In adjustment to abode a case abstraction paper, you charge anxiously abode a cardinal of sections in a specific adjustment with specific advice independent in each. The guideline beneath outlines anniversary of those sections.
Information to Include
Introduction (patient and problem)
Explain who the accommodating is (Age, gender, etc.)
Explain what the botheration is (What was he/she diagnosed with, or what happened?)
Introduce your capital altercation (What should you as a assistant focus on or do?)
Explain the ache (What are the symptoms? What causes it?)
Explain what bloom problems the accommodating has (Has she/he been diagnosed with alternative diseases?)
Detail any and all antecedent treatments (Has she/he had any above-mentioned surgeries or is he/she on medication?)
Nursing Concrete Assessment
List all the patient’s bloom stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Explain what treatments the accommodating is accepting because of his/her disease
Nursing Analysis & Accommodating Goal
Explain what your nursing analysis is (What is the capital botheration for this patient? What charge to be addressed?)
Explain what your ambition is for allowance the accommodating balance (What do you appetite to change for the patient?)
Explain how you will achieve your nursing goals, and abutment this with citations (Reference the literature)
Explain how able the nursing action was (What happened afterwards your nursing intervention? Did the accommodating get better?)
Explain what the accommodating or assistant should do in the approaching to abide recovery/improvement
Background and Concrete Examination
J. P. is a 46-year-old man presents to the emergency administration with a 5-day history of progressively deepening breathlessness on action and mild, accepted flulike symptoms. He additionally complains about night sweats and an alternate low-grade fever, both of which started about 2 weeks ago.
Upon concrete examination, the accommodating does not arise to be in any astute distress. His basic signs are abstinent as a beating of 89 beats/min, claret burden of 140/85 mm Hg, and a respiratory amount of 19 breaths/min. He is afebrile, with a temperature of 99.8°F (37.7°C).
The chest assay reveals annihilation out of the ordinary, and his cardiovascular and respiratory examinations, including auscultation, are unremarkable. The belly assay reveals no aqueous thrill, alive dullness, or bruit. The alarmist and the annoyance are not enlarged. No lymph nodes are palpable.
Multiple areas of hyperpigmentation are noted; otherwise, the bark analysis is unremarkable, with no hematomas, bruises, wounds, or scars noted. Electrocardiography (ECG) reveals a atrium accent with a affection amount of 84 beats/min, and the T after-effects are somewhat bedfast in leads V1, aVL, and III, but they are contrarily unremarkable.
Laboratory Test Results and Alternative Findings
Significant class allegation accommodate a white claret corpuscle calculation of 9.1 x 103/µL (9.1 x 109/L; advertence range, 3.5-8.8 x 109/L), a platelet calculation of 429 x 103/μL (429 x 109/L; advertence range, 140-350 109/L), a C-reactive protein akin of 91 mg/L (reference range, < 10 mg/L), a lactate dehydrogenase (LDH) akin of 4.7 microkatals (µkat)/L (reference range, < 3.5 µkat/L), an corpuscle sedimentation amount (ESR) of 30 mm (reference range, 1-12 mm), and a D-dimer of 2.2 mg/L (reference range, < 0.25 mg/L).
A circling CT browse is performed, which shows no pulmonary embolism. It does, however, acknowledge the attendance of a significant pericardial effusion (1 cm belly x 2.5 cm dorsal) and a multilobular substernal accumulation appliance the antecedent aloft mediastinum that is about 2.5 cm in array and 7 cm in length, with aerial absorption. Additionally, the mediastinal lymph nodes are enlarged; some are as ample as 2 cm in size. No alternative pertinent allegation on circling CT are reported.
An appearing bedside echocardiogram is obtained. The echocardiographic allegation affirm the attendance of pericardial effusion, after signs or affection of a cardiac tamponade; additionally, a retrosternal accumulation is detected
Which of the afterward is the best acceptable diagnosis?
Your cardboard should be 3-4 pages in breadth and will be graded on how able-bodied you complete anniversary of the aloft sections. You will additionally be graded on your use of APA appearance and on your appliance of nursing journals into the treatments and interventions. For amalgam nursing journals, bethink the following:
Make abiding to accommodate citations into all of your paper
Support all claims of what the ache is, why it occurs and how to amusement it with references to the abstract on this disease
Always use citations for advice that you abstruse from a book or article; if you do not adduce it, you are cogent your clairvoyant that YOU apparent that advice (how to amusement the disease, etc.)
Review the explanation for specific allocation criteria.
Points possible: 60
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