Essays on Medical History

Health History

Introduction Health history assessment is a vital part of the nursing process. This process establishes the foundation through which nurses can diagnose and create a care plan for their patients. That said, incorrect health assessments may result in misdiagnosis, hence wrongful care plan development. For this task, I interviewed Anna, L. (not her real name). The following discussion encompasses a review and reflection of this interview.

Demographic Data

Anna is a 26-year-old single female of Japanese descent. She recently moved to the US to pursue her degree at the University of Illinois at Chicago. Her hobbies include traveling, photography, blogging, dancing, ...

YourName

This case study presents J.W., a patient who went to the emergency room of the Community Hospital due to a persistent and severe headache over the last couple of days. Patient displayed signs and symptoms that her condition required blood testing and a head CT scan. However, Nurse Jackie, the nurse assigned to handle the patient’s case, only charted the symptoms but did not act on it or report it. The triage nurse, together with Nurse Jackie, also interviewed J.W. about previous neurological problems, headaches, or incidences of cerebral hematoma. But due to J.W.’s disorientation caused by ...

Introduction

The focus of the research is on determining how the changing role of the field of Transitional Nursing can affect the quality of healthcare that is provided to the elderly population. Initial research has revealed that people above the ages of 50 are considered to be more at-risk for contracting chronic diseases, and also for relapses because of various demographic and lifestyle factors. The focus of this paper is on developing a study design and sampling methodology for the research, as well as formulating flow charts and maps in order to better understand the dependent and independent variables involved ...

Medical genomic can be defined as the utilization of genome-based information in the making of clinical decisions. A broader concept, personalized medicine, is often used to describe the models of healthcare that emphasize the application of an individual’s unique environmental, genomic, genetic, and clinical information to the treatment and prevention of diseases (Brunicardi; Offit). In their practice, doctors combine the results of patient data, which include individual genomic information, family history, medical history, conventional test results, and symptoms. The combination of the data allows the physicians to diagnose diseases accurately and personalize treatment strategies (Alzu’bi et al.). ...

Proposal for Developing Electronic Medical Records

Proposal for Developing Electronic Medical Records

Executive Summary

An electronic medical record is a computerized version of a medical portfolio which stores all medical information of a patient including clinical history, medical condition, treatments received in the past, present medications, allergies etc. This file consists of data which is very useful for emergency treatments where delay can prove to be fatal, but in absence of critical information related to medical history of the patient, doctors are forced to delay treatment until they receive all clinical information about the patient. Healthcare organizations have started to rely increasingly on Electronic Medical Records of ...

Atrial Fibrillation

Atrial fibrillation is the most encountered cardiac rhythm disorder in clinical practice. It affects <1% of persons aged <60 years. This prevalence increases to 10% in persons aged >80 years (Amerena, Walters, Mirzaee and Kalman, 2013). Atrial fibrillation is a key differential diagnosis in patients presenting with chest pain, palpitations, shortness of breath, light-headedness, and syncope (Cruickshank, 2008). This paper will examine the differential diagnosis, pathophysiology, and paramedic implications of atrial fibrillation in relation to the case of a 43-year old male who presents with features and ECG findings of atrial fibrillation. It will first examine ...

ID Number For this Nursing Teaching Project, the chosen theme is recognizing the symptoms of anaphylaxis, its treatment, as well as the precautionary measures that need to be taken to ensure that the best possible health care is administered to the patients. The setting of the project is a summer camp, with children and teachers and other staff being the key players. Anaphylaxis is actually the human body’s allergic reaction primarily as a result of eating anything that has peanuts, fish, eggs, milk or sesame seeds . There has been a documented increase in the number of people suffering ...

