TR is a 78-year-old female, who weighs 83.2kg (183 lbs. 6oz) and stands 152.4 cm (5 ft.). She states she lives with her spouse of 55 years and both are independent and active. Her code status is DNR and her Physician is Dr. Jon Doe. She states she wears glasses due to an eye injury when she was young and also has hearing aids but left them both of them at home.

Allergies: Ace inhibitors—unknown reaction, Actos—dizziness, throat swelling, Endocet—hives, Penicillin’s –hives, Tomatoes (raw) itching/rash

Past Medical History: per patient and husband: Hypertension, Kidney Infections, Stage III Chronic Kidney Disease, Heart murmur, Aortic stenosis, Congestive Heart Failure, Bronchitis, GERD, GI bleed, Endoscopy (February 2016)

TR states she was feeling “fine” the past 24 hours. She then began to have “flu-like” symptoms: headache, neck /jaw pain, mid-abdominal pain, weak and tired, loose stools, nausea, dizziness, poor balance, and decreased appetite. She was brought to the ER by her spouse, after talking to her FMD. Some blood work was drawn HGB 5.7—2 units of Packed Red Blood Cells ordered, INR 4.3----Vitamin K given. Coumadin put on hold. Gastroenterologists were consulted after blood was detected during a + (positive)Hemoccult test, indicating upper GI bleed. IV fluids were started, and it was decided she would be admitted.

On admission to the Medical-Surgical Unit, TR: She states she has a headache and some neck & jaw pain, mid abdominal pain, loose stools since yesterday, a little nausea that gets better with eating a few crackers, fatigue, dizziness especially after standing up after sitting for a while, poor balance, and decreased appetite. She states she does look a little pale compared to her usual tan self. TR denies vomiting, chest pain, shortness of breath, problems with urination and denies visible bloody stools. The patient was made NPO for further testing and was admitted to a Medical-Surgical/Telemetry unit. Her VS. are T- 99.8F oral, HR 96 and irregular, RR 18, BP 100/58, POX 96% on room air.

Later in the day after receiving the blood transfusion her Hgb was 6.8 HCT was 20.1, and another 2 units of PRBCs were ordered. After the second blood transfusion her repeat Hgb was 10.1, INR 3.1. Small bowel push enteroscopy was ordered. Prior to the test her assessment revealed: she is alert, oriented x3, dressed in a patient gown. Her speech was clear, and she was able to answer questions appropriately, skin slightly pale with delayed turgor, s1 s2 heart sounds, with a murmur noted at the mitral valve, lungs sounds were clear, no adventitious sounds, her lips appeared dry with a few cracks. She used the restroom and her urine was noted to be dark yellow in color and measured 100 mL. TR said “don’t worry about that its always that way”. Abdomen slightly round, symmetrical, hyperactive bowel sounds in all 4 quadrants, soft but slightly tender RUQ and tympanic throughout.

She returned to the unit: Results of her: Schatzki ring (narrowing of lower esophagus), small hiatus hernia (part of stomach pushed up through diaphragm) gastric melanosis (excess melanin) resulting in benign mucosa changes, single bleeding angioectasia (acquired lesion--bleeding) in the duodenum that was clipped with MRI compatible clips. She was able to ambulate to the bed with a slight imbalance and required 1 assist with a Gait belt. She requested examination of her right heel because it was “sore” and bothering her. She also stated her feet often get tingly and numb. Upon inspection it was noted she had a blister on her right heel and her right great toe appeared red and was also sore to the touch. Her pedal pulse was noted to be a +1 on the right and +2 on the left, bilateral sluggish capillary refill. +3 pitting edema in bilateral lower extremities was assessed, to which patient stated, “they get like that sometimes”.   She was started on clear liquids which she consumed 50% without difficulty and stated she continued to feel slightly nauseated. Patient asked if she could have some eye drops because her eyes feel dry. Upon inspection her eyes have no drainage, sclera is noted to be white, and conjunctiva is red and dry in appearance.

