL 242 , ENGL 243, ENGL 244H, ENGL 244I, ENGL 246, ENGL 249, ENGL 251 FAAH: FAAH 227A, FAAH 227B, FAAH 227C,FAAH 228A, FAAH 229A, FAAH229B, FAAH 229C, FAAH229E , FAAH238, FAAH 232, FAAH 247, FAAH 265, FAAH/TH270 HIST: HIST 201, HIST202, HIST214, HIST 212, HIST 217, HIST 218, HIST 220, HIST220B, HIST 225, HIST 226, HIST 227, HIST 234, HIST 237, HIST 238, HIST 245, HIST 251, HIST 257, HIST 258AE, HIST 258AG, HIST258AH, HIST 258AI, HIST 258AJ, HIST 258AK, HIST 258B, HIST 259, HIST262 PHIL: PHIL 201, PHIL 205, PHIL 210, PHIL 213,PHIL214, PHIL217, PHIL 218, PHIL 222, PHIL 223, PHIL 230, PHIL 231, PHIL 232, PHIL 249, PHIL 252F, PHIL 256B. OTHERS: LDEM201, PSPA 210, SOAN207/ MCOM 202, MCOM280, SOAN225, SOAN 238A/ MCOM 291 List II: AMST : ARAB : AROL : ENGL: FAAH: HIST: PHIL: OTHERS: AMST240, AMST 276I, AMST276N AMST276O, AMST275P, AMST275T, AMST275U,AMST276Q ARAB 216,ARAB 231,ARAB 236,ARAB 246, ARAB290 AROL 211, AROL 213, AROL 215, AROL 216, AROL 223, AROL 224, AROL 235F, AROL 235L ENGL 205, ENGL 211, ENGL 212, ENGL 213, ENGL 214, ENGL 215, ENGL 218, ENGL 222, ENGL 223, ENGL 229, ENGL 233, ENGL 237, ENGL239, ENGL241, ENGL 244S, ENGL 248A, ENGL 250, ENGL 252 , ENGL 253. FAAH229D, FAAH 235, FAAH 240, FAAH 241, FAAH 244, FAAH 245,  FAAH 261, FAAH262, FAAH265. HIST258AD, HIST258AM, HIST 260,HIST261 PHIL 206, PHIL 209, PHIL216, PHIL 221, PHIL 251, PHIL251D, PHIL252G, PHIL256C, PHIL257B, PHIL 260, PHIL 260G, PHIL 260E, PHIL 260F, PHIL 262C, PHIL310, PHIL312/3 BUSS 215, EDUC 228, EDUC 229, EDUC 290C, ENGM504, LDEM260,MCOM204, PSPA 216, PSPA 217, SOAN215, SOAN217, SOAN243E. Social Sciences 3 List I: ECON: EDUC: PSPA: PSYC: SOAN: OTHERS: ECON 211, ECON 212, ECON 217 EDUC 215, EDUC 223,EDUC290K PSPA 202, PSPA212, PSPA218, PSPA222, PSPA 238 PSYC 202 SOAN 201, SOAN 203, SOAN 204/ MCOM 201, SOAN 205/ MCOM 203, SOAN 206/ MCOM 240, SOAN 210, SOAN213, SOAN221, SOAN 227,SOAN 228/ MCOM 220, SOAN 229/ MCOM 221, SOAN 230 MCOM 250, SOAN 231/ MCOM 251, SOAN 233/ MCOM 260, SOAN 236/ MCOM 241, MCOM242, MCOM252, SOAN 240, SOAN 241, SOAN 243/ MCOM 261, MCOM281, SOAN 290I, SOAN 290L ARCH 331, AGSC 212, AGSC 213, GRDS231, HBED/HPCH200, HBED/HPCH 201, MNGT 215, ENGL 230, ENGL235. List II: ECON: EDUC: PSPA: SOAN: OTHERS: ECON 203 EDUC 211, EDUC 218, EDUC 230 PSPA 201, PSPA 213, PSPA 221 SOAN 207/ MCOM 202, SOAN 232, SOAN 234/ MCOM 230, SOAN 235/ MCOM 231, SOAN 242, SOAN 245, SOAN 290/ MCOM 290. ENGL 247, HBED/HPCH 203, HMPD 204, HMPD 251. Natural Sciences BIOL: CHEM: GEOL: PHYS: OTHERS: BIOL 200, BIOL 201, BIOL 209, BIOL 210, BIOL 290EE CHEM 200, CHEM 201, CHEM 202, CHEM 204, CHEM 205, CHEM 207, CHEM 208, CHEM 209 GEOL 201, GEOL 205 PHYS 200, PHYS 204, PHYS 205, PHYS 210, PHYS  211, PHYS 212 ARCH151,AGSC203,AGSC204, AVSC 220, AVSC 224, AVSC281, BIOC 246, ENHL 220, LDEM 217, PHYL246. Quantitative Thought CMPS: MATH: OTHERS: CMPS 200, CMPS 206, CMPS 209 MATH 201, MATH 203, MATH 204, MATH 211, MATH 218 EECE 230, EPHD 203, EPHD 213, NURS 203, PHIL 211, PHIL220, STAT201, STAT210, EDUC271, PHIL256.

Effectiveness of Technology - 685 Words

Effectiveness of Technology Andrew Kelly University of Phoenix BUS/318 March 21, 2011 Effectiveness of Technology In every aspect of business today, technology is the core to a company’s success. Technology has altered the way managers of retail operate. Technology allows for communication, operations, and the planning of strategic aspirations. Technology’s Impact on the Role of Retail Managers Working as a retail manager requires great more knowledge than retail managers before them. As a retail manager or a manager period, knowledge of computers is a must. It is not simply turning a computer on and off. It is like running the whole†¦show more content†¦Retailers need to be able to better track consumers and sales information. Transparency between systems is a challenge that would help decrease this challenge. Gathering too much customer information is harmful because there is too much information to store. Retailing is a dangerous business, and the Internet and technology affect strategy and success in this industry more rapidly than perhaps any other industry. Beyond the classic forces like the global economy and razor-thin margins, competition in retail can now come from anywhere across the globe at any time. Customers are global customers, and social media and networking are driving consumer preference and uptake in a dizzying fashion. Even traditional luxury buyers are rethinking their spending patterns and seeking new value alternatives. 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