B.K. is a 63-year-old woman who is admitted to the step-down unit from the emergency department (ED)
with nausea and vomiting (N/V) and epigastric and left upper quadrant (LUQ) abdominal pain that is
severe, sharp, and boring and radiates through to her mid back. The pain started 24 hours ago and awoke
her in the middle of the night. B.K. is a divorced, retired sales manager who smokes a half-pack of cigarettes
daily. The ED nurse reports that B.K. is anxious and demanding. B.K. denies using alcohol. Her vital
signs (VS) are as follows: 100/70, 97, 30, 100.2° F (37.9° C) (tympanic), Spo2 88% on room air and 92% on
2 L of oxygen by nasal cannula (NC). She is in normal sinus rhythm. She will be admitted to the hospitalist
service. She has no primary care provider (PCP) and has not seen a physician "in years."
The ED nurse giving you the report states that the admitting diagnosis is acute pancreatitis of
unknown etiology. A computed tomography (CT) scan has been ordered, but unfortunately the CT scanner
is down and will not be fixed until morning. However, an ultrasound of the abdomen was performed,
and "no cholelithiasis, gallbladder wall thickening, or choledocholithiasis was seen. The pancreas was not
well visualized due to overlying bowel gas." Admission labs have been drawn; a clean-catch urine specimen
was sent to the lab, and the urine was dark in color.

Please help me write SBAR for this case

Cellular Aberration
1. Risk assessment and screening procedure of Prostate

2. Relevant information based on:
a. Chief complaints
b. Functional patterns
c. Physical examination of patient cellular aberrations

3. Pathophysiologic mechanics of Cellular aberration
a. Solid tumors
b. Liquid tumors

what is unconscious bias and how does it impact health care provision?

Case Scenario for CNS-Brain Cancer

This is a case of a 45-year-old female, smoker, non-diabetic, non-hypertensive who was

having on and off headache for 5 months prior to consult (April, 2015), this is associated

with nausea and vomiting. The headache was becoming recurrent until August of 2015

she decided to consult her doctor. Aside from nausea and vomiting, symptoms include

weakness of the left side of the body and numbness and tingling sensation. Apparently,

complete neurological examination was done and it was unremarkable. A CT scan was

done on Sept 30, 2015 with the following findings:

A contrast-enhanced brain MRI demonstrated a 3 × 3 cm right fronto-parietal resection

cavity surrounded by a 5 × 4 cm area of heterogeneous contrast enhancement extending to the right corona radiata and periventricular white matter with associated

cerebral edema (Fig. 1). The mass was not technically resectable due to location and

biopsy was consistent with GBM (Glioblastoma multiforme), wild-type isocitrate

dehydrogenase and unmethylated O6-methylguanine DNA methyltransferase (MGMT),

with an MIB-1 index of 50% (Fig. 2).

Fig. 1

T1-weighted brain MRI with contrast at the time of diagnosis of radiation-induced

glioblastoma multiforme.

Fig.2Radiation-induced glioblastoma multiforme demonstrating increased cellularity with

marked nuclear atypia, necrosis, and vascular endothelialization.

On January 25th of 2016, the patient underwent surgical therapy, including fronto

parietal craniotomy, with total resection of the tumor. On February 7th of 2016, a

histopathology examination, confirmed a diagnosis of the GBM IV stage.

In February 2017, approximately 13 months after her brain tumor surgery, Patient

Carlota had a follow-up diagnostic work-up, no brain tumor recurrence was found. Due

to the absence of tumor, no radiotherapy was considered, and “watchful waiting” was

recommended including brain imaging studies (CT or MRI) to be repeated every 3

months. Due to the lack of the patient's consent, no chemotherapy was implemented.

During the irradiation period, Patient Carlota had the first seizure episode, and was

started on antiepileptic therapy (Depakine 200 mg a day). she continued this therapy for

the rest of her life. After the radiotherapy, diagnostic follow-up examinations were

conducted every 3 months.

At the beginning of March 2018, tumor recurrence was found, and the tumor was

localized in an upper part of the tumor bed, within the previously irradiated area (its size

was 3.7 cm × 2.6 cm × 2.3 cm). Surprisingly, Patient Carlota had not experienced any

symptoms, and her physical and neurological examinations were unremarkable.

On March 13th of 2019, stereotactic radiotherapy was done, using a single dose of 8 Gy

applied to the area of recurrent tumor was performed. Unfortunately, on follow up

examination, on July 6th of 2018, further progression of the GBM was found, due to the

tumor expansion, resulting in cerebral edema, herniation, and multi-organ failure.

