Description
4 Case studies and 3 Handout, all the information are in the rubric and the case study assignment. is only copy and page and organizing. please the handout separate for case study. I need to add the information for one case studies.
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CASE STUDY ASSIGNMENT
Directions: In BAYADA University, use the Plan of Care (485) designated for the case study you selected
(pediatrics or adults). Use the guide listed below to complete your assignment, using additional reliable
resources as needed. If a section is not applicable to your client, mark “NA”. This case study guideline will
also be used to complete both case study assignments during the program (Week 1 and Week 5).
Information may be obtained from the client chart, Plan of Care (485), Clinical Manager/Clinical
Educator, Client Service Manager, field nurse (preceptor), or caregiver. A home safety assessment will be
completed in the client’s home.
CASE STUDY Required Content
I. Introduction/Demographics (client and family)
a.
b.
c.
d.
e.
Age, gender, diagnosis
Family structure- How does this impact the care you provide?
Cultural considerations- How will this impact the care you provide?
Psychosocial history- How will this impact the care you provide?
Home safety assessment- How does this impact the care you provide?
II. History
a. Discuss significant medical history (Including past surgeries) and 2-3 diagnosis related to why the
client requires skilled nursing care. Include prenatal history if significant.
III. Pathophysiology
a. Discuss the pathophysiology of each client diagnosis you selected. What effect does this
diagnosis have on other body systems?
IV. Nursing assessment
a. List all symptoms exhibited or potential symptoms that may be exhibited by the client and the
diagnosis the symptom is caused by. Some symptoms may relate to more than one diagnosis.
b. Complete Nursing Assessment (document information that would be included in your head-totoe assessment)
V. Nursing diagnosis and goals (Locater 22)
a. Identify the client’s problems or potential problems that may need to be addressed.
b. Identify goals for the client related to each problem or need.
c. Identify the correlation of care (diagnosis) as it relates to the modalities/interventions
(medications/treatments) the client receives. Is the care that is being provided to the client
relative to the client’s diagnosis?
1
VI. Nursing Interventions
a. Explain nursing interventions and treatments required for each identified client problem and
how the intervention relates to client diagnosis. (Why are we doing this treatment and how does
it impact the client’s outcome?)
b. Explain the mechanism of action of five (5) medications prescribed. How do the medications
relate to the client’s diagnosis? Choose medications that are relative to the client’s primary
diagnosis.
c. Discuss therapies being provided, their purpose related to the client’s diagnosis, and the nursing
responsibility for each.
d. Identify any potential emergency situations associated with the client’s diagnosis. How should
you assess the client? How does your assessment impact the client and the nursing
interventions, medications, and equipment required to intervene in an emergency. How would
you prepare for these potential emergency situations?
e. Detail the safety and falls risk measures that are required for this client based on diagnosis and
developmental age. (Locater 15)
f. List equipment required for this client. Include any backup equipment.
VII. Documentation:
a. Identify the abbreviations used in the note below. Annotate the meaning.
b. Identify ways to improve the below-listed nurse’s note:
Beginning of shift:
4 pm-Upon arrival, the client sits in bed watching television. Received report from previous SN (“CT has
had no changes CT has been in bed since noon and had 1 BM and two large voids.) After receiving the
report washed my hands and performed an emergency equipment check and completed across-the-room
assessment. Vital signs were obtained and WNL. CT is in a good mood. The client is in bed with no s/s of
increased work of breathing.
4:30-5:00 pm- client transferred from bed via mechanical lift and assessment completed lung sounds
clear bilaterally and bowel sounds active x4. Pupils are equally round and reactive to light. No tinting was
noted of skin turgor. Pulses equal bilaterally with cap refill less than 2 seconds.
Completion of shift: 10pm:
Client left in the care of PCG.
2
NRP Case Study Rubric
Section
Introduction
History
Pathophysiology
Nursing
Assessment
Nursing Diagnosis
& Goals
Rating
5 to >4.5
Exemplary. All elements gathered with details.
4.4 to >2.53 pts
Average. Necessary information gathered.
2.53 to >0 pts
Needs work. Key elements missing.
5 to >4.5 pts
Exemplary. Thorough history presented with detailed diagnoses.
4.5 to >2.53 pts
Average. History present, diagnoses not fully addressed.
2.53 to >0 pts
Needs work. Key elements of history and diagnoses missing.
10 to >6.7 pts
Exemplary. Thorough explanation of each diagnosis selected and its effect on other body systems.
6.6 to >3.4 pts
Average. Pathophysiology explained with a few elements missing.
3.3 to >0 pts
Needs work. Additional information needed; key elements missing.
20 to >13.4 pts
Exemplary. Thorough lists of symptoms. Complete nursing assessment (head to toe).
13.3 to >6.8 pts
Average. Symptoms are listed. Nursing assessment with minimal errors.