Discussing Modern Electronic Records, Online Venues and Mobile Devices

INTRODUCTION This is the 21st century, an era of ever-increasing advancements in the realm of science and technology. Year after year more advanced, more innovative and more efficient technologies continued to be developed. We see this in how many people rely on technological devices, like computers, “i-pads” or tablets and smart phones, to fulfill their job requirements, to gain an education and in their every day social lives. There are no major industries that have not developed or placed their dependence in some kind of technology, be it farming and manufacturing or banking and construction; the healthcare industry is ...

It is essential to create a health maintenance and screening plan that is designed to prevent potential health problems, and to identify complications as they develop. The U.S. Preventive Services Taskforce offers detailed recommendations for individuals of different age, gender, and health classes, in order to guide them to make the best medical decisions possible. The following is a health maintenance and screening plan, designed for a 57 year old male. When creating the health maintenance plan, it is important to consider the individuals unique health situation, including risk factors, age, weight, and a variety of other sets of ...

Delirium Case Study

Acute confusional states also known as delirium are medical emergencies associated with substantial morbidity, mortality, and healthcare burden (Bassetti, 2007). The core characteristics of delirium are acute cognitive dysfunction and inattention. Delirium can result in permanent sequelea or become chronic (Fong, Tulebaev, and Inouye, 2009). This paper will examine the case of a 64-year old lady who presents with acute confusion, disorientation, and agitation. It will identify the key information provided and other essential information that needs to be identified. It will also examine the differential diagnoses and the most probably diagnosis for the patient. It will explore the ...

Diabetes is a chronic disease that requires continuous medical care, ongoing patient self-management education and support to prevent its advancement and the occurrence of acute complications. It also requires evidence-based recommendations and management to reduce the risk of long-term complications. Of importance to note is that diabetes care is a complex endeavor that revolves around many issues that go beyond the glycemic control management. Research has shown that other interventions are required to support the improvement of diabetes outcomes (Burant, 2012). These are caring standards provided by patients, researchers, payers, and clinicians. These standards address how children suffering from ...

Introduction

Osteoarthritis of the knee also known as the degenerative arthritis is a major and growing problem for the elder population all over the globe. Approximately, 27 million individuals have been reported to suffer from osteoarthritis by the Arthritis Foundation in United States (US). Women have been more commonly reported to suffer from osteoarthritis as compared to men. The prevalence of developing arthritis has been found to increase after the age of 45 . Although, mostly elderly population are most affected yet there are few evidences of young people suffering from it. Osteoarthritis is also commonly defined as wear- and- tear ...

Abdominal Pain

Acute abdominal pain is a common presenting complaint. It can be due to a range of conditions some of which are benign and self-limiting and others life-threatening medical/surgical emergencies (Cartwright and Knudson, 2008). This paper will address the issue of abdominal pain from a paramedicine perspective in reference to a 29 year old male patient who presents with this complaint. It will interrogate the provided information and identify other essential information that is needed, three differential diagnoses for the patient, and the pathophysiology of the most probable diagnosis. Lastly, the implications of the case on paramedicine practice will be ...

Objective: Patient appears well-groomed and devoid of nervousness or anxiety. Vital signs are within normal limits (WNL), except for mild fever. Abdomen: Normal bowel sounds, no rebound or guarding, no masses, presence of mild epigastric tenderness on palpation.

Gastritis Gastroesophageal Reflux Disease (GERD) Irritable Bowel Syndrome (IBS) The primary diagnosis for this case is gastritis. Based on the subjective assessment findings, it is apparent that the symptoms described by the patient are consistent with gastritis. Additionally, the patient has a history of gastritis, hence making it a primary diagnosis. GERD may be excluded as a primary diagnosis since GERD-related ...

An electronic health record (EHR) is termed as a patient’s medical or paper chart in a digital and secure format. EHRs are an innovative and unique form of technology in the healthcare system wherein authorized users can access patient-centric information in real-time. EHRs are known to contain conventional clinical information of the patients. It includes medical history, current treatment and management interventions, current medical status and other personal information. However, EHR should not be restricted to clinical or patient-centric information but also vital information that could be of use at the healthcare provider’s office. In the nursing ...