Complete a physical assessment on TR using the case study to break the assessment into the following: General Survey, Integumentary, HEENT, Sensory-Neurologic, Cardiovascular, Gastrointestinal, Genitourinary, and Musculoskeletal.

Future considerations for APN roles. There are three troublesome issues that have emerged in the advancement of APRN practice,.These issues in APRN include: 1) the clear role development and morphed to fill gaps in services; 2) the lack of clarity regarding role uniqueness; and 3) the dearth in nursing specific outcomes. From your readings, discuu one of the thrre questions Begin your discussion with the question you will addressing.
  
    1. why might the development and morphing of roles based on gasps in medicine be problematic for advancement of APRN's. What actions might a nurse take to reduce this
    2. In what ways can an APRN distinguish his or her role from other nursing roles and medical counterparts? Why might this be important?
How can APRN s encourage nursing-based outcome studies?

Provide an electronic media device that shows your interest in public health, then write a 5-sentence paragraph explaining the media device.

For example, a twitter or other social media account, or an infographic you took a picture of, or a public health ad that you found interesting and allowed you to enter the field.

When we speak of life in the sense of relationships, dreams, and expectations for the future, we are speaking of?

CASE-1

Nurse Lucy works in the internal medicine service. Her patient Mary is staying in a quadruple room. While Mary was sitting in her room, her son Dylan came to visit. Dylan asked the ward nurse the day before for his mother to move into a quiet room. And he is angry when he sees that the situation has not changed, although the room was promised to be changed. With this anger, Dylan goes to the hallway and started to talk loudly, shouting for everyone to hear. He then quickly closes the door and returns to his mother's room.

Dylan is an only child. After discharge, he has to take care of his mother alone, and he has many difficulties in this regard.

a) In this case, what could be the reason for Dylan’s anger?

b) In this case, what would you do if you were nurse Lucy?

CASE-2

Dilek works in the surgery service as a nurse. She enters Mrs. Ayşe’s room, who will be operated on the next day. She sees that the patient is thoughtful:

Nurse: Mrs. Ayşe, I see you thoughtful. What do you think?

Ayşe: I'm going to have operation tomorrow, I'm thinking about it. I'm a little worried ...

Nurse: Nothing to worry about, it's a small operation. Many patients undergo this operation every day.

Ayşe: I'm afraid of anesthesia ..

Nurse: There is nothing to afraid of; you will sleep and wake up… Come on now rest. (says and leaves the room).

a) Assess the attitude of the nurse in the case given above? What are her right or wrong behaviors and why?

b) What could the patient feel during this communication?

c) What would you do if you were a nurse in such a situation? Write with your own sentences.

CASE-3

You are alone at home in the evening and study for your exam tomorrow. At that time, a friend of yours called you to chat. You want to hang up the phone, but your friend continues talking.

For this situation, write examples of passive, aggressive and assertive behaviors?

Passive behavior:

Aggressive behavior:

Assertive behavior:

QUESTION

Define the concept of empathy in communication. Write down the importance of empathy in nursing with your own words.

QUESTION

How does Joyce Travelbee define the concept of sympathy in the Human to Human Relationship Model? What are your opinions about this? Please write with your own sentences.

Submit report about following topics: ( Note: I don't want handwriting please )

a. Hydrostatic, or underwater weighing.

b. Air Displacement Plethysmography.

c. Neutron Activation Analysis.

d. Total Body Potassium.

The dearth in nursing specific outcomes
How can Advanced practice registered nurses encourage nursing-based outcomes studies?