6.7 to >0 pts
Needs work. Key symptoms missing. Nursing assessment missing key elements.
10 to >6.7 pts
Exemplary. Appropriate problems identified. Goals specific to each problem identified. Thorough
connections made between diagnoses and treatments prescribed.
6.6 to >3.4 pts
Average. Problems identified with appropriate goals. Missing elements in connecting diagnoses with
medications and treatments prescribed.
3.3 to >0 pts
Needs work. Key problems or goals missing. Missing correlation between diagnoses and modalities
prescribed.
Points
/5
/5
/ 10
/ 20
/ 10
NRP Case Study Rubric
Nursing
Interventions
Documentation
Total
Comments
25 to >16.7 pts
Exemplary. Thorough explanation of nursing interventions required for each problem identified and
how they affect the outcome. Clear explanation of medications and how they relate to the diagnoses.
Detailed therapies and nursing responsibilities along with identification of emergency situations.
Detailed safety assessment and list of equipment required.
16.6 to >8.4 pts
Average. Clear explanation of interventions, medications, therapies, emergency situations, safety
measures, and equipment necessary for diagnoses selected. Minimal errors noted.
8.3 to >0 pts
Needs work. Multiple details missing in the interventions, medications, therapies,
emergency.situations, safety measures, and equipment necessary for diagnoses selected.
10 to >6.7 pts
Exemplary. Abbreviations annotated with correct meaning. Nurses note improved with minimal error.
6.6 to >3.4 pts
Average. Abbreviations annotated. Nurse note improved with errors.
3.3 to >0 pts
Needs work. Abbreviations not fully annotated. Nurse note with key improvements missing.
/ 25
/ 10
/ 85
Pediatric Simulation Program
R5-Medications
Medications
Concentration
Dose
Fluticasone
50mcg/spray
100 mcg
Reglan
5mg/5ml
3 mg
Senokot
7.5 mg/5 ml
5.25mg
Cholecalciferol
Sodium Chloride 3% Hypertonic
Asmanex
Bactrim
(sulfamethoxazole-trimethoprim)
Acetaminophen
R5 Client Chart 2019-10
1 drop/200 International Units
4ml/vial
100 mcg/actuation
200-40mg/5ml
160mg/5ml
600 International Units
2 ml
100 mcg
223mg – 45mg
144 mg
1
CLIENT-SPECIFIC EMERGENCY PLANMEDICARE CERTIFIED HOME CARE OFFICES
Date:
Robyn Bayada
Client Name:
213 Grassy Pond Rd Sweet Valley, PA 19424
Address:
Karen
Primary Caregiver:
Client #:
DOB: 12-25-2017
Phone #: 570-987-1236
570-987-1236
Relationship: dad
Phone #:
484-951-2589
Cell #:
Frank
570-417-9874 work
Other Caregiver:
Relationship: mom
Phone #:
484-369-1478
Cell #:
412-258-9632
Robert
Grandfather
Emergency Contact:
Relationship:
Phone #:
570-951-3578
Cell #:
215-590-1236
570-632-1452
Physician(s): Dr. Castles
Phone #:
Fax #:
Dr. Sharma
215-987-1489
570-951-3654
Phone #:
Fax #:
Dr. Friend
215-590-7896
570-590-4789
Phone #:
Fax #:
Note: Not all contact information below is required for each client. Information may vary based on client.
Children’s Hospital
215-590-7800
Hospital:
Phone #:
Chester
County
Boro
Fire
&
Police
911
Fire/Police Department:
Phone #:
ABC Medical Supply
800-123-4567
Equipment Co:
Phone #:
Friendship #1
911
Ambulance/Rescue Squad:
Phone #:
570-987-1254
CVS
Pharmacy:
Phone #:
PECO
1-800-123-3698
Electric Co:
Phone #:
PSEGO
1-800-123-9876
1-800-222-1222
Gas Co:
Phone #:
Poison Control:
Other:
Phone #:
Radio or TV Stations:
KYW 1060 AM, ABC, CBS, NBC
Chester County Office of Emergency Management
215-631-6500
Local or Tribal Emergency Management Agency:
Phone #:
484-456-1234
State Emergency Management Agency: Pennsylvania Emergency Management Agency
Phone #:
Fire Safety
Location of Smoke Alarms: Basement, upstairs hallway, and livingroom
Under kitchen sink
Location of Fire Extinguishers:
Location of Circuit Breakers:
Basement wall next to outside staircase
Garage and client’s bedroom
Location of Oxygen (if applicable):
For Trach/Vent Clients
Back of W/C
Location of Trach Emergency Board and GO Bag:
None
Location Backup Ventilator, External Battery:
None
Location of Generator:
Client Evacuation Plan: Carry Robyn outside via the safest and closest exit. Exits @ front door, patio door, or basement. Meet at the corner a
57-1665
neighbors front porch.
