I have way more files to add, as it is a case study upon a patient which, I have a specific statement to follow the essay on. please read these carefully and I want someone who obviously understands nursing and has the knowledge to write the best paper for me.
DARRENS STORYANA MODULE 1 DARREN’S STORY Darren is a 51 year old male who lives in Cairns where he is the owner/operator of a diving boat tour company. He has moved to a more sedentary role over the last few years and misses getting out and working with the tourists. Darren has one son, Jake, 15 who lives in Wallan, Victoria with his mum Lisa, step dad Kevin and his 5-year-old stepsister Ruby. Jake and Darren have a good relationship, Jake fly’s to Cairns twice a year during school holidays to stay with his Dad. Darren’s History DOB: 23/11/1968 Address: 25 Happy Street Cairns Smoker: 30 per day for last 20 years Social Drinker 2 heavy beers a day after work and up to 10 a day on the weekends - Darren’s favourite saying -It’s 5 o’clock somewhere’ ^BMI -33 H: 1.8m W: 110Kg Waist: 115cm Darren has a past medical history including, hypertension, hyperlipidaemia, mild depression and GORD. He currently takes medication for these conditions. · Hypertension: High blood pressure · Hyperlipidaemia: your blood has too many lipids (or fats), such as cholesterol and triglycerides · Mild Depression: depressed mood or irritability · Gastric Oesophageal Reflux (GERD): Digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagues. This with asthma are at high risk of developing GERD. He has experienced two episodes of upper abdominal pain during the night with associated nausea and vomiting within the last month. Medications Generic name Trade name Dose Atorvastatin Lipitor 10mg Daily Atenolol Noten 50mg Daily Sertraline Zoloft 20mg BD Ranitidine Zantac 150mg daily Generic name Trade name Purpose Atorvastatin Lipitor Lowers cholesterol in blood, lowers bad cholesterol & triglycerides in your blood. Atenolol Noten Beta blocker to treat high blood pressure, chest pain. Sertraline Zoloft Is an antidepressant, or selective serotonin reuptake inhibitor (SSRI), helps restore serotonin Ranitidine Zantac Helps decrease stomach acid production, treats GERD Procedure Description Cholecystitis Inflammation of the gallbladder, it is the organ right side of your abdomen, beneath your liver. creates abdominal pain often with nausea and vomiting. Elective laparoscopic + open cholecystectomy Common elective surgical procedure in the abdomen. Darren does not attend regular check-ups with his GP. He last had his medications reviewed when he presented to the GP around 12 months ago with his first presentation of upper abdominal pain, nausea and vomiting. He was commenced on Ranitidine at this time. In the last month, Darren has had two more severe episodes of upper abdominal pain with nausea & vomiting. He ignored the first episode and it settled after 24 hours. However, Darren has presented to the Emergency Department in Cairns 1/7 ago with similar symptoms but more severe. Darren’s diagnosis is mild- severe Cholecystitis. Darren has been transferred to the surgical ward where he is awaiting an elective Laparoscopic +/- Open Cholecystectomy. Darren has had pre- operative blood pathology collected including his Cholesterol, which is reading high. This is part of Darren’s pre-operative work up. URN O75486 SURNAME Roberts GIVEN NAME Darren ADDRESS 25 Happy St Cairns DATE OF BIRTH 23/11/1968 DOCTOR Smith Admission day 2230 M R 3 2 4 P R O G R E S S N O T E S PROGRESS NOTES Including Initial History and Examination NURSING: O/A: Presented to ED with an acute episode and recent Hx of upper epigastric pain. P’t report pain 7/10 radiating across upper abdomen,and has a positive Murphy's sign. ------------------------- CNS: Pt. is alert and orientated to person place and time, GCS -15, PEARLA. Morphine 5mg administered via 18g IVC inserted in L)hand. NVS: CWMS present in all peripheries, Capillary refill <3sec, and pedal pulses present. cvs: hr 99bpm/reg, bp, 155/88, temp - 37.6, nil chest pain, base line ecg attended. resp: rr 26rpm, minimal increase in wob, pt. able to speak in full sentences, nil cough or sputum, o2sats 95% ra, air entry equal/bilateral on auscultation, nil adventitious breath