Guide questions:

1. What are the significant assessment findings that you have noted on the case?

2. Based on the case given above, Identify the risk factors related to the case.

3. Trace the pathophysiology of the condition and course of the disease mentioned

on the case. (Connect the signs and symptoms, laboratory and diagnostic

procedures as well as the prioritized problem/ nursing diagnosis)

4. What are your nursing responsibilities related to the laboratory and diagnostic

examination including the procedures and medications?

5. What are the treatments and procedures performed during the course of

hospitalization?

6. Enumerate appropriate discharge plan and health teaching for your patient?

7. Identify at least three (2) priority nursing problems and formulate 2 nursing care

plans with appropriate objective and evaluation of care.( with Scientific Rationale

on the Nursing Diagnosis and Rationale on the Interventions)

CASE STUDY: PARKINSON’S DISEASE

Miss Rose is a 74 year old female, who is a retired widow and lives with her son for the past five years. Both enjoy planting seedlings and own a community agriculture store. She does not suffer with hypertension or diabetes and has an active lifestyle. She is also not known to have any psychiatric illnesses. Over the past six months Miss Rose’s son and herself noticed physical changes and decided to visit her General Practitioner. At her visit she mentioned to the doctor that she was having difficulty rising up from a sitting position after grooming her plants or turning from one table to another when she has customers. Documentation on her clinic file noted that she previously complained of difficulty walking and falling when coming out of bed. She was sent for an X-ray but there were no clinical findings. The physician asked her to describe what happened when she fell. Miss Rose verbalized that when she got up from bed and starting walking she started moving forward and backward then stooped forward with small fast steps and then she fell. Her son mentioned to the doctor that he has noticed that when she is pruning her plants she has abnormal rhythmic movement of the upper and lower limbs. She occasionally has a slight limp and her handwriting has become smaller over the past months. This has stopped her from doing her daily yoga exercises and she has been very disturbed about it. Miss Rose then further explained that the movement started on the distal part of both upper limbs at the same time. She also expressed that during rest she noticed the movement in her limbs and as she started her tasks the movements became more aggravated. Urinary incontinence is also a problem for Miss Rose and she is having difficulty in her swift movements to her bathroom. The patient was later diagnosed with Parkinson’s disease.

After the assessment and interview of Miss Rose the Physician documented the following:

Physical Assessment Vital Signs: BP- 130/74 mmHg Temperature - 36.7 C, Pulse- 78 bpm regular and bounding Respiration- 20 bpm Height- 5ft 7 in Weight- 70 kg Facial expression- Masklike Gait- Shuffling gait with tendency to fall forward and backward CNS Examination Alert and oriented to time, person and place Level of consciousness GCS- 15/15 Sleeping patterns- normal Swallowing gag reflex- normal Cogwheel rigidity present Tremor present Bradykinesia present Dysphonia present Instructions:

a) Briefly discuss the Anatomy and Physiology of this disease.

b) Briefly discuss the pathophysiology of the disease process. .

c) Discuss what home care activities can be implemented to ensure the patient’s health and safety.

d) State the medications used to treat this disease and its therapeutic effects it has on the patient.

A.S. is a 70-year-old white woman who presented to the emergency department because of a 4-day history of increased shortness of breath and generalized weakness. A.S. stated that she has been able to do her daily chores at home independently, but for the past few days, it was getting difficult for her to get around and that she needed to take frequent breaks because she was short of breath and had no energy. She has a long history of heart failure, type 2 diabetes, and hypertension. She is admitted with a tentative diagnosis of acute kidney injury (AKI).

Subjective Data

• Has been having headaches on and off, with nausea and dizziness
• Reported that she had not been taking her medications regularly at home because of “forgetfulness”
• Has not been urinating a lot
• Feels “puffy” in her legs and hands

Objective Data

Physical Examination

• Blood pressure 178/96, pulse 110, temperature 98.9°F, respirations 24, and an oxygenation of 93% on room air
• Alert and oriented to person, place, and time
• Mild jugular venous distention
• Fine crackles in bilateral lower lobes
• Heart rate regular, no murmurs
• Bowel sounds normoactive and present in all four quadrants
• 2+ edema bilateral lower extremities and hands

Diagnostic Studies

• Echocardiogram shows decreased left ventricular function
• Urinalysis: Urine dark yellow and cloudy, protein 28 mg/dL, negative for glucose and ketones, positive for casts, red blood cells and white blood cells
• 24-hour urine output = 380 mL
• Laboratory Tests:

Case Study Questions

                        Name:                                                                         Date:

• 1. A.S. has to have a 24-hour urine collection performed, as she is not urinating a lot. Describe in steps the collection procedure by the nurse.
• 2. What is your interpretation of A.S.'s BUN, Cr, and BNP?

