Clinical Scenario:

REASON FOR CONSULTATION: Desaturation to 64% on room air 1 hour ago with associated shortness of breath.

HISTORY OF PRESENT ILLNESS: Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.

REVIEW OF SYSTEMS:

Constitutional:  Negative for diaphoresis and chills. Positive for fever and fatigue.

HEENT: Negative for hearing loss, ear pain, nose bleeds, tinnitus. Positive for throat pain secondary to her laryngeal cancer.

Eyes:  Negative for blurred vision, double vision, photophobia, discharge or redness.

Respiratory: Positive for cough and shortness of breath. Negative for hemoptysis and wheezing.

Cardiovascular: Negative for chest pain, palpitations, orthopnea, leg swelling or PND.

Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.

Genitourinary: Negative for dysuria, urgency, frequency, hematuria and flank pain.

Musculoskeletal: Negative for myalgias, back pain and falls.

Skin: Negative for itching and rash.

Neurological: Negative for dizziness, tingling, tremors, sensory changes, speech changes.

Endocrine/hematologic/allergies: Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.

Psychiatric: Negative for depression, hallucinations and memory loss.

PAST MEDICAL HISTORY: Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric bypass surgery, which she had approximately 3 years ago. Laryngeal cancer Hypertension Hypercholesterolemia Pneumonia Arthritis Hypothyroidism Atrial fibrillation Acute renal failure Chronic kidney disease, stage IV – on 07/30/2013 a renal biopsy was completed, which showed focal acute tubular necrosis and patchy tubular atrophy, moderate to severe interstitial fibrosis with patchy acute and chronic interstitial nephritis, normal cellular glomeruli with no white microscopic evidence of a primary glomerulopathy. Baseline creatinine is 1.9. Peptic ulcer disease Skin cancer Anemia Osteoporosis

PAST SURGICAL HISTORY: Laparoscopic gastric bypass – 3 years ago Closure of mesenteric defect. Radical neck resection on -3 months ago

FAMILY HISTORY: Mother has diabetes diagnosed at age 55 and high blood pressure. She is deceased. Father had heart disease diagnosed at age 60. He is deceased. She had a sister with diabetes, thyroid disease, CKD, on dialysis, with unknown etiology.

SOCIAL HISTORY: She denies any smoking or alcohol use. She denies any drug use.

MEDICATIONS: Calcitriol 0.5 mcg PO every other day Vitamin B12 2500 mcg sublingual every Monday and Thursday Docusate sodium 100 mg PO BID Fentanyl patch 100 mcg every 72 hours Gabapentin 800 mg PO BID Levothyroxine 50 mcg daily Multivitamin 1 PO Daily Oxybutynin 5 mg PO BID Hydrocodone 5/325 1-2 tablets every 6 hours PRN pain

ALLERGIES: SHE IS ALLERGIC TO CIPRO, WHICH CAUSES URTICARIA AND HIVES, CONTRAST DYE, HONEY AND BEE VENOM, ADHESIVE, AND SULFAS, WHICH CAUSE HIVES.

PHYSICAL EXAMINATION:

Vital signs: 38.6, 120, 22, 138/38, 64% on room air. O2 sat of 91 on 4 liters nasal cannula.

Constitutional: She is somnolent. Oriented to person and place. Appears ill and mildly dyspneic.

Head: Normocephalic and atraumatic. Nose: Midline, right and left maxillary and frontal sinuses are nontender bilaterally.

Oropharynx: Clear and moist. No uvula swelling or exudate noted.

Eyes:  Conjunctivae, EOM and lids are normal. PERL. Right and left eyes are without drainage or nystagmus. No scleral icterus.

Neck: Normal range of motion and phonation. Neck is supple. No JVD. No tracheal deviation present. No thyromegaly or thyroid nodules. No cervical lymphadenopathy noted bilaterally.

Cardiovascular: rapid rate, S1 and S2 without murmur or gallop. Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally.

Chest: Respirations are regular and even with mild dyspnea.

Lungs are coarse and with some rales posterior bases.

Abdomen:  Soft. Bowel sounds are active, nontender, no masses noted. No hepatosplenomegaly noted. No peritoneal signs.

Musculoskeletal: Full range of motion of the bilateral shoulders, wrists, elbows.

Neurologic: Somnolent. Cranial nerves II-XII are intact.

Skin: Warm and dry.

Psychiatric: Mood and affect are normal. Calm and cooperative. Behavior, judgment is intact.