Client Clinical Care Needs during Evacuation:
Client’s Mobility Status:
Ambulatory
Amb/Assist
Non-ambulatory
Wheelchair
Bedbound
Does the client use any life-saving equipment (e.g. ventilator, ambu bag)?
Yes
No
Is the lifesaving equipment able to be transported (e.g. battery operated, transportable, condition of equipment
etc.)?
Yes
No
Does the client have special needs (e.g. communication challenges, language barriers, intellectual disabilities,
special dietary needs etc.)?
Yes
No
www.bayada.com
0-9233 9/17 © BAYADA Home Health Care, 2017
R5 Client Chart 2019-10
Page 1 of 2
CLIENT-SPECIFIC EMERGENCY PLAN
FOR MEDICARE-CERTIFIED HOME CARE OFFICES
2
CLIENT-SPECIFIC EMERGENCY PLANMEDICARE CERTIFIED HOME CARE OFFICES
Emergency Response Instructions for Interruption of Service:
The following information must be reviewed with the client in addition to Section 1: How we work with you of the
Admission Booklet.
Evacuation
Take important papers such as your Medicare card, insurance papers, driver’s license.
Remember to take all medication bottles or a list of medications with you.
Shelter in place
Maintain a supply of non-perishable foods for seven days
Maintain adequate supply of bottled water
Be prepared to close, lock and board/seal windows and doors if necessary (e.g. place a wet towel at the base of the
door)
Have an emergency supply kit prepared
Slightly open window and hang sheet or light colored article of clothing out of window
Call 911 and alert them of your location in the home; if in the school setting: follow the school’s shelter in place plan.
Special Needs Considerations
Speech or communication Issues
If you use a laptop computer for communication, consider getting a power converter that plugs into a cigarette lighter.
Hearing Issues
Have a pre-printed copy of key phrase messages handy, such as “I use American Sign Language (ASL),”“I do not
write or read English well, “If you make announcements, I will need to have them written simply or signed”
Consider getting a weather radio, with a visual/text display that warns of weather emergencies
Vision Issues
Mark your disaster supplies with fluorescent tape, large print, or Braille.
Have high-powered flashlights with wide beams and extra batteries.
Place security lights in each room to light paths of travel.
Assistive Device Users
Label equipment with simple instruction cards on how to operate it (for example, how to “free wheel” or “disengage
the gears” of your power wheelchair) Attach the cards to your equipment.
If you use a cane, keep extras in strategic, consistent and secured locations to help you maneuver around obstacles
and hazards.
Keep a spare cane in your emergency kit.
Know what your options are if you are not able to evacuate with your assistive device.
Date
Initials
Signature
www.bayada.com
0-9233 9/17 © BAYADA Home Health Care, 2017
R5 Client Chart 2019-10
Date
Page 2 of 2
Initials
Signature
CLIENT-SPECIFIC EMERGENCY PLAN
FOR MEDICARE-CERTIFIED HOME CARE OFFICES
3
2 1/2 yr old
R5 Client Chart 2019-10
24.5lbs.
7
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9
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R5 Client Chart 2019-10
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16
Department of Health and Human Services
Health Care Financing Administration
Form Approved
OMB No. 0938-0357
HOME HEALTH CERTIFICATION AND PLAN OF CARE
1. Patient’s Hl Claim No.
2. Start of Care Date
3. Certification Period
From:
05-17-2020
302-258-1245
SAMANTHA BAYADA
974 WONDER WAY
12-22-2021
6. Patient s Name and Address
G12.21
9. Sex
M
XF
03-17-2020
12. Surgical Procedure
Date
13. Other Pertinent Diagnosis
Date
M41.45
J96.20
Z93.1
E16.2
08-20-2020
02-16-2020
10-02-2020
12-02-2020
NEUROMUSCULAR SCOLIOSIS, THORACOLUMBAR ->
ACUTE AND CHR RESP FAILURE, UNSP W ->
GASTROSTOMY STATUS
HYPOGLYCEMIA, UNSPECIFIED
57-1605
02-19-2022
BAYADA
2490 BOULEVARD OF THE GENERALS SUITE 130
NORRISTOWN, PA 19403-0000
610-648-9200
F:610-648-9446
Date
AMYOTROPHIC LATERAL SCLEROSIS
5. Provider No.
7. Provider s Name, Address and Telephone Number
CLIFTON HEIGHTS, PA 19018
8. Date of Birth
05-23-1980
11. Principal Diagnosis
4. Medical Record No.
To:
10. Medications: Dose/Frequency/Route (N)ew (C)hanged
1) GLYCOPYROLATE 2.5MG-TID-GT
2) ALBUTEROL SULFATE 0.083% (2.5MG/3ML) 2.5MG-PRN EVERY 4HRS
WHEEZING, SOB-NEBULIZER(IF INEFFECTIVE FOLLOW WITH PROAIR MDI)
3) BUDESONIDE (1MG/PUFF) 2MG-PRN EVERY 4 HRS WHEEZING,
SOB-INHALANT
4) ACETAMINOPHEN LIQUID (500MG/5ML) 1000MG-PRN EVERY 6HRS FOR
FEVER > 100.5 DO NOT EXCEED 3000MG IN A 24HOUR PERIOD-GT
5) IBUPROFEN LIQUID (100MG/5ML) 400MG-PRN EVERY 6HRS FOR PAIN.