sounds, git: history of n&v for last few days, nil since admission, bowel sounds present in all 4 quadrants, bowels regular and patient continent of bowels and urine, bgl 3.5mmol, increase pain on gentle palpation consistent with positive murphy's sign. integ: braden score - 18, skin intact, slightly warm and moist. adls: pt. normally attends to all adls independently. safety: provided with call bell and explained how and when to use it, social: no nok present, pt.s son lives in melbourne -pt. is worried about him, pt owns his own company and is also concerned about how this will run without him on site. declined pastoral care. mse: pt. is anxious regarding needing to be admitted to hospital ....................................................................................sally grimm rnd1 medical 0300: bloods, ultrasound and ct scan r/v'd by surgical team and diagnosis of acute cholecystitis. consent gained by patient for an open cholecystectomy procedure. patient prepared for transfer to surgical ward when bed is available. plan: theatre at 0800 in the morning. anaesthetist will see p’t in the am ...........................................................................................................................................gbrigs rmo medical 0315: documentation from emergency admission is incomplete, this will be sent to the ward asap .........................................................................................................................................g brigs rmo nursing: darren transferred to surgical ward @ 0400 hours from ed. cns: gcs 15, alert & oriented, pain 2/10 at rest, 3/10 on movement, cvs: hr90 reg, bp 110/85, t37.8, nil chest pain, ivc insitu in l) hand, vte assessment completed, ted stockings insitu resp: rr 20, nil increase in wob, able to speak in full sentences, o2sats 96%ra, git: nil n&v, fasting for procedure in the morning, safety: pt, oriented to ward, provided with call bell and instructed when and how to use it. social: aws assessment attended, made arrangements for darren to contact his son and business in the morning prior to surgery...... di symes rnd1................................................................................................................................................................. nursing:darren seen by anaethetist at 0700hrs, consent signed, ed documentation has arrived and is in patients file, pre-operative checklist completed. awaiting tansfer to theatre.............rachel mckenzie rnd1 nursing:patient transferred to theatre @ 0740hrs.......................................................rachel mckenzie rnd1 day 1 0300 day 1 0315 day 1 0400 day 1, 0715hrs day 1, 0740hrs clinical reasoning cycle consider the patient situation as a patient what makes this patient different from the “typical” case what is this patients “normal” as a person what is this patients story what past experiences might influence this presentation are there other factors –social/cultural/personal collect cues/ information what do we already know – existing patient charts, documented history, lab & diagnostic reports what do we need to know – subjective & objective patient assessment what is my knowledge of this –do i need to review pathophysiology/pharmacology/physiology/ethics etc. process information interpret – do i understand all the patient data? what is normal vs abnormal and="" pedal="" pulses="" present.="" cvs:="" hr="" 99bpm/reg,="" bp,="" 155/88,="" temp="" -="" 37.6,="" nil="" chest="" pain,="" base="" line="" ecg="" attended.="" resp:="" rr="" 26rpm,="" minimal="" increase="" in="" wob,="" pt.="" able="" to="" speak="" in="" full="" sentences,="" nil="" cough="" or="" sputum,="" o2sats="" 95%="" ra,="" air="" entry="" equal/bilateral="" on="" auscultation,="" nil="" adventitious="" breath="" sounds,="" git:="" history="" of="" n&v="" for="" last="" few="" days,="" nil="" since="" admission,="" bowel="" sounds="" present="" in="" all="" 4="" quadrants,="" bowels="" regular="" and="" patient="" continent="" of="" bowels="" and="" urine,="" bgl="" 3.5mmol,="" increase="" pain="" on="" gentle="" palpation="" consistent="" with="" positive="" murphy's="" sign.="" integ:="" braden="" score="" -="" 18,="" skin="" intact,="" slightly="" warm="" and="" moist.