LABORATORIES AND DIAGNOSTICS:

WBC 7.2, Neutrophil 63%

Creatinine 2.5 mg/dL, BUN 45 mg/dL, Na 144 mEq/L, Potassium 4.4 mEq/L, Total Bilirubin is 0.9 mg/dL, Platelets 100,000

BNP 242 pg/mL

Lactate 1.0 mg/dL

All other labs are unremarkable

Chest x-ray: Right lower lobe infiltrate

EKG: NSR, no ST or T wave changes

Questions: Develop a list of differential diagnoses specific to hypoxia. What are the four most important differential diagnoses to consider?  Based on the available clinical data, what is the most likely diagnosis for the hypoxia? What other acute (new) diagnoses do you need to treat? List them all below. There are a total of 4 diagnoses.  What additional diagnostic tests should be ordered to further evaluate this patient?  Write an assessment and treatment plan for all four acute diagnoses you identified in question 2. Each diagnoses must have a complete treatment plan. All written orders must have complete instructions. For instance, a medication order must have the name, dose, frequency, and route. Lab orders must include the lab name and frequency. If an order should be done now, stat, urgent or routine that also should be indicated.  What is the most appropriate level of care for this patient? What physician specialty or other interprofessional consults should be ordered? What anticipatory guidance/patient education should you provide to the patient?

 NURN 3103 Theorist Paper Instructions and Grading Rubric 

Choose a nursing theorist/theory relevant to your nursing practice. Do not use non-nursing theorists (such as Maslow, Erikson, Piaget, Bloom, etc). Click on the “LINK”, and go to the website. Choose your theorist/theory: Link (Links to an external site.)Links to an external site.

You may NOT choose Florence Nightingale.

Guidelines for your paper:

Introduction: Provide a brief description of the theorist’s framework. You may use your textbook and other sources for this section. The description should be as much as possible, in your own words. Be careful not to plagiarize your information. Remember all direct quotes are to be cited, with author, date, and page number. Description should include all major aspects of the theory, not just one part or concept. You may use bullet points if there are several aspects of your theory to describe Limit the number of quotes in your paper. A paper of quotes is not a paper authored by you. Do NOT include a biography of the theorist. This paper is about the theory itself, not the theorist. (8 points)
Application of theory to Clinical Scenario: (8 points total for this section)
Describe a specific clinical scenario (interaction with patient and/or family) that you have experienced in your practice.
Clearly correlate the identified nursing theory to the clinical situation, describing how the theory and its specific concepts apply specifically to the situation. Make sure to include basic concepts related to the theory as well as a clear depiction of the implications for nursing practice.
All important concepts must be clearly applied to the situation.
Evidence of understanding theory in guiding care throughout the nursing process, not just one segment of the process.
Conclusion: Define the benefits of utilizing this specific nursing theory when examining patient care or patient issues. (4 points)
APA, References, & Paper Requirements:(5 points total for this section)
Follow APA style for formatting. APA includes, but is not limited to the title page, headings, running heads, subheadings, in text referencing, and reference page. The paper will be evaluated on grammar, spelling, and professional writing. All formal papers should have an introduction, body, and conclusion. No abstract required.
The paper should be NO LESS than 3 pages and NO MORE than 5 pages double-spaced. Page counts do not include the title page and the reference page. 
Include a minimum of 3 professional nursing old.journal references less than 10 years old. You may also use your textbook. No websites should be used unless pre-approved by the instructor.
Submit the paper to the assignment drop box by the due date. The paper must submitted electronically through Canvas. 
Total points for paper = 25 points

Criteria

High Quality
Satisfactory Quality
Low Quality

Introduction
-Theory presented is accurate, current and all major components described clearly and completely.
-theory presented is limited in depth but is accurate, current and relevant with the major components included.
Theory description is unclear. Limited depth noted. .
-No integration of sources noted.
Not addressed

Application of theory
-clearly describes a clinical example
– Clearly correlates the specific theory chosen to this scenario.
-identifies elements and concepts of the theory that applies
-evidence of theory understanding

– briefly describes a clinical example with limited detail
– attempts to apply the specific theory chosen to this scenario however relationship to situation unclear
-identifies concepts of the theory that applies however not integrated.
– unclear if understanding evident. -Paper more about listing of theory components

-clinical scenario not clearly described.
-theory named but concepts not discussed.
-limited to no application of the concepts to this situation.
Not addressed

Conclusion
Clearly Defines the benefits of utilizing this specific nursing theory when examining patient care or patient issues
Attempts to define the benefits of utilizing this specific nursing theory when examining patient care or patient issues, however, unclear
Minimally addresses the benefits of using this theory. Speaks only to theory globally.
Not addressed

Grammar,
Spelling,
APA

Specific criteria
Consistent correct use of the rules of grammar usage, punctuation, and spelling
-correct APA
-3 -5 pages
-3 professional journal references
Consistent correct use of the rules of grammar, punctuation, and spelling, with a few minor errors.
-APA errors noted
-references not all from professional journals

Several grammatical, spelling and punctuation errors
-many apa errors.
-did not follow page limits
-did not meet reference requirements
Not addressed 

What is the main issue for your organization in addressing a solution to evidence-based nursing practice? Discuss what might be the first step in addressing and resolving this issue.