When I work as a nurse with Beth Israel Hospital, I had a great experience. The profession of nurse should protect the patients against health care errors. On June 1st 2016, I have assigned to a methadone patient. It was my first exposure to psychairic and I was quite nervous about the patient reaction’s and how he would respond to me. I have collected a past medical history about the patient that he was Hypertension, Diabetes Mellitus type 2, and also he had strong abuse of drugs. He had NKA were denied pain in right arm. By communicating ...

Abstract

The literature defines hypertension as a medical condition experienced when the systolic blood pressure (BP) is equal or greater than 140 mm Hg or when the diastolic blood pressure is equal or greater than 90 mm Hg. Additionally, it offers a description of systematic, cellular, as well as molecular causes of hypertension. High blood pressure within the arteries is referred to as systemic hypertension (SH). The primary role of the systemic arteries is the transportation of oxygenated blood from the heart to the tissues of the body. The constriction of the arterioles (small arteries) is responsible for the high ...

Introduction

Electronic health documentation (EHR) was introduced under the 111th American Recovery and Reinvestment Act in 2009. The aim was to achieve an electronic health record for every citizen of the USA by the year 2014. The technological change in the nursing field has been met with both accolades and criticism. Those who endorse the method of recording patient information argue that it is safer and more convenient relative to the traditional paper method. The critics argue that the method is open to abuse by the hospital administrators and can be shared without the consent of the owners. Among these ...

Patient Care Issue: The outstanding patient care issue for the organization

The patient in question is a 67-year-old female patient according to the medical history provided by the hospital. The patient suffered from a laparoscopic hysterectomy and after a series of complications she was operated on and admitted to hospital. It is important first to understand that healthcare is crucial and hospitals should provide utmost care to patients. A patient’s confidence is determined by the level of quality embedded in healthcare management for a particular hospital and as such, the patient requires understanding how the hospital works and whether there is cohesiveness in operations as well as outstanding patient ...

Age: 75 years

Medical Record No: 66543N History and physical examination conducted: June 21, 2016 Source: The patients presents his own medical history and is a reliable source Chief Complain presented: Abdominal pain The History of the Present Illness Past medical history The patient presents with diabetes diagnosed 10 years ago, that is well controlled with Metoprolol medication. He also presents with depression and the patient uses Prozac medication for depression management. Mr. X had been previously hospitalized in 2010 due to MI and cardiac catheterization was done therefore, the patient present with a positive history of surgery.

Social history

Family history The patient ...

R M. G

Dr. S P. A., a 56 year old Italian male that identifies with the Italian culture with no significant past medical history presents to the emergency department with the chief complaint of recurrent chest burning. P.A. says his wife believes that he is showing symptoms of having GERD but he has never been diagnosed. P.A states that “the chest burning and discomfort began five days ago and just got progressively worse despite his self medicating with TUMS” he presented to the emergency department on 05-31-16 and felt “some improvement” after a GI cocktail was administered. One set of biomarkers ...

The article “A Brief History of Medical Diagnosis and the Birth of the Clinical Laboratory”, by Darlene Berger, is an interesting read, which thoroughly explores the subject at hand. This article, which is Part 1 in a series of four articles, discusses medical advances from. “Ancient times through the 19th century.” Berger makes very succinct observations about advances in medicine and the advent of the clinical laboratory. She does an excellent job of objectively discussing many of the important discoveries in medical history, providing stirring examples of success and of failure in the context of medical history, and cites ...

The chief complaints of a patient, which will be discussed in this paper, are of a female student who is nineteen years old and raised an issue as she states, “I experience irritation and feel scratchy because of the rash behind my knees and on my arms.” The subjective and objective data will be collected to evaluate the complaint of the patient and the patient will be guided according to the health promotional strategies.

Subjective Data

Presenting complain: I experience irritation and feel scratchy because of the rash behind my knees and on my arms. History of presenting complains: The onset ...

