Acute on Chronic Respiratory Failure with Hypoxia

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Acute on Chronic Respiratory Failure with Hypoxia


Background Information


Demographic

The patient who I will refer to as M.J is a 55-year old single male Caucasian American living in Cleveland OH. He relocated to Cleveland 10 years ago from South Carolina where he has family. He has never been married. He has 4 siblings, a sister 20 years his junior who he claims he has never met and 3 brothers ages 22, 25 and 35 years respectively. His family according to M. J still reside in South Carolina. He has no family here in Cleveland. The assessment was done on June 10, 2019, at Metro Health Cleveland.


History of Present Illness

M.J has been relatively healthy until a month ago when he had noticed difficulty breathing while doing yard work around his property. He has been doing this for the past 5 years without any issues but was now experiencing shortness of breath after working on a small family garden. The symptoms according to M.J did not decrease with time but has gotten worse over the past few days. M.J mentioned he has shortness of breath for simple things like taking a shower, walking his dog two blocks from his home and lying down for a nap. He said he had always slept with his windows closed and one pillow, but now must sleep with his windows open, a working fun and two to three pillows with the bed adjusted to a 30 to 45-degree angle. M.J also said he has recently suddenly gain lost about 5 to 15-pound weight without trying.


Relevant Past Medical and Surgical History

He has no known drug-related allergies and is a full code patient. He has no past surgical history. Additional findings of M.J past medical history includes Cirrhosis of the Liver diagnosed within the past 3 years, hepatitis C, severe back and shoulder pain from a work-related injury, pressure headaches, depression, COPD, anxiety, abdominal distension, GERD and GOUT. M.J said he quit drinking and smoking 2 years ago. He reported smoking approximately 108 pack of cigarettes a year an average of 2 packs a day for the past 40 years. He also reported drinking 9 ounces of alcohol a day for 40 years. The patient was admitted to Metro Health Cleveland on June 7, 2019, for exacerbation of respiratory symptoms. The rest of M.J medical history is unremarkable. The patient upon arriving at the hospital did not use supplementary oxygen at home and at the time of his hospital assessment. He reported bowel incontinent which he stated started about 4 months ago and consistently occur once or twice a week. He gets about 4 loose liquid like stool per day.


Admitting Diagnosis(es)

He was rescued with a bipap for shortness of breath (dyspnea). The patient was diagnosed with the following including but not limited to, acute on chronic respiratory failure with hypoxia, COPD exacerbation, Paroxysmal A-fib and pneumonia of the left upper lobe due to an infectious organism, Atrial Fibrillation (also called AFib or AF) with RVR (HCC) after an EKG was ordered. The patient initial RVR responded to diltiazem however he developed RVR again after a few hours that failed to respond to bolus. His heart rate was now at 98 with diltiazem drip and jumping up.


Laboratory and Diagnostic Tests

A chest X-ray revealed bilateral pleural effusions. Chest x-ray showed changes consistent with COPD. An electrocardiogram showed Paroxysmal atrial (A-fib). A transthoracic echocardiogram revealed a dilated left atrium, an increase in right-sided filling pressure, and mild to moderate mitral regurgitation. The left ventricular ejection fraction (LVEF) was within normal limits. The patient’s Vital signs were as follows: temperature, 99.4 F(37.4°C); heart rate, 62 beats per minute; respiratory rate, 23 breaths per minute; blood pressure, 92/56 mmHg. The patient was well-nourished and in an acute on chronic hypoxic and hypercapnic respiratory distress (oxygen saturation of 96% on room air). His current weight was 71.5kg with a height of 5’8 inches. The patient’s physical exam was normal with clear respiratory sounds and no lower extremity edema. However, the patient failed NIV due to increased work of breathing and was intubated and sedated on mechanical ventilation. The ventilation settings were as follows FiO2 (30), Tidal Volume (400), Respiratory Rate (23), PEEP (5). Lab ordered included WBC count 17.4, RBC count 4.25, Hemoglobin 12.9,Hematocrit 38.4,Platelet count 211,APTT 20,Sodium 135 mEq/L, Potassium 4.5 mEq/L ,Chloride 118 mEq/L ,Magnesium 1.3 mEq/L,CO2 21 mEq/L, BUN 8 mg/dL ,Creatinine 0.5 mg/dL, AST 28 U/L, ALT 17 U/L, Total protein 6.8 g/dL, Albumin 4.6 g/dL,  Total bilirubin 0.9 mg/dL,  Direct bilirubin 0.2 mg/dL and BNP of 827.


