Care plan provided rationale for choosing a particular treatment modality.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
•Search term page to identify the codes applicable to the care plan. https://www.cms.gov/Medicare/Coding/ICD10/index.html
•This link will lead to an excel version of the latest codes: https://www.cms.gov/Medicare/Coding/ICD10ProviderDiagnosticCodes/codes.html
Click here to download the care plan template to help you design a holistic patient care plan. The care plan example provided here is meant only as a frame of reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patients care plan.
Format
Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be 2 to 4 pages double-spaced and in 12pt font.
Name your document: SU_NSG6001_W2A2_LastName_FirstInitial.doc.
Submit your document to the W2 Assignment 2 Dropbox by Saturday, September 26, 2015.
Grading Criteria
Maximum Points
Care plan demonstrated involvement of the client in the process of recognition, planning, and resolution of the problem.
15
Care plan included effective nursing interventions that are customized for the client and appropriate to the goal.
15
Care plan included diagnostic work-up, medications, conservative measures, and follow-up plan.
15
Care plan provided rationale for choosing a particular treatment modality.
15
Care plan demonstrated logical diagnosis that was substantiated with relevant evidence.
10
Care plan focused on patient education and maintained a fine balance between major and minor health issues of the patient.
10
Care plan included nursing interventions that are specific, appropriate, and free of essential omissions.
10
Used APA standards consistently and accurately.
10
Total
100
THIS IS THE CASE OF STUDY FOR THIS WEEK
Pulmonology Case Study
HPI
A 65-year-old Caucasian female presents with a chief complaint of cough for two weeks. She has been complaining of dry cough since the past two weeks and low grade fever that started two days ago, and was as high as 101 orally. She has had a decreased appetite but no nausea and vomiting. The cough occurs during the night and she needs to sit up in a chair to be able to breathe easier. The cough is mainly dry, rarely productive.
She had been prescribed inhalers in the past; they have been helpful but she does not use them on a routine basis. She has been prescribed antibiotics in the past as well and that seems to help when she is acutely ill. She has been suffering from shortness of breath for the past two weeks following any kind of activity mainly because of the dry cough. She thinks its possible that theres some problem with her “heart.” She is also complaining of slight sore throat, especially in the morning and feels she may have lung cancer.
The patients symptoms have been worsening over the past two days.
She has had similar episodes in the past. The last was three months ago when she had to go to the emergency room and they told her that she needed to be hospitalized. She declined hospitalization at that time and was treated and released. She says they gave her antibiotics and an inhaler before discharging her. She mentioned that though it took some time to feel better, there was gradual improvement in her condition following that treatment. According to her, this is the worst episode that she can remember. Shes very concerned today that she could have pneumonia and might require hospitalization.
She is seeking medical attention today because of the fever and prolonged nature of her illness.
PMH
Though she has been treated for this problem in the past with antibiotics and inhalers, she has not been hospitalized. The patient had a chest investigation the last time she had this problem. She states that she did not have pneumonia but did have “emphysema.” The healthcare professionals wanted to do pulmonary function tests, but she declined.
X-ray report:
X-ray results: Hyperinflation of both lungs with an increased AP diameter. There is evidence of emphysema. .
She states that she had asthma as a child and is a cigarette smoker. She also had a hysterectomy way back in 1970s. Besides these, she has no known chronic medical problems.
ROS
Shortness of breath with activity. No diaphoresis. She has had a fever. No nausea and vomiting. Denies chest pressure sensation with physical activity. No palpitations.
MEDICATIONS
The patient does not take any prescription medicines. She takes occasional over-the- counter Tylenol for pain.
Tylenol 650 mg, 2 PO as needed.
ALLERGIES/REACTIONS
She is allergic to sulfa drugs that cause a rash.
SOCIAL HISTORY
The patient has been widowed for 20 years. She is receiving an annual pension of
$40,000.00 and has some money that she has saved in the bank. She has a high school diploma and owns her house. Though she has little disposable income, her finances are essentially stable. She has little knowledge of community resources that are at her disposal.
She has a primary care provider, whom she sees three to four times every year for a physical examination. The physician is very busy and does not spend much time with her. She has insurance but it does not cover all her prescription medications. She relies on a lot on samples.
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