BUN (10 -20 mg/dL)

Cr (<1.2 mg/dL for women <1.4 mg/dL for men)

BNP (<100 pg/mL):

3. Should you be concerned about A.S..'s potassium level of 5.2 meq/L? (Yes/No)

List two treatment types that the health care provider might prescribe if deciding to treat A. S. hyperkalemia.

1.

2.

• 4. Based on A.S.’s presentation, what nursing assessments, interventions, and monitoring skills need to be performed by you the registered nurse? Student must list at least six:
• 5. What orders do you as the nurse, anticipate the physician will order? Student must list at least six (frequencies not necessary to list; only what you think the physician will order):

6. Explain what might have contributed to A.S.’s present condition as described above? What are two evidence-based preventive health care provisions/programs that if put in place early might have prevented this from occurring?

Explain what might have contributed to A.S.’s present condition:

Evidence-based Preventive Health Care Provisions/Programs:

1.

2.

7. What is the significance of A.S.’s Hemoglobin, Hematocrit, and RBC levels being significantly decreased?

8. You are planning discharge for A.S. What would you include in your discharge instructions/teachings and what other interdisciplinaries/health professionals would you include? Student must list at least five each:

Nursing Teaching/Instructions                    Other Health Professionals

1.                                                             1.
2.                                                             2.
3.                                                             3.
4.                                                             4.
5.                                                             5.

1. A 55-year-old patient has been diagnosed with cervical cancer. She reports that she has a strong family history of cancer; two sisters have breast cancer. Her mother died of cancer when the patient was a child, and she is not certain of the type of cancer. Because of her strong family history, she is concerned about the health status of her twin daughters who are in their early 30s. She has asked you to discuss the risks for cancer with them

• Identify the evidence base for the counseling and education and the strength of that evidence.
• How will you approach your counseling and education?

Your client asks your opinion about different weight loss options beyond diet and exercise. Her BMI is 37 and she has type 2 diabetes, high blood pressure and high cholesterol. What clinical weight loss procedures is she eligible for based on the clinical continuum or care for obesity? How did you determine this?.

Case 1:

A 57-year-old female with systemic sclerosis presents with progressive breathlessness. Her spirometry is well preserved but the diffusion capacity of the lungs for carbon monoxide (DLCO) is 45% of predicted. There is no fibrosis or thromboembolic disease on computed tomography (CT) scanning of her lungs. Right heart catheterization reveals a mean pulmonary arterial pressure of 42 mm Hg (normal values <25 mm Hg) and a pulmonary arterial wedge pressure of 12 mm Hg (normal values ≤15 mm Hg) together with a reduced cardiac output. The likely form of pulmonary hypertension is:  

1. Pulmonary arterial hypertension (PAH) (group 1).
2. Pulmonary hypertension associated with left heart disease (group 2).
3. Pulmonary hypertension associated with lung disease (group 3).
4. Chronic thromboembolic pulmonary hypertension (group 4).
5. Pulmonary hypertension associated with multifactorial mechanisms (group 5).

Case 2:

A 42-year-old with idiopathic pulmonary arterial hypertension (PAH) who is normally treated with sildenafil and who is anticoagulated with warfarin is admitted with a 24-h history of marked deterioration in exercise capacity. His blood pressure is 95/60 mm Hg, heart rate 130 beats min−1 and saturation 95% on room air. Chest X-ray shows clear lung fields and his C-reactive protein is 3 mg litre−1 (normal range is <8 mg litre−1) ECG demonstrates new-onset atrial flutter with 2:1 atrioventricular block. The most appropriate management is:

1. Addition of an endothelin receptor antagonist.
2. Commencement of intravenous iloprost.
3. Commencement of intravenous dobutamine.
4. DC cardioversion.
5. Increase in sildenafil dose.