Medications

The patient’s medications included, Albuterol (proventil), Propofol infuse and Fentanyl just to mention a few. (a). Albuterol (Proventil) 0.083 % nebulizer solution 2.5mg/3ml. This medication belongs to a class of drugs known as bronchodilators. Therapeutic use of the medication is to relax patient muscles in the airways and increases air flow to the lungs helping him breathe easily without laboring. Major adverse effects include dysphonia, increased sweating, and dry mouth just to mention but a few. Nursing interventions- assess Bp, lung sounds, pulse before a domain and during peak, observe for wheezing, and note amount, color, and character of sputum produced. (b). Propofol infuse 30 mcg/kg/min. Diprivan. Generic Name: propofol; Brand Name: Diprivan. This medication belongs to a class of drugs known as anesthetic, sedative-hypnotic. This medication used as part of balanced anesthesia and on conscious sedation in the mechanically ventilated patient. Major adverse effects include respiratory depress, hypotension, bacterial infection, seizures, and increased triglycerides (prepared in lipid emulsion). Nursing interventions- use strict aseptic technique when preparing and dedicated IV line due to lipid base and a chance of infection, discard after 12 hrs., respiratory support nearby, constant monitoring pump. (c). Fentanyl- the trade name for Fentanyl is Sublimize. Is a synthetic opioid analgesic that suppresses pain by agonizing opioid receptors in the central nervous system. Adverse reactions include Euphoria, Drowsiness, Pupillary constriction, Respiratory arrest, Decreases gastric motility, Nausea, and vomiting, Bradycardia, Chest wall rigidity. Nursing intervention -Initiate safety measures -Assess pain and pain relief with appropriate pain scale -Assess BP, pulse, and respiratory rate/status -Assess the level of sedation -Assess bowel function and prevent constipation -Perform good oral hygiene and intervention to decrease dry mouth.


Nursing Diagnoses and Nursing Interventions and Rationales


Nursing Diagnoses

include possible ineffective airway clearance and breathing pattern; high risk for aspiration, infection, and/or altered respiratory function;

Assessments

include determining baseline respiratory status (assess patient’s ability to cough and deep breathe effectively, auscultate the chest, and note the breathing pattern); monitor chest x-rays, blood gas levels, CBC, sputum cultures, and pulmonary function tests.

Nursing Interventions

include frequent suctioning, intubation and ventilator support, as well as supplementary oxygen and consultation with pulmonologist, if necessary, and the respiratory regimen of chest percussion, and deep breathing due to the patients  ventilator; assist with cough as needed; provide tracheostomy care every 4 hours, chest physical therapy and deep breathing exercises every 2 – 4 hours, IPPB every 4 hours, and use of incentive spirometer every 4 hours. This will reveal the level of decompensation as well as if interventions are effective Complete a full respiratory assessment to detect changes or further decompensation as early as possible and notify MD as indicate.

Nursing Diagnoses

include decreased cardiac output, altered tissue perfusion, the risk for peripheral neurovascular dysfunction, dysrhythmias, DVT, and hypovolemia.

Assessments

include monitoring vital signs, cardiac monitoring for arrhythmias, monitoring response to head elevation, observation for signs of thrombophlebitis, DVT, and PE, and EKG, electrolyte and coagulation tests.

Nursing Interventions

include treating life-threatening arrhythmias, heparin to prevent DVT, use of sequential compression boots, vasopressors and consultation with a cardiologist as needed. Provide supplemental oxygen as appropriate- Supplemental oxygen will ideally increase patient oxygen levels. (Use caution with COPD patients, as they cannot breathe out the CO2 adequately, so over-oxygenation is a concern, and they also may have a lower baseline SpO2 level). Ensure patient is in an optimal position to decrease work of breathing- Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up) Prepare for rapid sequence intubation, if necessary-Helpful to be prepared, as this can progress quickly. Know where the necessary meds and equipment are and how to get ahold of assistive personnel. Remove any negative/distracting stimuli: turn the TV off, encourage family members to be calm When patients are anxious or cannot focus it can increase their work of breathing and exacerbate the issue. Promote a calming environment so all the patient must worry about is breathing. Provide oral care- If a patient is intubated or receiving oxygen via nasal cannula/face mask or tent, or other methods of delivery, oral care is essential to protect the mucous membrane and prevent infection. Cluster care- Decreases oxygen demands if the patient’s rest can be maximized


