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DUE REAL 1
Name: Linda McCarthy
Age: 86 years
Provider: K. Townsend MD
Codestatus: DNI
BMI: 24.1
Allergies: penicillin, atorvastatin, red dye, latex
Admitweight: 145 lbs (65.8kg)
Linda McCartchy had a rough night. She was pretty restless and only slept two hours.
This morning she was having an issue with her hearing aids not working. They kept
whistling. I went to change the batteries, but she was out of them. Her family will be
bringing them in later today.
Nursing Assessments and notes
11/1
0700
Neuro/Cognitive: Alert and oriented to person and place. She intermittently
confused and called staff by the names of her children. Speech raspy. 4/5
strength in all extremities.
Cardiovascular: S1 and S2 heart sound present. Heart rate regular and even.
No edema was noted. Pedal pulses +2, radial pulses +3. Capillary refill less
than 3 seconds.
Respiratory: Even, regular, unlabored. Lung sounds wheezing through all
lung fields. Chronic dry cough. Wears 2 L via nasal cannula chronically.
Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended,
non-tender. Last bowel movement 2 days ago.
Genitourinary: Occasional stress incontinence.
Integumentary: Scattered bruising. Various stages of healing.
Sensory: Hard of hearing. Wears hearing aids and glasses.
11/1
0730
ADLs: Independent with utensil holders
Activity: Ambulated 100 feet with a roller walker
11/1
0830
Nursing Note: Client resting quietly in bed. Looking out the window, not
responding to staff prompts for verbal interaction. Moves all extremities
appropriately. Morning medications were administered without difficulty. Able
to state name but unsure of her birthday. Up in the hall with physical therapy.
Shuffling gait with use of a rolling walker.
11/1
1100
Nursing Note: RN called to bedside. The client stated that the staff took her
favorite earrings. Earrings were found in the client’s tissue box at the bedside.
11/1
2015
Nursing Note: Client evening hygiene offered. The client begins yelling, “No!
No! No!” as staff offer to assist with teeth brushing and denture care. Attempts
were made to deescalate the client and place her hearing aids so that she
could hear the conversation. The client begins attempting to hit and bite staff.
Client sitting in bed. Staff leave room to reduce stimulation.
11/1
2015
Neuro/Cognitive: Alert, oriented to self only. She believes it is 1965 and that
there are strangers in her house. Client calling out for her mother. Extremely
hard of hearing with hearing aids in place.
11/2
0700
Nursing Note: The client is awake in bed, staring around her room, rubbing
her eyes, and frequently yawning. Noted to have redness and purulent
drainage from right eye. Provider notified; prescriptions received.
11/2
0900
Nursing Note: Appetite poor, ate 5 small bites only, Drank a cup of juice.
Weight down. Will encourage protein supplement drinks between meals.
Date Intake Source & Amount
11/1 0700 Oral 240 mL
11/1
0900
Client Information:
Medical History: Presbyopia, bilateral cataracts, Alzheimer’s dementia,
hearing loss, hypertension, hyperlipidemia, osteoarthritis, ambulatory
dysfunction, chronic obstructive pulmonary disease
Medications:
● Rivastigmine 6 mg by mouth twice daily
● Lisinopril 20 mg by mouth daily
● Ezetimibe 10 mg by mouth daily
● Simvastatin 40 mg by mouth daily
● Docusate sodium 100 mg by mouth daily
● Polyethylene glycol 17 g by mouth daily – diluted in 8 oz of beverage
● Duloxetine 60 mg by mouth daily
● Artificial tears 1-2 drops into eyes PRN for dry eyes
● Oxygen 2L/NC PRN for difficulty breathing
11/2 0730 Prescriptions:
● Ciprofloxacin ocular ointment 0.5-inch right eye three times
daily
Your Experience & Research Articles
Based on this week’s reading, share a qualitative research article that is useful and applicable to your practice based on your readings. Critique and evaluate this article based on the credibility, audibility, and fittingness proposed by Guba & Lincoln in Chapter 6 of your textbook.
Discussion tip #1: Review Table 6.2 in your textbook and discuss each point in relation to your qualitative research.
Discussion tip #2: Do you have an article that uses qualitative research?
Consequences of plagiarism on master's level
For this assignment, we want you to write a short reflection (approximately 400 words) on the consequences of plagiarism in higher education, specifically at the master’s level. Discuss why academic integrity is crucial, potential consequences for students who engage in plagiarism, and how to avoid it. Be sure to cite any sources you use properly less than 5 years old. and at least 2 references.
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From a financial standpoint, what impact would this scholarship have on your education?
Discuss how your interest in your field or major developed. Describe your experience in the field and what you gained from this involvement. Please provide a minimum of 200 words.
When did you know that you wanted to pursue this degree? What makes now the time to pursue or continue your pursuit of your degree? Please provide a minimum of 200 words.
What are your short- and long-term career goals, and how will earning this degree contribute to achieving those goals? Please provide a minimum of 200 words.
Describe the skills and traits you possess that help you overcome obstacles. Please describe an experience or accomplishment that you are proud of. Please provide a minimum of 200 words.
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I was really surprised by my results from the essential self-assessment the 2nd time around. I made sure not to look at the 1st one before I completed it. My score was initially 36 and now is 46. I had significantly more excellent than the very good column than before. Two areas that I have learned a great deal in. I have a better understanding of the use of CIS systems to document interventions related to achieving nurse sensitive outcomes. I also recognize the role that information technology plays in improving patient care outcomes and creating a safe care environment.
Understanding the difference between a CIS system and an EHR is important to understand how each work. Knowing now that a CIS system focuses on management of clinical data and information that allows practitioners and patients to use the date. CIS systems provide the infrastructure to bring all applications together. The goal of an EHR system is to improve quality and safety of patient care by benefits of improved accuracy and completeness of patient health information.
“Information technology is the process of searching, organizing and managing data supported by the use of computers” (Hebda et al., 2018). With the use of science to support the use of technology in healthcare, our patients can have safer and better outcomes in care.
As I continue my nursing career, I will use the knowledge I have learned to help provide the best care to my patients. I currently use the CIS system at my current position. But now understanding its use better, I plan to help educate my patients on the ability for them to create an account to manage their health. By receiving recent lab results, vital signs, and physician notes on after care summaries, patients can take better control of their health. They can also use the system to make future Dr. appointments and chat with the practitioners. Using information technology has been something my hospital continues to grow on. I will use information technology more to identify areas in our practice that can benefit from updating our nursing practice. Using our charting system, I can identify areas that nursing practice may be lacking such as IV start success rates. “Technology aids the nurse in the collections, analysis and application of data for decision making” (Chamberlain Lesson 8, 2023) By researching, analyzing, and applying what I’ve learned, I can help our nursing staff enhance performance in delivering of safe patient care.
Resources:
Chamberlian University. (2023, September).
Week 8 Lesson: Informatics as a specialty [Lecture Notes].
Week 8: Lesson: Informatics as a Specialty: RN Information Systems in Healthcare-Wells-Kersbergen (instructure.com)
Hebda, T., Hunter, K., & Czar, P. (2018). Handbook of Informatics for Nurses & Healthcare Professionals (6th ed.). Pearson Learning Solutions.
https://ambassadored.vitalsource.com/books/9781323903148
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