DO NOT EXCEED 1200MG IN A 24 HOUR PERIOD-GT ->
14. DME and Supplies
15. Safety Measures
STANDER,OXYGEN”E” TANKS,NASAL CANNULA, ACCU-CHEK GLUCOMETER,->
Formula: KATEFARMS PEPTIDE (1.5CAL/ML)->
O2 PRECAUTIONS, ASPIRATION PRECAUTIONS, SIDERAILS UP, STANDARD->
17. Allergies SULFA, LATEX
18 A. Functional Limitations
Amputation
1.
Bowel/Bladder
(Incontinence)
2. X
Contracture
3.
Hearing
4.
18 B. Activities Permitted
Complete Bedrest
1.
Bedrest
BRP
2.
Up
as
Tolerated
3. X
4. X Transfer Bed/Chair
5. X Exercises Prescribed
16. Nutritional Req.
19. Mental Status:
5.
6.
7. X
8.
1. X
2.
Paralysis
Legally Blind
9.
Dyspnea With
A.
Minimal Exertion
Other
Limitation
B. X
Endurance
Ambulation
MUSCULAR WEAKNESS
Speech
Oriented
3.
4.
Comatose
Forgetful
Depressed
20. Prognosis:
1.
Poor
2.
Guarded
21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)
6.
7.
8.
9.
Partial Weight Bearing
Independent at Home
Crutches
Cane
A.
B.
C.
D. X
Wheelchair
Walker
No Restrictions
Other (Specify)
STANDER
5.
6.
Disoriented
Lethargic
7.
8.
Agitated
3.
Fair
4. X Good
Other
5.
Excellent
SKILLED NURSING SERVICES 18HRS/DAY 4 DAYS/WEEK FOR 60 DAYS CERTIFICATION PERIOD.
SN TO OBTAIN AND ASSESS VITAL SIGNS (PULSE, RR, TEMP, PAIN) QSHIFT, PRN CHANGE IN BASELINE, AND CLIENT/CAREGIVER
REQUEST. OBTAIN O2 SAT Q4HOURS WHILE AWAKE, CONTINUOUS WHILE CLIENT IS ASLEEP, AND PRN S/S ILLNESS, RESPIRATORY
DISTRESS, OR CLIENT/CAREGIVER REQUEST. SN MAY OBTAIN BP PRN CHANGE IN BASELINE AND CLIENT/CAREGIVER REQUEST
RISK FOR ER VISITS AND HOSPITALIZATION: CURRENTLY TAKING 5 OR MORE MEDICATIONS
CLIENT DOES NOT HAVE AN ADVANCE DIRECTIVE
1. INEFFECTIVE RESPIRATIONS R/T ALS DIAGNOSIS
– COMPLETE A RESPIRATORY ASSESSMENT AT THE BEGINNIG OF THE SHIFT/VISIT AND WITH STATUS CHANGES USING THESE
THREE COMPONENTS:->
22. Goals/Rehabilitation Potential/Discharge Plans
1. MAINTAIN A PATENT AIRWAY AS EVIDENCED BY 02 SATS >92% ON ROOM AIR WITH NO EVIDENCE OF INCREASED WORK OF BREATHING.
2. MAINTAIN ADEQUATE NUTRITIONAL STATUS AS EVIDENCED BY ELASTIC SKIN TUGOR, TOLERATING ENTERAL NUTRITION, WITH WEIGHT
GAIN/MAINTENANCE AS DOCUMENTED AT MD APPOINTMENTS
3. MAINTAIN OPTIMAL JOINT MOBILITY AND SKIN WILL REMAIN INTACT->
23. Nurse’s Signature and Date of Verbal SOC Received
24. Physician s Name and Address
SUSAN MAGARGEE
600 HAVERFORD RD
SUITE 1000
HAVERFORD, PA 19041
23 B. Time Verbal SOC Received *
25. Date HHA Received Signed POT
610-658-1930 26. I certify/recertify that this patient is under my care, and I have authorized
the services on this plan of care and will periodically review the plan.
