What medical diagnosis is your patient taking this drug for?

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Learning Goal: I’m working on a nursing case study and need a sample draft to help me learn.Course Project Case Study Mrs. Ingalls is an 86-year-old female Caucasian resident in a long-term care facility. After several falls, she was admitted six months ago due to not being able to adequately care for herself. Her husband and daughter visit daily and is very involved in her care. Mrs. Ingalls speaks Italian as a first language but is proficient in English. She is Roman Catholic and attends mass in the facility weekly. She is a retired secretary. She has a medical history of gestational diabetes (40 years ago), hypertension, CHF, hypothyroidism, shingles, and depression. Her husband was recently diagnosed with lung cancer and will be undergoing chemotherapy over the next few months. Orders include: Do not resuscitate NAS diet Ambulate with gait belt and 1 standby assist Fall precautions PT/OT daily Medications Include: Furosemide 40 mg PO daily Potassium Chloride 20 meq PO BID daily with meals Levothyroxine 75 mcg PO daily Metoprolol ER 100 mg PO daily Celexa 20 mg PO daily Course Project Instructions Your project will be submitted as a formal (APA) paper. You will submit this paper in three parts. Use the medication template and the nursing care plan templates below (upload into your paper). *Make sure you follow APA in your paper. ALL APA papers must include an introduction and a conclusion. You must use headings per APA. Cite ALL your sources. Start the reference page, adding to it for each successive part. Make sure it is alphabetized. Put the reference page at the end. Follow the grading rubric for more details. If your paper is not in correct APA format you will lose points. Part 1: 10 Points Medications
Choose 5 primary medications that your patient is taking and complete the information below. Upload this table directly into your paper. The information included below should directly relate to your assigned case study client. Drug Name Trade & generic name, dose, route & frequency Pharmacological & therapeutic drug class & Expected action in the body What medical diagnosis is your patient taking this drug for? How will it help them? Side Effects & Adverse Reactions/ Complications/Top drug interactions Nursing Administration Special Instructions & Assessments Client Education Evaluation of Medication Effectiveness (e.g. Pain Scale)
LABS AND DIAGNOSTIC TESTS Choose five labs or diagnostic tests that might be ordered for your case study client. Note normal results (Rasmussen lab values), expected abnormal values, and what that would signify for your client. Part 1 Grading Rubric Topic Points Medication summary is complete & detailed (5 meds). 5 Laboratory and/or diagnostic tests summary is complete & detailed (5 tests) 5 *Must include title page/reference page/citations or points will be deducted Part 2: 25 points Health Assessment, Health History, and Nursing Diagnoses In this second submission of your Course Project, you will be completing a health history, physical assessment and client interview and determining their nursing diagnoses. This written assignment should include the following: Describe the medical diagnoses of your assigned client (you need to research it). Include the admitting diagnosis as number one and then four other medical diagnoses (for a total of 5). The admitting diagnosis is reason for being in the facility. If post-surgical, include surgery and reason for surgery. The secondary diagnoses include a history of pre-existing medical diagnoses). You need to include 4 secondary diagnoses. For each diagnosis, provide at least a 5-sentence explanation of the pathophysiology of the condition/problem. MAKE SURE YOU CITE YOUR SOURCES.
Write a detailed physical assessment and interview on your case study client. You will have to know what to expect in your client by using the information from #1 above and your case study. You will have to be creative.
5 Nursing diagnoses (only the NDx, you will complete the careplan for week 10). Make sure they are in the correct format. If you give me only the label you will not get any points for nursing diagnoses.
Rubric for Part 2: 25 Points Topic Points Medical history- describe the Pathophysiology of the admitting diagnosis & 4 secondary medical diagnoses (at least 5 sentences per diagnosis) 10 Head to Toe Assessment and client interview 10 Identify 5 priority NANDA nursing diagnoses written in correct format 5 *Must include title page/reference page/citations or points will be deducted Part 3: 35 points Complete Plan of Care on your client (10 points) In this third and final submission of your Course Project, you will be completing the comprehensive care plan. Include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion. This written assignment should include the following: Your Nursing diagnoses from Part 2 (use the table below)
One short term goal and one long term goal per NDx
Four Nursing interventions per NDx . .
Prioritization per Maslow with an explanation and an expected evaluation. Make sure to include a teaching plan in your care plan. Upload the table below into your paper. Reflect on the following in your paper: Which of your nursing diagnoses are priority using Maslow’s Hierarchy of Needs? If you were to implement this plan of care, would you expect any of your short-term expected outcomes met during your shift? Explain. How might you revise your care plan next time to achieve at least one outcome during your shift?
Nursing Diagnoses Use your Assessment data to ID clinical problems Expected Outcomes (S.M.A.R.T.) Specific, measurable, attainable, realistic, & time-oriented (ID a future time or date for reassessment/evaluation) Nursing Interventions What can you, the nurse, do to reach the goal and improve the problem? #1 R.T. A.E.B. The patient will… Short-term goal: Long-term goal: The nurse will… 1. 2. 3. 4. #2 R.T. A.E.B. Short-term goal: Long-term goal: 1. 2. 3. 4. #3 R.T. A.E.B. Short-term goal: Long-term goal: 1. 2. 3. 4. #4 R.T. A.E.B. Short-term goal: Long-term goal: 1. 2. 3. 4. #5 R.T. A.E.B. Short term goal Long term goal 1. 2. 3. 4. Part 3: 35 pts Topic Points Complete Nursing Care plan following instructions above and prioritization using Maslow and how you would evaluate the plan of care 10 Presentation to clinical group (done individually – see below) 15 APA and Mechanics (for all 3 parts) 10

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