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- History of Present IllnessTwo hours prior to admission, at 4am, patient Jake was jogging along LacsonStreet when a group of bystanders had approached him and stabbed himmultiple times. He claims that he does not know these people. He tried todefend himself resulting to multiple injuries in his upper extremities where hehad 3 lacerations, cheeks where he had a laceration on the left, right chest andright upper abdominal quadrant. Medications: Tetanus Toxoid 0.5 ml/amp, give 1 ampule via deep IM, now at right deltoid ATS 3,000 IU/amp, give 1 ampule via deep IM, now, ANST at left deltoid Piperacillin Tazobactam 2.25 grams/vial, give 1 vial via IV drip to run for 3 hours Q8H Tramadol 50 mg/amp, give 1 ampule very slow IV push now then Q6 PRN for pain Omeprazole 40 mg/amp, give 1 ampule via IVTT ODHS Latest Vital Signs : Blood Pressure: 90/60 mmHg Heart Rate: 121 bpm Respiratory Rate: 26cpm Temperature: 37.3 ⁰C Pain Scale: 10/10 NURSING CARE PLANHistory of patient: “A 12 year old girl presented to the A&E department at a weekend, with pain on movement of the left shoulder. Initially there was no history of trauma. Although when seen in clinic, she mentioned having played rugby a few days before the onset of pain.” Physical examination: “…revealed minimal tenderness above the clavicle and painful shoulder movement.” Imaging: Radiography was performed, see Figure 1. “The initial radiograph was reported as no bony injury, the ‘fracture’ diagnosed [by the radiologist] as an anomalous articulation.” Treatment: a collar and cuff (Figure 2) and analgesia. Follow up: “Another radiograph [Fig 3] six weeks later showed callus around the ‘anomalous articulation’, which supported our earlier diagnosis of fracture [of the first rib]. She…has had an uneventful recovery.” In other words, the radiologist got this wrong, when s/he diagnosed an “anomalous articulation” on the first x-ray. This patient did not break any…KINDLY PROVIDE 2 SIGNIFICANT DIFFERENCES EACH TERMS
- Immediately following the insertion of an intercostal catherter, list five nursing assessments with rationale you would perform on the patient.Stroke patient was administered four ounces of food thickener, orally. Enter code(s)A nurse is assisting with the care of a client following an abdominal aortic aneurysm resection. List five (5) actions that will be required to care for this client during the first 4-hours of the postoperative period.
- Given the following Doctor’s Orders, Interpret or Translate the underlined word(s) using the correct medical terms or abbreviations:Dr. Falcone is an emergency department physician who has just called the OR desk concerning a patient. He tells the charge nurse, “we have a 23-year old male patient status post MVA, no airbag deploy, moderate facial injuries, bruising and swelling about the left eye, diplopia and enophthalmos. CT confirmes left orbital floor fracture. Hell be up in 10 minutes.” If the fracture isn’t stable after being reduced, what instrument tray should the CST have available?Outpatient—Ambulatory Surgery (Musculoskeletal) Patient Name: Loretta Michaels Diagnosis: Torn medial collateral ligament of the left knee Procedure: Repair of medial collateral ligament, left knee A 24-year-old patient twisted her knee while attempting a new ski maneuver. The patient underwent various forms of noninvasive treatment, for which there was only limited recovery. Due to the patient's active lifestyle, surgical repair was indicated. The patient underwent outpatient surgical repair of the medial collateral ligament of the left knee. She was suggested for a derotation knee brace and advised to follow up with her primary care provider to begin physical therapy to strengthen the knee. Instructions: Assign ICD-10-CM, CPT, and HCPCS level II codes for this case, including ICD-10-CM external cause codes. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code.
- Mr. Wright is recovering from abdominal surgery. When thenurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he hasconsistently refused his pain medication. What would be apriority nursing diagnosis for this patient? a. Acute Pain related to fear of taking prescribed post-operative medications b. Impaired Physical Mobility related to surgical procedurec. Anxiety related to outcome of surgeryd. Risk for Infection related to surgical incisionMrs. Reyes, 71 years old, while doing household chores has fallen her front steps. She had a large bruise on her right temple and her right face and is brought to the emergency department by ambulance. Upon assessment her vital signs are HR 125; BP 110/76; RR 16; T 37.6°C; and pain 4/10. Document a brief neurologic exam on this patient.