F:610-658-1998
27. Attending Physician s Signature and Date Signed
For Medicare Beneficiaries only: I certify/recertify that this patient is
homebound and needs intermittent skilled nursing care, physical therapy
and/or speech therapy or continues to need occupational therapy. At
recertification: I estimate the duration of continued Home Health services
for this patient to be _______ days weeks months.
28. Anyone who misrepresents, falsifies, or conceals essential information
required for payment of Federal Funds may be subject to fine,
imprisonment, or civil penalty under applicable Federal Laws.
Form HCFA-485 (C-4) (10-15) (Print Aligned)
PROVIDER
* Time Verbal SOC applicable to all Medicare-certified offices and as required by State regulation
PAGE 1 OF 3
Department of Health and Human Services
Health Care Financing Administration
ADDENDUM TO:
1. Patient’s Hl Claim No.
2. Start of Care Date
05-17-2020
6. Patient s Name
SAMANTHA BAYADA
8. Item
No. 10
13
Form Approved
OMB No. 0938-0357
PLAN OF TREATMENT
3. Certification Period
From: 12-22-2021
MEDICAL UPDATE
4. Medical Record No.
To: 02-19-2022
5. Provider No.
57-1605
7. Provider s Name
BAYADA
6) OXYGEN 0.5-4 LPM-PRN TO MAINTIAN 02 SATS > 92%-VIA NC OR BIPAP
REGION
HYPOXIA OR HYPERCAPNIA
14
LANCETS, ALCOHOL PADS, 2X2 GAUZE, ACCU-CHEK TEST STRIPS, ACCU-CHECK CONTROL SOLUTIONS, HALYARD MIC-KEY BUTTON
14FR/1CM-15CM LOW PROFILE G/J TUBE, MIC-KEY EXTENSION TUBING, 2X2 SPLIT GUAZE, iBREEZE BiPAP MACHINE, iBREEZE
TUBING, iBREEZE FACE MASK, DISTILLED WATER, BAG VALVE MASK, COUGHASSIST T70 BY PHILLIPS, YANKAUR, SUCTION
MACHINE: , SUCTION CATHETERS # 14 FR., SUCTION TUBING, JARS AND LIDS, NEBULIZER: PHILLIPS INNOSPIRE, PULSE
OXIMETER: NELLCOR OXIMAX N-600, PULSE OXIMETER PROBES:, FORMULA: KATEFARMS PEPTIDE 1.5CAL/ML, ENTERAL FEEDING
PUMP: , IV POLE, ENTERAL FEEDING BAGS: , MEDICATION SYRINGES: 5ML, 10ML, 20ML
15
PRECAUTIONS, Priority level 3, FALL PRECAUTIONS, TRANSMISSION BASED PRECAUTIONS;COVID PROTOCOL
16
1245ML/DAILY
21
A. PULSE RATE
B. RESPIRATORY RATE
C. AUSCULTATION OF BREATH SOUNDS
– AFTER RESPIRATORY INTERVENTIONS, ASSESS AND DOCUMENT THE FOLLOWING:
A. CLIENT TOLERANCE AND RESPONSE TO TREATMENT
B. BREATH SOUNDS
– PULSE OXIMETER: SPOT CHECK Q 4HRS WHILE AWAKE AND PRN S/S OF ILLNESS, RESPIRATORY DISTRESS,
CLIENT/CAREGIVER REQUEST. PROVIDE CONTINUOUS PULSE OX WHILE CLIENT IS ASLEEP
– CHECK ALARMS AT BEGINNING AND END OF EACH SHIFT HIGH HEART RATE 150 BPM LOW HEART RATE 60 BPM LOW SAT 92
% HIGH SAT OFF %
– CLOSELY OBSERVE FOR S/S OF RESPIRATORY DISTRESS INCLUDING INCREASED RESPIRATORY RATE, INCREASED WORK OF
BREATHING, RETRACTIONS, NASAL FLARING, PALLOR/CYANOSIS,INABILITY TO MAINTAIN 02 SATS >92% ON R/A WITH
INTERVENTIONS SUCH AS REPOSITIONING,SUCTIONING,NEB TX, CPT.
– MAINTAIN PATENT AIRWAY WITH 02 SATS > 92%. APPLY OXYGEN AS NEEDED PER LOCATOR #10
– CHEST PHYSIOTHERAPY: WITHOUT POSTURAL DRAINAGE Q SHIFT AND PRN INCREASED CONGESTION OR INCREASED WOB.
