Please Complete Chart Explained for Students (Easy Guide)
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Original Question
Please complete the chart using the resources listed below Detail Clinical Significance/Impact It is Monday evening (Time 1830), and you are working in a busy emergency department. History of present illness: You are caring for a 27-year-old female (Lizzie) diagnosed with Relapsing Remitting Multiple Sclerosis. The patient is presenting with pain, weakness in her lower limbs. Allergies: NKDA Social History (from Lizzie) Clinical Significance/Impact Medical History:Surgical history: none Subjective History (from Lizzie) Clinical Significance/Impact Subjective History (from Lizzie): Medication Dose Last dose taken Alesse Am today Ocrelizumab 2 IV infusion of 300 mg Given 2 weeks apart Take 10 days ago Nursing Assessment: What assessment data is important and why? Detail Clinical Significance/Impact Objective Data General Appearance: Lizzie in pain and indicates she has numbness and weakness in her lower extremities. Her gait is off center. Temp: 37.2°C BP: 115/75 mmHg HR: 95 bpm RR: 16 SpO2:99% on RA What objective data is presented in the case study? What diagnosis do you suspect and why? Clinical Significance/Impact Review the NICE 2003 guidelines. You review the Patient Centered Goals Clinical Significance/Impact Short Term Long Term Resistance Training Aerobic Training Balance and Coordination Training The RN receives the following orders from the provider. Clinical Significance/Impact Apply oxygen therapy as needed to keep Sp02 above 92% Monitor vital signs Administer methylprednisolone Self reported Test Results Clinical Significance/Impact LEFS PHQ-9 FSS Family Education What education is essential to communicate to Lizzie about the possible triggers to her MS exacerbation causes? Lizzie asks if she should ask her doctor to prescribe corticosteroid treatment to manage her symptoms. What would explain about the benefits and risks? Considering Lizzie’s history, what information is important to include in the coordination of referral to outpatient interprofessional health care team members? Practice using the SBAR format. Situation: Background: Assessment: Recommendation: What medication orders will nurse anticipate? Clinical Significance/Impact What medication orders will the nurse anticipate and why? What is the adverse reaction between methylprednisolone and Lizzie’s other medications? Discharge Instructions You are preparing Lizzie for discharge back home. Consider the collaboration with other health care professionals in your discharge planning. What instructions will be included for her at discharge?
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