In most cases successful involves Mediation involves numerous steps that are al intended to improve the patient outcomes. Some of the steps that are crucial include taking the patient’s medical history, laboratory examinations, physical examinations, and drawing the assessment and treatment plan. Primarily, one should listen to the patient’s main complain before starting any examination. They should give a narration of their present illness, including the signs and symptoms as well as the present regimen, if any (Quinn et al., 2013). While establishing the medical history, the practitioner should ask the patient whether they have suffered from ...

As Nurse Manager, I would implement a new system that is designed to increase the efficiency of the nursing program, by decreasing the amount of information that nurses have to take down, and record in reports, for incoming patients. The key objective is to increase efficiency, so that nurses can spend a greater amount of time on patient care, and less time on record keeping or initial report style paperwork. This will not only reduce the number of nurse shat the care center needs on staff at a given time, but will also improve patient experiences by ensuring that ...

The patient is a 9-year-old boy, who visited the general practitioner with his 37-year-old mother. The general practitioner reviewed the patient’s medical history and conducted an interview with the patient’s mother to learn more about the boy’s family history, as well as the history of the boy’s chronic cough. The mother reported having seasonal allergies, especially during springtime when plants release their pollen. However, the boy had no known allergies or respiratory problems according to his mother and his medical history. The physical examination included the assessment of the patient’s vital signs, nasal canals, ...

Patient and Study Identification

The patient is a 10-year-old boy sent by the referring specialist neurologist, whom the patient visited after his mother had found him experiencing seizure twice during the past month. The patient was first diagnosed with absence epilepsy when he was 5 years of age, and has not experienced seizures since he was 8 years of age. The purpose of this electroencephalography (EEG) study is to identify the type of epilepsy in this case so that the patient can receive the correct treatment.

History

The patient had a normal birth and experienced healthy development until the age of 5, when his ...

Introduction

With the various changes witnessed in the society’s demographic structure and delivery of the healthcare services, the nursing profession is largely recognizing the importance of the family in regard to the wellbeing as well as the health of individuals and families. Essentially, nursing practice involves caring for individuals as well as families whereby this requires nurses to have the relevant skills and knowledge to enable them work with families and foster healthy choices among individuals and families (Carlson & Carlson, 2014). As such, in order to establish healthy and collaborative relationships and foster the involvement of families in their ...

What is chronic heart failure?

It is a condition where the heart is unable to sufficiently pump oxygen rich blood to the rest of the body to meet the body’s metabolic needs.

Nursing Implications and indictors of chronic Heart Failure

When a patient presents signs and symptoms of chronic heart failure, a set of assessment and diagnostic test should be conducted to ascertain the presumed diagnosis. The most imperative patient assessment should be the evaluation of patient’s medical history. A nurse is always the first person to obtain the patient’s medical history. It is important to determine the patient’s risk profile, patient’s cardiac history and what were ...

1. Recommend the type or types of research you would propose. Answer. Owing to the current situation of pre-crisis phase for the organization, the research should focus on the assessment of those factors that might help to save the organization’s image during the crisis (Coombs, 2014). Hence, a comparative crisis communication oriented qualitative research is recommended for the current situation (Schwarz, Seeger & Auer, 2016). The comparative crisis communication research will focus on comparing the situation of the victims at the San Diego and Atlanta stores before and after their collapse. 2. Determine what kind(s) of information you ...

Abstract

This paper is about the investigation of Parkinson’s disease, and in particular is involved with the examination of its symptoms, stages, causes, prevalence, diagnosis and treatment, and social impacts. Finally, the paper analyzes and evaluates two ongoing on Parkinson’s disease researches, which are also examined in respect to their impact on Parkinson’s disease patients. Key words: Parkinson disease, Parkinson disease causes and impacts, Parkinson disease symptoms and prevalence, Parkinson disease diagnosis, and Parkinson disease ongoing research.