– SUCTION: ORALLY OR NASALLY PRN WITH YANKEAUR SUCTION TIP
– SUCTION AFTER CPT
– SUCTION PRN INCREASED CONGESTION
– NON-INVASIVE BIPAP VIA MASK AT HOURS OF SLEEP & PRN WITH INCREASED WORK OF BREATHING, INCREASED
SECRETIONS, AND/OR LETHARGY.BiPAP SETTINGS: IPAP: 10CM/H20, EPAP: 5CM/H20, RR: 12BPM, FiO2: 100%
– CHECK WATER LEVEL AND REFILL WITH DISTILLED WATER IF LOW
– KEEP RESPIRATORY EQUIPMENT CLEAN. SN TO WASH MASK QDAILY. CLEANSE WITH WARM SOAPY WATER, RINSE WELL, AND
ALLOW TO AIR DRY USING CLEAN/ASEPTIC TECHNIQUE. ONCE FULLY DRY, REASSEMBLE FOR FUTURE USE.
2. ALTERATION IN NUTRITIONAL STATUS R/T G/J GASTROSTOMY TUBE AND ENTERAL NUTRITION
– SN TO OBTAIN AND RECORD WEIGHT Q MD APPOINTMENT.
– SN/CLIENT/PCG TO ASSESS BLOOD GLUCOSE VIA ACCU-CHECK GLUCOMETER MONITORING DEVICE Q MORNING , AND PRN
SIGNS AND SYMPTOMS OF HYPO/HYPERGLYCIA AND RECORD.
– NOTIFY PHYSICIAN IF BS >150, OR
9. Signature of Physician
10. Date
11. Optional Name/Signature of Nurse/Therapist
12. Date
Form HCFA-487 (C-4) (02-94) (Print Aligned)
PROVIDER
PAGE 2 OF 3
Department of Health and Human Services
Health Care Financing Administration
ADDENDUM TO:
1. Patient’s Hl Claim No.
2. Start of Care Date
05-17-2020
Form Approved
OMB No. 0938-0357
PLAN OF TREATMENT
3. Certification Period
From: 12-22-2021
6. Patient s Name
SAMANTHA BAYADA
8. Item
No. 21
22
MEDICAL UPDATE
4. Medical Record No.
To: 02-19-2022
5. Provider No.
57-1605
7. Provider s Name
BAYADA
– HOB ELEVATED 30-45 DEGREES
– MAINTAIN CLIENT UPRIGHT DURING AND FOR 30-60 MIN. AFTER FEEDS
– FEEDING ORDERS:KATEFARMS PEPTIDE (1.5CAL/ML) 415ML TO BE ADMINISTERED VIA BOLUS BY G-PORT OF G/J TUBE
THREE TIMES DAILY AT 0800, 1200, 1600.
– CHECK RESIDUAL AC AND PRN. REPORT VOLUMES > 30 CC’s TO PHYSICIAN. RETURN RESIDUAL VIA GT.
– SN/PCG TO REINSERT, MIC-KEY 14FR/1CM-15CM GJT Q AND PRN ACCIDENTAL DISLODGEMENT, CLOGGING, OR
MALFUNCTION. Q 3 MONTHS AND PRN CLOGGING, ACCIDENTAL DISLOCATION, OR MALFUNCTION.
– ADMINISTER MEDICATIONS VIA G-PORT OF G/J TUBE AMD FLUSH AFTER MEDS WITH 10ML OF H20
– MAINTAIN PATENCY OF G-PORT OF G/J TUBE BY FLUSHING AFTER FEEDINGS WITH 10ML OF H20
– MAINTAIN 5ML OF WATER IN G/J TUBE BALLOON AT ALL TIMES. CHECK BALLOON QWEEK AND S/S OF LEAKAGE
– VENT GT PRN GASTRIC DISTENSION, S/S OF GI DISTRESS
– PROVIDE G/J TUBE SITE CARE QDAILY AND PRN DRAINAGE, CLIENT COMFORT, OR CLIENT/CAREGIVER REQUEST. CLEASE
AREA WITH WARM SOAPY WATER, RINSE WELL, PAT DRY, AND LEAVE OPEN TO AIR USING CLEAN/ASEPTIC TECHNIQUE. MAY APPLY
PRN 2X2 SPLIT GAUZE PER CLIENT/CAREGIVER REQUEST OR LEAKAGE
3. ALT IN JOINT MOBILITY R/T DISEASE PROCESS.
– ASSESS FOR SKIN IRRITATION/REDNESS WHEN MAFO’S AND TLSO REMOVED.
– NOTIFY PT/OT/PHYSICIAN FOR REDNESS PERSISTING > 20 MINUTES AFTER REMOVAL OF SPLINTING DEVICES.
– FOLLOW INSTRUCTIONS OF PT,OT,ST,EI AS AVAILABLE FOR INTERVENTIONS TO OPTIMIZE DEVELOPMENTAL PROGRESS.
– PROM TO ALL EXTREMITIES DAILY
– PROVIDE CLOSE SUPERVISION AT ALL TIMES. USE ALL SAFETY STRAPS IN SEATING DEVICES.
– REPOSITION CLIENT Q EVERY 2HRS AND PRN CLIENT REQUEST/COMFORT.