="" adls:="" pt.="" normally="" attends="" to="" all="" adls="" independently.="" safety:="" provided="" with="" call="" bell="" and="" explained="" how="" and="" when="" to="" use="" it,="" social:="" no="" nok="" present,="" pt.s="" son="" lives="" in="" melbourne="" -pt.="" is="" worried="" about="" him,="" pt="" owns="" his="" own="" company="" and="" is="" also="" concerned="" about="" how="" this="" will="" run="" without="" him="" on="" site.="" declined="" pastoral="" care.="" mse:="" pt.="" is="" anxious="" regarding="" needing="" to="" be="" admitted="" to="" hospital="" ....................................................................................sally="" grimm="" rnd1="" medical="" 0300:="" bloods,="" ultrasound="" and="" ct="" scan="" r/v'd="" by="" surgical="" team="" and="" diagnosis="" of="" acute="" cholecystitis.="" consent="" gained="" by="" patient="" for="" an="" open="" cholecystectomy="" procedure.="" patient="" prepared="" for="" transfer="" to="" surgical="" ward="" when="" bed="" is="" available.="" plan:="" theatre="" at="" 0800="" in="" the="" morning.="" anaesthetist="" will="" see="" p’t="" in="" the="" am="" ...........................................................................................................................................gbrigs="" rmo="" medical="" 0315:="" documentation="" from="" emergency="" admission="" is="" incomplete,="" this="" will="" be="" sent="" to="" the="" ward="" asap="" .........................................................................................................................................g="" brigs="" rmo="" nursing:="" darren="" transferred="" to="" surgical="" ward="" @="" 0400="" hours="" from="" ed.="" cns:="" gcs="" 15,="" alert="" &="" oriented,="" pain="" 2/10="" at="" rest,="" 3/10="" on="" movement,="" cvs:="" hr90="" reg,="" bp="" 110/85,="" t37.8,="" nil="" chest="" pain,="" ivc="" insitu="" in="" l)="" hand,="" vte="" assessment="" completed,="" ted="" stockings="" insitu="" resp:="" rr="" 20,="" nil="" increase="" in="" wob,="" able="" to="" speak="" in="" full="" sentences,="" o2sats="" 96%ra,="" git:="" nil="" n&v,="" fasting="" for="" procedure="" in="" the="" morning,="" safety:="" pt,="" oriented="" to="" ward,="" provided="" with="" call="" bell="" and="" instructed="" when="" and="" how="" to="" use="" it.="" social:="" aws="" assessment="" attended,="" made="" arrangements="" for="" darren="" to="" contact="" his="" son="" and="" business="" in="" the="" morning="" prior="" to="" surgery......="" di="" symes="" rnd1.................................................................................................................................................................="" nursing:darren="" seen="" by="" anaethetist="" at="" 0700hrs,="" consent="" signed,="" ed="" documentation="" has="" arrived="" and="" is="" in="" patients="" file,="" pre-operative="" checklist="" completed.="" awaiting="" tansfer="" to="" theatre.............rachel="" mckenzie="" rnd1="" nursing:patient="" transferred="" to="" theatre="" @="" 0740hrs.......................................................rachel="" mckenzie="" rnd1="" day="" 1="" 0300="" day="" 1="" 0315="" day="" 1="" 0400="" day="" 1,="" 0715hrs="" day="" 1,="" 0740hrs="" clinical="" reasoning="" cycle="" consider="" the="" patient="" situation="" as="" a="" patient="" ="" what="" makes="" this="" patient="" different="" from="" the="" “typical”="" case="" ="" what="" is="" this="" patients="" “normal”="" as="" a="" person="" ="" what="" is="" this="" patients="" story="" ="" what="" past="" experiences="" might="" influence="" this="" presentation="" ="" are="" there="" other="" factors="" –social/cultural/personal="" collect="" cues/="" information="" what="" do="" we="" already="" know="" –="" existing="" patient="" charts,="" documented="" history,="" lab="" &="" diagnostic="" reports="" what="" do="" we="" need="" to="" know="" –="" subjective="" &="" objective="" patient="" assessment="" what="" is="" my="" knowledge="" of="" this="" –do="" i="" need="" to="" review="" pathophysiology/pharmacology/physiology/ethics="" etc.="" process="" information="" interpret="" –="" do="" i="" understand="" all="" the="" patient="" data?="" what="" is="" normal="" vs="">