By Aida Van Herk, RN, JD, Risk Management - AMN Healthcare A 39-week pregnant patient presented to Labor & Delivery at 2300 complaining of contractions since 1800. After she was examined by the physician, Pitocin was started at 2mu/minute. Prolonged decelerations in the fetal heartbeat were noted at 0100 and the Pitocin was turned off. At 0130, the physician ruptured the patient’s membranes and a deceleration was noted with immediate return to baseline of 140-150 BPM. The Pitocin was restarted at 0200 at 4mu/minute. Between 0240 and 0340, the Pitocin was turned down to 2mu/minute when frequent contractions with an unstable baseline, decelerations, and minimal variability were noted. From 0354 to 0404 there were more decelerations and absent variability with a baseline of 170-180 BPM. At 0405 the physician was called. The infant was born 25 minutes later via emergency cesarean section. She was blue, flaccid, with a nuchal wrap x4, low and unstable blood pressure, and a cord pH of 6.6. She was intubated, resuscitated, transfused and given medications to elevate her blood pressure. The infant remained in the neonatal intensive care unit for one month before being discharged home. She was diagnosed with cerebral palsy and experienced developmental delays. The family sued the physician and the nurse, alleging that the delay in delivery resulted in profound brain damage. They argued that the nurse failed to properly monitor and evaluate the patient and appropriately notify the physician. The nurse’s position: “When working as a nurse on the night shift, I would often need to exercise my clinical judgment about a change in a patient’s status. After my initial assessment of the situation, I decided to text page the physician that there was a problem. After 30 minutes without a response, I attempted once more. I finally called to report fetal distress and he arrived immediately thereafter.” The obstetrician’s position: “When working as an intern at nights, I relied on the assessment skills of the nurses and hoped they knew when to call. Many messages are received daily but critical information warranted direct communication, not a text message. The text page did not describe an emergency situation. After receiving the nurse’s call, I came immediately.” After unfavorable expert reviews, the case was settled for more than $3 million, with the nurse bearing primary responsibility. An analysis of this case highlights two areas of concern: Failure to communicate and failure to document. Failed communication between nurses and physicians is a major source of patient injury and professional liability litigation. When critical information is being transmitted to the physician, direct discussion can avoid delay in treatment. While reports not requiring urgent attention are generally sent through routine channels, urgent communications require extra effort to ensure they are received. In this case scenario, the nurse recognized a pattern consistent with the fetus responding to hypoxia and sent the physician a text page that was not responded to in a timely manner. It would have placed little burden on the nurse to call instead of paging the physician with that information. Because of the communication failure, the delivery of this high-risk fetus was delayed. It is best practice to personally communicate critical information to the physician and thoroughly document that discussion. Lack of Documentation is the second area of concern in this case study. Regardless of a nurse’s recollection of an event, the chart is still the best evidence as to what was done to and for the patient. In this case, there were a few places on the fetal monitoring strip where the nurse had documented “Report,” but no indication as to what was reported or to whom. The nurse was adamant she had reported fetal distress to the physician much earlier, but lack of documentation compromised her testimony and defense. If the nurse notified the physician there was a problem when she gave the report, she should have documented the details of that communication thoroughly and immediately. Moreover, if the doctor did not respond appropriately, she should have documented the response and gone further through the hospital chain of command. The nurse was charged with the responsibility of being the patient’s advocate, and as such is required to evaluate the condition of the patient and timely notify the physician if a problem is identified. In many cases, particularly in obstetrics, the window of time for an intervention may be very narrow and the nurse must act promptly. In this case, the documentation does not suggest that the nurse promptly recognized signs of distress or undertook any measures to assist with the alarming fetal condition demonstrated on the fetal monitoring strips. There was no documentation as to why the Pitocin was increased after the first prolonged deceleration or why the Pitocin was later only decreased instead of being turned off. The records do not show that supplemental oxygen was ever applied, or that proper attempts were made to reach the physician. As patient advocates, nurses must uphold their duty to properly monitor and evaluate each patient and appropriately notify the physician of changes in the patient’s condition.

Written records provide vital information and can help decision making in uncertain times. Relate the same to the above scenario.

provide examples of Professional Nursing and State-Level Regulations in California and another states