Case 3:

A 63-year-old female with pulmonary arterial hypertension (PAH) associated with systemic sclerosis is admitted with increased breathlessness. She is currently treated with sildenafil and ambrisentan. Her blood pressure is 110/65 mm Hg, heart rate 95 beats min−1 and saturation 94% on room air. Her ECG shows sinus rhythm and a chest X-ray shows a new small right-sided pleural effusion. Her C-reactive protein is 4 mg litre−1 (normal range is <8 mg litre−1) and her creatinine is 115 μmol litre−1 (normal range is 49–90 μmol litre−1). She has a raised jugular venous pressure and pitting oedema to her thigh. The most appropriate initial treatment is:

1. Further reduction of right ventricular afterload with the addition of intravenous prostanoid.
2. Improvement in right ventricular contractility with the addition of intravenous dobutamine.
3. Improvement in systemic perfusion pressures with the addition of intravenous norepinephrine.
4. Optimization of right ventricular preload with the addition of intravenous loop diuretic.
5. Optimization of right ventricular preload with a fluid challenge

Make it comprehensive and minimum of 10 sentences

• Alcoholism

Discussion: Pharmacokinetics and Pharmacodynamics

As an advanced practice nurse assisting physicians in the diagnosis and treatment of disorders, it is important to not only understand the impact of disorders on the body, but also the impact of drug treatments on the body. The relationships between drugs and the body can be described by pharmacokinetics and pharmacodynamics.

Pharmacokinetics describes what the body does to the drug through absorption, distribution, metabolism, and excretion, whereas pharmacodynamics describes what the drug does to the body.

When selecting drugs and determining dosages for patients, it is essential to consider individual patient factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. These patient factors include genetics, gender, ethnicity, age, behavior (i.e., diet, nutrition, smoking, alcohol, illicit drug abuse), and/or pathophysiological changes due to disease.

For this Discussion, you reflect on a case from your past clinical experiences and consider how a patient’s pharmacokinetic and pharmacodynamic processes may alter his or her response to a drug.

To Prepare

• Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
• Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
• Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
• Think about a personalized plan of care based on these influencing factors and patient history in your case study.

By Day 3 of Week 1

Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.

A screening test for prostate cancer has been shown to increase mean survival time by 5 years, and patients diagnosed via screening have demonstrated a better response to treatment than those not detected by screening.

Would you determine this screening program a success?

Why/why not? Provide at least 3 detailed reasons for your answer.

Review the case study and complete the questions to increase your knowledge of Fundamentals content. Copy and paste the questions into a document to type your answers. Copy and paste the questions and answers back into messaging to your coach. You coach will provide you with feedback on your answers.

A 70-year-old female has been admitted to the hospital. The client has had nausea and vomiting for the past three days. Upon admission the client is slightly confused and weak. Her vital signs are: 99 F (37.2 C), respirations 20 breaths/minute, pulse 102 beats/minute, BP 96/66 mm Hg, and her pain level is an “8”on a scale of 0-10. Breath sounds are clear bilaterally upon auscultation. Pulse oximetry is 95% on room air. Bowel sounds are absent in the right and left lower quadrants and in the left upper quadrant. Abdomen is hard and distended. When questioned as to her last bowel movement, the client responds, “I have not moved my bowels in over one week.” Mucous membranes dry; skin turgor poor.

The health care provider (HCP) orders the following:

1. IV of Lactated Ringers (LR). Infuse 1 Liter of LR over 6 hours by infusion pump now. When completed infuse LR at 100 mL/h
2. Insert indwelling urinary catheter to straight drainage
3. Obtain urine analysis (UA) and urine culture and sensitivity (C& S)
4. Insert nasogastric (NG) tube to intermittent suction
5. Diet: NPO
6. Vitals signs every 4 hours
7. Labs: CBC and electrolytes stat
8. Monitor I & O every shift

Questions:

1. The HCP ordered 1 Liter of LR to infuse over 6 hours. Calculate the flow rate you will program the infusion pump.      _____________________mL/h (round to the nearest whole number).

2. The client states she has pain to her left forearm four (4) hours after the start of the infusion. Upon inspection and palpation of her forearm, the nurse notes redness and swelling at the IV site and the forearm is warm to touch. What is the initial action the nurse should take?

3. What are the recommended nursing interventions when an IV becomes infiltrated? What are the recommended nursing interventions when phlebitis is noted?

4. A urine culture C& S is ordered. How would the nurse obtain a urine C& S from a indwelling urinary catheter?

5. To whom can the nurse delegate the task of taking the urine sample to the labatory? How should the specimen be transported?

6. After an X-ray has confirmed placement of the NG tube, how would the nurse check for placement prior to the administration of medication(s) and/or feeding(s) through the NG tube?

7. The nurse is checking placement of the NG tube, what would a gastric pH of 4 or lower indicate? What would a pH of 6 or higher indicate?

8. Name two complications that can occur with an NG tube? List nursing actions to prevent these complications.

9. The client asks the nurse if she could have a glass of water because she is extremely thirsty. What is the best response for the nurse to make?

10. The client’s lab results have returned. What findings (urine and serum) would indicate dehydration?

11. What would be a priority nursing diagnosis for this client? List one short-term goal. List three interventions for your priority nursing diagnosis.