Idiopathic Parkinson disease (PD) is a progressively evolving disease with main manifestations resting tremor, muscle stiffness, slow movement and loss ...

SOAP NOTE

Women’s Health / Primary Care SOAP Age Range: 20-30 Gender: Female Occupation: Home maker. Subjective: ID: M.M.

Reliability: Pt is reliable, dependable and a knowledgeable source of information.

Reason for seeking Care (CC): Patient states “I have missed last two menstrual cycles of mine. I just need to confirm if I am pregnant.” History of Present Illness: Patient is a 29-year-old Asian female with no significant medical illness in the past history. Patient is a new patient to the clinic, and has come to confirm if she is pregnant. Travel History past 30 days: Patient has returned from a trip to her home land last week..

Current Medications: She uses some Homoeopathic medicines for constipation and heartburn sometimes.

Allergies (Medication, ...

Based on the initial symptoms, the patient most likely suffers from hypothyroidism or low thyroid hormone disorder. Further clinical tests and an examination of the family’s medical history reveals that the particular disorder could be Hashimoto’s disease; also called Hashimoto thyroiditis. Hashimoto thyroiditis is classified as an autoimmune disease. In autoimmune disease, one's immune system attacks the body’s tissue specifically the thyroid gland (Skugor & Wilder, 2006, p.2). By attacking the thyroid gland, the disease reduces the gland’s ability to produce thyroid hormones of substantial quantity. This condition leads to hypothyroidism. Thyroid hormone deficiency presents with ...

Hypothesis statement

There are many ailments that are often associated with old age. Reduced immunity and other factors lead to the susceptibility to diseases at old age because of increased risk factors. One of the most ailments in people of advanced age is Alzheimer’s disease. Alzheimer is the most common form of dementia which is a term that denotes sets of symptoms that causes problems in intellectual abilities coupled with memory loss, language, thinking and disorientation, lack of motivation, mood swings, and problem-solving abilities. In some cases, some behavioral issues can be observed in a person who is reporting symptoms ...

Patient Initials: CJ

Clinical Site: Identifying Information: CHIEF COMPLIANT/HISTORY OF PRESENT ILLNESS: Mother (What is the patient saying? Quote the patient if possible)

Behavior: Disruptive and impulsive

Depressive symptoms: Detected Anxiety symptoms: Detected Psychotic symptoms: Absent Vegetative symptoms: Absent as patient is motile Suicidal ideation: Absent Homicidal ideation: Absent Compliance: Intermittent Cognitive symptoms: Not consistent with incidences of forgetfulness History of any mania in the past: None Sleeping patterns: Short sleeping hours less than 5 hours a day Appetite: Highly selective (Including any significant weight loss or weight gain)

PREVIOUS PSYCHIATRIC HISTORY

(Including any previous psychiatric hospital admissions): None

Any past suicide attempts: None

Failed medications: None tried before PREVIOUS PSYCHIATRIC FAMILY HISTORY: ( ...

SOAP NOTE

Women’s Health / Primary Care SOAP Age Range: 25- 30 Gender: Female Occupation: Receptionist Subjective: ID: M.L.

Reliability: Patient is a knowledgeable and a reliable source of information.

Reason for seeking Care (CC): Complaint of heaviness and pain in the left breast on and off since the last 4 months. History of Present Illness: Not applicable. No history of change in surgical, medical or family history.

Travel History past 30 days: No history of travelling in the last 30 days.

Current Medications: Denies being on any medication currently or in the past. Allergies (Medication, Food, Environmental): Not allergic to any medication, food or environmental influences. Immunizations: Received all the immunizations in a timely manner. History of Present Illness: The patient was ...