Collaborative Management

BiPAP therapy targets these dysfunctional breathing patterns. The nurses, especially the respiratory nurses, bedside nurses, and primary care physician play a big role in the management of the condition. It is responsible for the medical team to work together in managing the patient condition and to advocate for things when the condition worsens. On the other hand, the home physician plays a role in ensuring all the medications, exercises and deities are followed well to avoid further complications (Toshikuni et al., 2014).


Therapeutic Modalities

The critically ill individual requires close examination of the essential elements that affect the functioning of the individual. Administration of synthetic food and readily dissolving minerals is essential to rescue the individual (Bernardi et al., 2014). The more critical a critically ill individual requires the engagement of the exercises that are performed through the help of the mechanic machines. The engagement with exercises is limited as the person may lack enough energy. The individual needs to take precautions such as a healthy diet and lifestyle that plays an essential role in avoiding further damage to their health.


Nursing Role Reflection

My interaction compares to what I have learned is very similar. M.J was very cooperative in answering my question and the assessment went smoothly without any difficulty in communication. The assessment took place on Thursday, June 7, 2019, at 10: 30 am. It took place questions herself to clarify things if he did not understand me. There was no communication at the critical care unit at Metro Health Cleveland. The questions were honestly answered, but asked questions herself to clarify things if he did not understand me. There were no communication barriers since we both spoke English. With M.J very cooperative and all the information needed for the assessment gained no unanticipated challenges. As a nursing student, this assessment gave me a glimpse into life as a critical nurse, what will be expected of me when attending to critically ill patients. It is important for me to always show confidence and make my patient feel comfortable and safe during the assessment and process. The experience was a good one I will never forget since M.J was very kind enough to trust me with his care and to allow me to ask the necessary questions. However, there is nothing I will alter to my approach next time since the assessment was successful, but I can always ask for more details with the client’s response. With that said, I am always open to learning and be taught.  Collaborative Resources-Health and Quality of Life Outcomes. Anxiety, depression, and Personality: The Concept of a Directing Object and Its Applications.


Summary

Acute on chronic respiratory failure with hypoxia is caused by many factors that affect the normal functioning of the patient especially the lungs. The common causes include certain lung diseases which can cause chronic respiratory failure. Conditions that affect the way in which the brain, muscles, bones, or surrounding tissues support breathing can also cause chronic respiratory failure. Diseases and conditions that commonly lead to chronic respiratory failure include chronic obstructive pulmonary disease (COPD) complicated pneumonia. An injury to the chest or ribs alcohol overdose, which can harm the brain and affect breathing Lung damage from breathing in smoke which my patient drunk and smoked most part of his life. Excessive consumption of alcohol and smoking over a decade contributes significantly to the development of the disease at a median age of 55 years. Both male and female are at risk of getting the condition in cases where an unhealthy lifestyle is involved. Treatment varies depending on the underlying cause. Antiviral drugs are used in the case where infection or pneumonia is involved, and excessive consumption of alcohol and smoking requires therapy against alcohol consumption and smoking. Some medications are involved in the balancing of oxygen and carbon dioxide in the blood. Regulation of the body temperature and proper diet are employed in the treatment of the critical condition. Home health care following physicians, nurses and all medical team involved are essential in helping individuals in critical conditions.


References

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Brugada Syndrome: Sudden Cardiac Death | Literature Review

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BRUGADA SYNDROME: SUDDEN CARDIAC DEATH

Review of Literature and Case Report.

  • Dr. Nanda Pai
  • Dr. Sanjeeta Umbarkar
  • Dr. Akshay Bafna
  • Dr. Jinal Vaghela

KEYWORDS:

Brugada Syndrome, sudden unexpected death syndrome (SUDS)

ABSTRACT

Brugada Syndrome or Sudden Unexpected Death Syndrome was first discovered by P. Brugada and J. Brugada in 1992

1

. It is a rare genetic disorder characterised by ST segment elevation in V

1

– V

3

leads on ECG, ventricular fibrillation and ventricular arrhythmias which can cause sudden unexpected death in an otherwise normal patient. We wish to highlight the fact that with thorough pre-operative anaesthetic and cardiac evaluation these potentially life threatening patients can be effectively treated for minor oral surgical procedures using regional anaesthesia with lignocaine thereby avoiding general anaesthesia.

