Answered step-by-stepI. Initial Presentation: Susan Jones is
Answered step-by-stepI. Initial Presentation: Susan Jones is a 42-year-old… I. Initial…I. Initial Presentation: Susan Jones is a 42-year-old… I. Initial Presentation: Susan Jones is a 42-year-old African-American female with a past medical history of diabetes mellitus type II. She works in a manufacturing plant in her hometown. While at work, she feels faint and has to sit down. The occupational nurse is contacted to assess her. Susan Jones is married and a mother of two elementary age children. She has been employed in her current position for two years. 1. What data from the present problem are RELEVANT and must be NOTICED as clinically significant by the nurse? RELEVANT Data from Present Problem: Clinical Significance: 42 years old, a female She works in a manufacturing plants in her hometown Past medical history of diabetes mellitus IIWhile at work she feels faint and has to sit down As the nurse responsible for this patient, you promptly review the medical history and note that she has NKDA. This is her PMH and current home medications documented in the employee’s medical record: What is the RELATIONSHIP of the past medical history and current medications? Why is your patient receiving these medications? Complete the medication tracking sheets on each medMedical History (PMH): Hypertension GERD Type II diabetes mellitus I. Initial Presentation: Susan Jones is a 42-year-old African-American female with a past medical history of diabetes mellitus type II. She works in a manufacturing plant in her hometown. While at work, she feels faint and has to sit down. The occupational nurse is contacted to assess her. Susan Jones is married and a mother of two elementary age children. She has been employed in her current position for two years. 1. What data from the present problem are RELEVANT and must be NOTICED as clinically significant by the nurse? RELEVANT Data from Present Problem: Clinical Significance: 42 years old, a female She works in a manufacturing plants in her hometown Past medical history of diabetes mellitus IIWhile at work she feels faint and has to sit down As the nurse responsible for this patient, you promptly review the medical history and note that she has NKDA. This is her PMH and current home medications documented in the employee’s medical record: What is the RELATIONSHIP of the past medical history and current medications? Why is your patient receiving these medications? Complete the medication tracking sheets on each medMedical History (PMH): Home Medications: Hypertension GERD Type II diabetes mellitus ASA 81 mg PO daily Lisinopril 40 mg PO daily HCTZ 25 mg PO am Metformin 875 mg PO BID Omeprazole 20 mg PO daily ASA 81mg PO daily is taken to prevent heart attack Lisinopril 40mg is taken for lowering blood pressure and prevention of stroke (to treat hypertension)HCTZ 25mg PO am is taken to lower blood pressure ( To treat hypertension)Metformin 875mg PO BID is used to treat diabetes Omeprazole 20 mg PO daily is used to treat GERD II. Present Problem: Susan had an exercise stress test six months ago and was evaluated by a cardiologist. She was referred by her primary care provider due to risk factors of stress, obesity, hypertension, smoking, diabetes mellitus and a positive family history of coronary artery disease. Susan had a negative exercise stress test, but was frightened by the experience. In the past six months, she has stopped smoking, began exercising and lost 20 pounds. She has eliminated many processed foods in her diet and has adopted a “clean eating” approach. What data from the present problem are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Family history of coronary artery diseaseHypertension Diabetes mellitus Recognizing a potential problem, you collect a full set of vital signs and complete a nursing assessment: Current VS: P-Q-R-S-T Pain Assessment: T: 98.4 F/36.9 C (o) Provoking/Palliative: Reports no pain at this time P: 90 (reg) Quality: R: 15 (reg) Region/Radiation: BP: 100/70 Severity: O2 sat: 99% room air Timing: Blood Glucose finger stick: 101 What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Current Assessment: GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, sitting in chair NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants GU: Reports no changes in urinary habits. Urine reported as clear, non-odorous, not painful, no burning, frequency of urination INTEGUMENTARY: Skin warm, but diaphoretic, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds. Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Interpreting relevant clinical data, identify actual and potential nursing diagnoses. What additional data is needed to identify Likely Problems: Additional Clinical Data Needed: Recognizing that a problem is present, use SBAR to concisely communicate your concern to the primary care provider: Situation: Name/age: BRIEF summary of primary problem: Background: RELEVANT past medical history: RELEVANT background data: Assessment: Most recent vital signs: RELEVANT body system nursing assessment data: RELEVANT lab values: Patient response: INTERPRETATION of current clinical status (stable/unstable/worsening): Recommendation: Suggestions to advance the plan of care: Results of lab data: 12 Lead EKG is normal sinus rhythm-rate 72. The following diagnostic test results just posted in the electronic health record: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 7.0 13.1 250 55 0 Most Recent: 8.5 12.8 225 65 0 Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 135 3.4 105 0.9 Most Recent: 137 3.7 117 0.85 Urinalysis + UA Micro Color: Clarity: Sp. Gr. Protein Nitrite LET RBCs WBCs Bacteria Epithelial Current: dark yellow clear 1.025 neg neg neg neg neg neg neg Misc. Hgb A1c Urine hCG Current: 6.4 Neg Most Recent: 6.6 n/a Utilizing the NUR 110 care plan worksheet, develop a care plan for one priority nursing diagnosis that is appropriate for this client. ASA 81 mg PO daily Lisinopril 40 mg PO daily HCTZ 25 mg PO am Metformin 875 mg PO BID Omeprazole 20 mg PO daily II. Present Problem: Susan had an exercise stress test six months ago and was evaluated by a cardiologist. She was referred by her primary care provider due to risk factors of stress, obesity, hypertension, smoking, diabetes mellitus and a positive family history of coronary artery disease. Susan had a negative exercise stress test, but was frightened by the experience. In the past six months, she has stopped smoking, began exercising and lost 20 pounds. She has eliminated many processed foods in her diet and has adopted a "clean eating" approach. What data from the present problem are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Family history of coronary artery diseaseHypertension Diabetes mellitus Recognizing a potential problem, you collect a full set of vital signs and complete a nursing assessment: Current VS: P-Q-R-S-T Pain Assessment: T: 98.4 F/36.9 C (o) Provoking/Palliative: Reports no pain at this time P: 90 (reg) Quality: R: 15 (reg) Region/Radiation: BP: 100/70 Severity: O2 sat: 99% room air Timing: Blood Glucose finger stick: 101 What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Current Assessment: GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, sitting in chair NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants GU: Reports no changes in urinary habits. Urine reported as clear, non-odorous, not painful, no burning, frequency of urination INTEGUMENTARY: Skin warm, but diaphoretic, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds. Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Interpreting relevant clinical data, identify actual and potential nursing diagnoses. What additional data is needed to identify Likely Problems: Additional Clinical Data Needed: Recognizing that a problem is present, use SBAR to concisely communicate your concern to the primary care provider: Situation: Name/age: BRIEF summary of primary problem: Background: RELEVANT past medical history: RELEVANT background data: Assessment: Most recent vital signs: RELEVANT body system nursing assessment data: RELEVANT lab values: Patient response: INTERPRETATION of current clinical status (stable/unstable/worsening): Recommendation: Suggestions to advance the plan of care: Results of lab data: 12 Lead EKG is normal sinus rhythm-rate 72. The following diagnostic test results just posted in the electronic health record: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 7.0 13.1 250 55 0 Most Recent: 8.5 12.8 225 65 0 Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 135 3.4 105 0.9 Most Recent: 137 3.7 117 0.85 Urinalysis + UA Micro Color: Clarity: Sp. Gr. Protein Nitrite LET RBCs WBCs Bacteria Epithelial Current: dark yellow clear 1.025 neg neg neg neg neg neg neg Misc. Hgb A1c Urine hCG Current: 6.4 Neg Most Recent: 6.6 n/a develop a care plan for one priority nursing diagnosis that is appropriate for this client. Health ScienceScienceNursing Share Answer & Explanation Get youranswered by our Expert TutorsOur tutors typically answer within 15-30 minutesGet answer Ask Expert Tutors Let our expert tutors help you get unstuck 24/7. 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