How to address the appointment with Chloe

Children, especially toddlers suffer from many complications that physicians find difficult to establish because the victims cannot express themselves. A health professional presented with the case of a young child uses available literature and professional skills to plan for the patient’s appointment. One of the most common examinations used by doctors to diagnose children with developmental problems like Chloe is neurological examination. The doctor examines the child’s nervous system that includes the brain, the spinal cord, and the nervous systems originating and ending at these sections (Dulac, Lassonde & Sarnat, 2013). Chloe presented some clinical symptoms and medical ...

Introduction

Major depressive disorder can be a cause for the irregular functioning of individuals depending on the severity of the case. The disorder can lead to physical, social, emotional and intellectual malfunctions in the human body. Individuals portray the effects of major depression in different ways, and the symptoms may vary depending on the circumstances that the people are exposed. The cases of depression may be prevalent in individuals of any age. The major depressive disorder tends to vary, with some of the conditions ranging in the episodes that the people experience. There are different variations of the causes of ...

A referral system is a system used in health institutions to transfer safely patient care services across different departments, such as referring to a specialist, conducting assessments and treatments, and coordination of services for complex patients. An automated referral system is online. An electronic form is filled out with information about the patient and the primary care provider and the reasons for the referral request with relevant exam results and case history. Upon getting the request, the specialist reviews the form and begins to manage the case. The speciality aims at ensuring that the patients get the needed care ...

Competency is the possession of knowledge, skills, behavior, and the capacity to enhance the patients’ safety, medical outcome and satisfaction. Informatics as a nursing competency focuses on the integration of technology as an evolving practice of nursing. The use of electronic health records in the healthcare management has been critical in the promotion of the patient’s safety, medical outcome, and promotion of efficiency in health institutions. This paper will study the importance of informatics competencies in enhancing patients’ safety, medical outcome and satisfaction. Also, the study will put into perspective the implications of informatics on nursing education, practice, ...

SOAP NOTE

Age in years: 42 Gender: Female Subjective CC (Chief Complaint): A 42 year old female presented to the Gynaecology clinic with the complaint of severe pain in abdomen with heavy menstrual bleeding (on the 3rd day of the menstrual cycle). History of Present Illness: The patient was apparently well almost 3 months back when she gradually developed extreme pain in the lower abdomen prior to and during the menstrual cycle. The cycles were normal before these three months. She never had such excruciating pain before. The pain used to commence a day or two prior to the cycles ...

Upper respiratory disease is a term that encompasses acute infections ranging from the benign common cold to life-threatening conditions (e.g., epiglottitis). Cases of upper respiratory disease are easy to recognize because the patients will complain about the following symptoms (Centers for Disease Control and Prevention [CDC], 2016):

Runny nose (always)

Sore throat (always) Coughing (common, usually in cases of viral etiology) Sneezing (common, usually in cases of viral etiology) Other symptoms depend on the patient’s age, medical history, and the pathogen causing the infection, so it is important to conduct a thorough assessment which consists of the following steps:

Interview the patient.

Perform ...

Introduction

Approximately 2.5 million individuals in the United States contract pneumonia annually, and 55,000 of those individuals die as a result. In fact, pneumonia was the eighth prominent cause of morbidity and is the number one communicable disease in the United States. Pneumonia is the leading deadly hospital-contracted disease and contributes to a sizable amount of deaths in unindustrialized countries as well. It is a grave illness that can impact individuals in all age groups, but it is especially serious in adolescents, the elderly population, and in people with fundamental medical issues such as ischemia, low blood sugar, and ...

Introduction

HIV is one of the most deadly viruses affecting the human immune system. Scientists across the globe work day and night to search for the cure of the HIV bit to date no solution has ever worked. Despite there no cure for HIV, scientists have developed various treatments to assist the victim live longer and fight opportunistic infections. The paper discusses the case of a young female who had other symptoms diagnosed with HIV.

Common modes of HIV transmission in the developed countries and the populations at a greater risk of acquiring HIV

The HIV infection is transmitted through open cuts and breaks in the skin. It is also transmitted through mucous membranes, such as the ones inside ...