INTRODUCTION

“In 1992, Pedro and Josep Brugada for the first time introduced a new clinical entity with ST segment elevation in V

1

– V

3

leads and right bundle branch block (RBBB) pattern associated with a high incidence of ventricular tachycardia/ventricular fibrillation (VT/VF)

1

”. This new entity was termed Brugada Syndrome (BrS) or Sudden Unexpected Death Syndrome (SUDS), occurring in structurally healthy hearts in young individuals, causing life threatening arrhythmias and sudden death. Most of the patients are between second and fourth decades of life however “the youngest patient clinically diagnosed with the syndrome is 2 days old and the oldest is 84 years old

2

”. There is a male predilection, “due to the presence of more prominent I­

to

channels in males than in females

3

” and in many countries it is the 2

nd

highest cause of death in younger men after vehicular accidents.

Signs and symptoms include presyncopal and syncopal attacks and cardiac arrest (many a times during sleep). Routine ECG shows ST segment elevation in leads V

1

– V

3

. Fever may precede syncope or tachycardia. There are 3 types of Brugada ECG Patterns

Type 1: coved type, where ST segment elevation > 2 mm.

Type 2: saddle back type, where ST segment elevation > 2mm with positive ‘T’ wave.

Type 3: coved or saddle back type, where ST segment elevation < 1mm with inverted T wave.

Brugada Syndrome is inherited as an autosomal dominant trait. In 1998, the Syndrome was linked to mutations in SCN5A, the gene that encodes the alpha subunit for the sodium channel and since then over 300 mutations of SCN5A have been identified

4

. Mutations of gene SCN5A cause loss of expression of sodium channel protein which decreases the sodium current resulting in slow conduction in the heart. Bezzina et al presented evidence supporting the theory that an SCN5A promoter polymorphism, common in Asian modulates, variability in cardiac conduction and may contribute to the high prevalence of Brugada Syndrome in Asian population

5

.

CASE REPORT

A 27 year old male patient reported in the department of dentistry, with excruciating pain in lower right second molar and insisted on getting it extracted. Clinical examination and orthopantomogram revealed an extremely carious second molar. The patient was a recently diagnosed case of Brugada Syndrome (Type 3). He gave a history of chest pain about 7 years ago, however, a couple of months ago he had persistent chest pain for which he was admitted in the intensive care unit for about 10 days, during which time he had 3 presyncopal attacks. On cardiac evaluation, ECG revealed an elevated ST segment in V

1

– V

3

leads and partial RBBB pattern but structurally normal heart valves with normal pericardium and absence clots or vegetation. His left ventricular ejection fraction was 60%. CST (Cardiac Stress Test) was performed by Bruce protocol where patient walked for 30 minutes with 10.1 METS which showed no angina/arrhythmia. Basal ECG showed RBBB persisted throughout the test. However there were no significant ST segment changes during the test. Adequate chronotropic and ionotropic response was achieved. CST was negative for stress induced reversible ischaemia/and for arrhytmia. His family history revealed sudden death of his father at a younger age (42 years) with unknown cause. However, there was no diagnosed case of Brugada Syndrome in the family. His past surgical history revealed an appendicectomy and septoplasty. He was a chronic smoker and occasionally consumed alcohol.

Since it was a minor dental surgical procedure and given the patient’s history, the tooth extraction was planned under local anaesthesia using lignocaine hydrochloride with adrenaline (1:2, 00,000) thereby avoiding general anaesthesia and the various drugs used with it that could trigger ventricular tachycardia in a BrS patient. Given the patient’s history of chest pain and diagnosis of Brugada Syndrome, patient was thoroughly evaluated by the anaesthetist and cardiologist prior to the dental treatment. High risk fitness was obtained.