DISCHARGE PLAN IS TO HAVE OBTAINABLE GOALS MET AND
REHAB POTENTIAL GOOD FOR STATED GOALS.
9. Signature of Physician
10. Date
11. Optional Name/Signature of Nurse/Therapist
12. Date
Form HCFA-487 (C-4) (02-94) (Print Aligned)
PROVIDER
PAGE 3 OF 3
BAYADA Nurse Residency Program
Understanding Your Orders – 485 Week 2
Using the 485 for Week 2 Breakout Materials, answer the following questions:
1. What are her Primary and Other Diagnoses? (4)
2. What is SMA ? (brief)
3. List her Nursing Diagnoses (4)
4. What are her scheduled medications? (3)
5. What are her PRN medications? (5)
6. Looking at the Zone Tool, what would you expect vital signs to be if she were in the Green
Zone?
7. What would her Yellow Zone nursing interventions be?
8. What are her ordered Safety Measures/ Precautions?
9. Looking at her nursing orders for Nutrition:
•
•
What additional assessment is ordered and how often will you perform?
How/what would you document?
1. What are her FEEDING ORDERS?
•
•
•
•
•
formula
rate
route
flushes
other
10. Medication Order specifics:
• What is the route for medications?
• What is the order for flush after medications?
• What nursing intervention must be performed prior to giving medications?
11. What are her stoma care orders?
12. What would you document for her progress on Goals/Rehabilitation Potential /Discharge Plans?
[Box 22] (4)
Understanding Your Orders – 485 Week 3
Using the 485 for Week 3 Breakout Materials, answer the following questions:
1. What are her diagnoses?
•
Primary:
•
Other:
2. What are the vital signs orders for Robyn?
3. What are the Nursing diagnoses?
4. The Zone tool states **Check Airway First** for signs of respiratory distress. Why?
5. What would her baseline respiratory assessment look like?
6. What are her Pulse Oximeter alarm limits and when do you document them?
7. What are the indications for CPT (Chest Physiotherapy)?
8. What are her orders for the suction of oral and nasal secretions?
9. List scheduled respiratory medication orders(dose/amount):
10. List PRN respiratory medication orders (dose/amount):
11. List examples of Aspiration precautions:
12. Robyn wakes up from a nap with +moist cough, +upper airway/nasal congestion, +rhonchi,
O2 sats 93% , RR 28? What would you do?
Understanding Your Orders – 485 Week 4
Using the 485 for Week 4 Breakout Materials, answer the following questions:
1. What are her diagnoses?
•
Primary:
•
Other:
2. What are the Nursing diagnoses?
3. What are the vital signs orders for Noelle?
4. What are the safety measures ordered?
5. What are her seizure precautions?
6. What amount of formula is given in 24 hours per nutrition orders? What is the frequency of
feedings? Any special considerations?
NPO?
7. What would her baseline Neuro assessment look like?
8. Describe her baseline seizure activity and frequency?
9. How do you respond to a seizure?
10. What are her Pulse Oximeter alarm limits and when do you document them?
11. What are her orders for the suction of oral secretions?
12. Using the MAR and the 485, make a time management chart for Noelle for your shift
0700 to 2100.
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N1 Client Chart 2018-02
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N1 Client Chart 2018-02
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N1 Client Chart 2018-02
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NRP Case Study Rubric
Section
Rating
Introduction
5 to >4.5
Exemplary. All elements gathered with details.
4.4 to >2.53 pts
Average. Necessary information gathered.
2.53 to >0 pts
Needs work. Key elements missing.
/5
5 to >4.5 pts
Exemplary. Thorough history presented with detailed diagnoses.
4.5 to >2.53 pts
Average. History present, diagnoses not fully addressed.
2.53 to >0 pts
Needs work. Key elements of history and diagnoses missing.
/5
10 to >6.7 pts
Exemplary. Thorough explanation of each diagnosis selected and its effect on other body systems.
6.6 to >3.4 pts
Average. Pathophysiology explained with a few elements missing.
3.3 to >0 pts
Needs work. Additional information needed; key elements missing.
/ 10
20 to >13.4 pts
Exemplary. Thorough lists of symptoms. Complete nursing assessment (head to toe).
13.3 to >6.8 pts
Average. Symptoms are listed. Nursing assessment with minimal errors.
6.7 to >0 pts
Needs work. Key symptoms missing. Nursing assessment missing key elements.
/ 20
History
Pathophysiology
Nursing
Assessment
Points
Nursing Diagnosis
& Goals
10 to >6.7 pts
Exemplary. Appropriate problems identified. Goals specific to each problem identified. Thorough
connections made between diagnoses and treatments prescribed.
6.6 to >3.4 pts
Average. Problems identified with appropriate goals. Missing elements in connecting diagnoses with
medications and treatments prescribed.