Health Information Management

In the medical field, there also exist fraud and abuse of resources and the information about patients’ confidentiality. The fraud can majorly be as a result of stolen medical record files, lost patient receipts, and missing drugs for patients. All the misconduct results from the misappropriating handling of data. In such setups, the physicians can play a crucial role in mitigating the fraud and abuse (Green & Bowie, 2005). The practitioners can lessen the cases of fraud by being on the frontline in the keeping and recording of the health centers data and information. This paper discusses the role of ...

According to Web Med (2016), asthma is a chronic condition that mainly affects the air passages. The internal surfaces of these air passages are usually swollen thereby making it a challenge for air to pass through into the lungs which eventually results to compromised respiratory functions of the body. According to CDC (2013), the total number of children under the age of 18 years with this disease stood at 6.1 million which represented 7.3% of the total population of individuals with the condition. Currently, the morbidity levels of the condition stand at 6.3 million children which represent 8.3% of ...

The Role of Patient Records and the Information contained within those Records

A health record is an essential and powerful tool that allows the physician to track a sick individual’s medical history and highlight patterns or problems that may assist in understanding the course of the healthcare. The primary directives of patient records are to help in the delivery of quality and continuous care as well as providing evidence and assessments of medical interventions. The records contain the patient’s story to facilitate every encounter with health professionals who take part in his or her care (Lavin, Harper & Barr, 2015). They are built to share information amongst the practitioners in ...

Judith Milien

Argosy University Family Health Portrait Essentially, a family health portrait facilitates recording of the family health history, which is a complete record of health information involving immediate members of a person’s family, such as the parents, brothers and sisters, children as well as uncles and aunts among other close relatives. Concerning health, close relatives share some of the factors that may give the lead to health professionals that include genes, shared environments and the ensuing lifestyle for the family. As such, family health history would enable the health professions to determine the genetic medical conditions that run in ...

Ms. Smith is a 34-year-old Caucasian female who presented at the office for her first prenatal appointment. Ms. Smith lives in Palm Beach County and maintains a full-time accounting position. She complains of nausea that occurs particularly in the morning and subsides by 10 am for the past two (2) weeks. However, this nausea has not subsided for three (3) days. Ms. Smith is usually active but has noticed experiencing greater fatigue at the end of the day. She has reported no vaginal bleeding or fetal movement. Her last menstruation was on October 25, 2015. The patient believes she ...

Abstract

Prevention of pressure injury may beneficial because it helps in reducing treatment costs. A treatment plan can be effective in addressing the risk of old people from acquiring pressure injuries. Professional collaboration is recommended because the efforts of nurses, nutritionists, and physicians play a critical role in prevention. The patient needs may be fulfilled if the environment and the care providers are collaborative. Therefore, a collaborative approach can be effective in achieving positive patient outcomes. This may help in reducing health costs incurred during admission or treatment of injuries. However, knowledge and skills are critical for patients who are at risk ...

Presenting complaints: This is a presentation of a 14 year old female known as Mary X. who presented with a right side abdominal pain of 6 hours duration (started since 10am). Reason for admission/ History of presenting complaints: Mary’s abdominal pain begins near the belly button with tenderness around the central abdomen. This pain with a dull consistency at onset later increased in severity as it moves towards the right lower abdominal region. The pathophysiology that is associated with this condition is that which is caused by the fecalith blocking the appendix in about 50-80 percent of cases while in the ...

Abstract

This study analyzes the benefits and challenges of implementing an electronic medical system in both hospital and clinic environments. The overall research problem addressed in this study is determining how to effectively manage and communicate expectations associated with perceived benefits and challenges derived from a new install of an electronic medical record. The purpose of this study is to analyze perceptions associated with both the benefits and challenges derived from installing an electronic medical record system. This problem is relevant to many such as those who ...

In the case study examined, the patient was vomiting intermittently in postoperative care while receiving Morphine intravenously. The patient’s nurse Pamela is not responsible or trained for prescribing medication, so she decides to seek advice from a senior nurse. The senior nurse Jane orders Pamela to cease the Morphine administration and changes the protocol to 10mgs of Metoclopramide. While Pamela stops the Morphine administration, she refuses to administer Metoclopramide without a prescription. Despite the warnings against administering regulated medication, Jane proceeds to act on her decision and administers the Metoclopramide intravenously, which causes the patient to respond with an allergic ...

Question 1

President Clinton made a strategic miscalculation in health reforms and at the end experienced disappointments. The republicans, moderate democrats, the American Medical Association and the Health Insurance Association of America backtracked from a policy that they had agreed to support (Clinton & Clinton, 1993). The health reform suggested for implementation of universal care coverage that failed terribly remained a dream that never came true. Clinton failed to consider the matters of interest groups as he made a blunder of becoming a partisan in the health reform. The president planned to empower his leadership by public opinions and tried to play the politics of health, which ...

The HIPAA passed in 1996, protects patients’ confidentiality, ensure people keep their health insurance upon job loss, and assist in controlling administrative costs. The Act addresses three key areas: portability, administrative simplification, and privacy. The law applies to healthcare providers, healthcare clearinghouses and health plans such as Medicare and Medicaid. Personal health information that the law considers confidential include names, significant dates such as birth dates, contact information, social security numbers, photographs and any other unique identifying information. The Act prescribes several medical forms that patients must sign in order to protect their privacy and confidentiality rights regarding the ...

An EHR system is an electronic health records system that stores all the medical information about a patient. The system is a digital version of keeping records that can be located at any moment. When accessed, the system will show the medical journey of a patient, from a previous diagnosis, allergies, the medication they have been given and the laboratory test results. Because of this, the system helps in promoting the management of the risks that occur with errors on medication. In addition, the systems operate on a digital network that makes it easy for any healthcare to access information about a patient at any ...

The Health Insurance Portability and Accountability Act (HIPAA) 1996 include two titles. Title one is related to protecting the rights of employees and their families if they lose or switch their jobs. Title two includes an Administrative Simplification provision which requires health care providers to have national standards in their health care transactions. Along with this, national identifiers are required for providers, health insurance plans, and employers. The Act takes into consideration the threat to the privacy of health information. Consequently, the Congress has included in the Act a Federal Privacy Protection for individually identifiable health information (HHS). Individuals between ...

If I prescribe medication to my friend without looking at the medical history or without a suitable diagnosis, I am violating both legal and ethical regulations. According to the nursing code of ethics, the nurse has to establish professional boundaries (American Nurses Association [ANA], 2001). Unlike purely personal relationships, relationships with patients need to be structured relationships aimed at improving the patients’ well-being. Several other ethical standards are violated as well because I engaged in a questionable practice that could possibly jeopardize my friend’s safety. Furthermore, prescribing controlled substances without a systematic approach and diagnostic evidence is a violation of the ...

In carrying out a patient assessment, important components such as patient health history and physical health should be examined using a holistic approach. A nurse would require information from the patient, friends and family, diagnostic tests and patient medical records (Jarvis, 2004). A comprehensive assessment should include a detailed survey of physical signs such as weight and height, an assessment of the patient’s body systems and organs. On the other hand, a priority assessment is a short evaluation, normally completed within 5 minutes, which gives an overall evaluation of the patient. However, a more in-depth assessment of the patient is required to make a diagnosis.

First Chart Case

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Jerry is a trained medical assistant and has the sufficient knowledge to issue a refill. However, in the situation he is faced with, he has to examine the medical history of the patient. He has further to consult with Dr. William who has been treating him and has some background and determine if the patient can be issued with a refill. In the event that Dr. William is not immediately reachable, he will have to examine the patient because he lacks any background information. Thorough medical checks have to be carried out so as to avoid a situation where a patient is issued with ...