3.3 to >0 pts
Needs work. Key problems or goals missing. Missing correlation between diagnoses and modalities
prescribed.
/ 10
NRP Case Study Rubric
Nursing
Interventions
Documentation
Total
Comments
25 to >16.7 pts
Exemplary. Thorough explanation of nursing interventions required for each problem identified and
how they affect the outcome. Clear explanation of medications and how they relate to the diagnoses.
Detailed therapies and nursing responsibilities along with identification of emergency situations.
Detailed safety assessment and list of equipment required.
16.6 to >8.4 pts
Average. Clear explanation of interventions, medications, therapies, emergency situations, safety
measures, and equipment necessary for diagnoses selected. Minimal errors noted.
8.3 to >0 pts
Needs work. Multiple details missing in the interventions, medications, therapies,
emergency.situations, safety measures, and equipment necessary for diagnoses selected.
10 to >6.7 pts
Exemplary. Abbreviations annotated with correct meaning. Nurses note improved with minimal error.
6.6 to >3.4 pts
Average. Abbreviations annotated. Nurse note improved with errors.
3.3 to >0 pts
Needs work. Abbreviations not fully annotated. Nurse note with key improvements missing.
/ 25
/ 10
/ 85
CASE STUDY ASSIGNMENT
Directions: In BAYADA University, use the Plan of Care (485) designated for the case study you selected
(pediatrics or adults). Use the guide listed below to complete your assignment, using additional reliable
resources as needed. If a section is not applicable to your client, mark “NA”. This case study guideline will
also be used to complete both case study assignments during the program (Week 1 and Week 5).
Information may be obtained from the client chart, Plan of Care (485), Clinical Manager/Clinical
Educator, Client Service Manager, field nurse (preceptor), or caregiver. A home safety assessment will be completed
in the client’s home.
CASE STUDY Required Content I.
Introduction/Demographics (client and family)
a.
b.
c.
d.
e.
Age, gender, diagnosis
Family structure- How does this impact the care you provide?
Cultural considerations- How will this impact the care you provide?
Psychosocial history- How will this impact the care you provide?
Home safety assessment- How does this impact the care you provide?
II. History
a. Discuss significant medical history (Including past surgeries) and 2-3 diagnosis related to why the
client requires skilled nursing care. Include prenatal history if significant.
III. Pathophysiology
a. Discuss the pathophysiology of each client diagnosis you selected. What effect does this diagnosis
have on other body systems?
IV. Nursing assessment
a. List all symptoms exhibited or potential symptoms that may be exhibited by the client and the
diagnosis the symptom is caused by. Some symptoms may relate to more than one diagnosis.
b. Complete Nursing Assessment (document information that would be included in your head-totoe
assessment)
V. Nursing diagnosis and goals (Locater 22)
a. Identify the client’s problems or potential problems that may need to be addressed.
b. Identify goals for the client related to each problem or need.
c. Identify the correlation of care (diagnosis) as it relates to the modalities/interventions
(medications/treatments) the client receives. Is the care that is being provided to the client relative to
the client’s diagnosis?
1
VI. Nursing Interventions
a. Explain nursing interventions and treatments required for each identified client problem and how the
intervention relates to client diagnosis. (Why are we doing this treatment and how does it impact the
client’s outcome?)
b. Explain the mechanism of action of five (5) medications prescribed. How do the medications relate to the
client’s diagnosis? Choose medications that are relative to the client’s primary diagnosis.
c. Discuss therapies being provided, their purpose related to the client’s diagnosis, and the nursing
responsibility for each.
d. Identify any potential emergency situations associated with the client’s diagnosis. How should you assess
the client? How does your assessment impact the client and the nursing
interventions, medications, and equipment required to intervene in an emergency. How would
you prepare for these potential emergency situations?
e. Detail the safety and falls risk measures that are required for this client based on diagnosis and
developmental age. (Locater 15)
f. List equipment required for this client. Include any backup equipment.
VII. Documentation:
a. Identify the abbreviations used in the note below. Annotate the meaning.
b. Identify ways to improve the below-listed nurse’s note:
Beginning of shift:
4 pm-Upon arrival, the client sits in bed watching television. Received report from previous SN (“CT has
had no changes CT has been in bed since noon and had 1 BM and two large voids.) After receiving the
report washed my hands and performed an emergency equipment check and completed across-the-room
assessment. Vital signs were obtained and WNL. CT is in a good mood. The client is in bed with no s/s of
increased work of breathing.
4:30-5:00 pm- client transferred from bed via mechanical lift and assessment completed lung sounds
clear bilaterally and bowel sounds active x4. Pupils are equally round and reactive to light. No tinting was
noted of skin turgor. Pulses equal bilaterally with cap refill less than 2 seconds.
Completion of shift: 10pm:
Client lef