The patient was taken up in the intensive care unit. A ventilator and a defibrillator were kept standby. A 12 lead ECG was attached and was monitored continuously throughout the procedure. An I.V. line was secured. The anaesthetist and cardiologist along with the maxillofacial surgeons formed the surgical team. A right inferior alveolar nerve block was given using 3 ml lignocaine with adrenaline solution. Another 1 ml was used for intra-pulpal infiltration. After checking for subjective and objective signs the tooth was surgically extracted after sectioning the roots. The wound was closed using 3 – 0 vicryl. Patient tolerated the procedure well. Intra operatively patient was given 4 mg Dexamethasone along with injection Augmentin (Amoxicillin Clavulanate) 1.2 gm. Post operatively he was put on oral tablet Augmentin 625 mg and tablet Paracetamol twice a day. Patient was discharged the same day and was followed up in the dental department.

DISCUSSION

Brugada Syndrome is a major cause of sudden unexplained death syndrome (SUDS) and death is caused by ventricular tachycardia and fibrillation (a lethal arrhythmia) in the heart which appears with no warning. The diagnosis in Brugada Syndrome is based on the characteristic patterns on an electrocardiogram, which may be routinely precipitated by administration of certain drugs (ajmaline or flecainide). Brugada ECG pattern is very often hidden, but certain factors can unmask or trigger it like sodium channel blockers, febrile state, vagotonic agents, autonomic nervous system changes, excessive stress, tricyclic or tetracyclic antidepressants, first generation antihistamines (dimenhydrinate), a combination of glucose and insulin, hyperkalaemia, hypokalaemia, hypercalcaemia, alcohol toxicity, heavy meals at night just before sleeping, excessive vomiting, hot humid climatic conditions

6

.

According to Nademanee and Veerakul

6

, north-eastern part of Thailand where SUDS is prevalent and where temperatures can soar to 41

o

C a study is underway to gauge the climatic influences on occurrence of SUDS and they feel that physicians should factor in temperature as a cause of arrhythmogenesis in BrS. Several drugs could precipitate ventricular tachycardia and fibrillation which are listed in world Brugada registry in

Introduction

(Accessibility verified July 04, 2014). All Brugada patients and their treating physicians should be aware of these precipitating drugs at all times.

Many Brugada patients are asymptomatic and the classical pattern on ECG is picked up only by an experienced and trained physician. This pattern should be correlated with age of patient, family history, chest pain, fever and presyncopal/syncopal attacks. Bupivacaine has been reported to unmask Brugada like ECG patterns when administered epidurally

7

. Hence we avoided bupivacaine and used lidocaine with adrenaline (1:2, 00,000 dilution) instead for our patient which was well tolerated by him. Lignocaine (class 1b antiarrythmic agent) displays rapid dissociation kinetics and produces little to no ST segment elevation in patients with congenital BrS

8

. The ventricular tachycardia in BrS can be prevented by avoiding certain aggravating factors like medication, drugs, fever and excessive stress. Brugada patients need to be regularly followed up over a long period of time. In severe cases the only line of treatment is placement of an implantable cardioverter defibrillator (ICD).

Kloesel et al

9

in 2011 did a literature search and compared results of previous reports with theirs regarding outcomes of patients with BrS who underwent surgeries and anaesthetic care and found 21 case reports and 4 case series. They collected data of 52 anaesthetics and 43 patients. In our literature search we found mention of only 2 patients of BrS who underwent surgeries in the maxillofacial region. 1) Plate fixation for mandibular fracture in 56 year old male. 2) Tooth extraction, incision and drainage of odontogenic infection in 55 year old male

10

. However both these patients were treated under general anaesthesia. We decided to avoid general anaesthesia thereby keeping the drugs to be used to the minimum.

By thorough pre-anaesthetic evaluation, proper patient counselling, intra-operative pain control using optimum amount of lignocaine, 12 lead ECG continuously monitored at all times during procedure, constant blood pressure monitoring, avoiding use of certain drugs like bupivacaine, keeping a defibrillator standby and by having a cardiologist and anaesthetist in your surgical team these patients can be successfully managed. Post-operatively ICU monitoring is must for a minimum of 4 hours. There is a dearth of articles in the Maxillofacial and Dental literature regarding the management of these patients and we feel there is a need of more awareness of this not so rare cardiac condition among the dental and maxillofacial surgeons. With proper planning these patients with potentially life threatening and unique cardiac conditions can be safely and efficiently managed by maxillofacial surgeons for dental treatment.

FUNDING

None.

COMPETING INTERESTS

None declared.

ETHICAL APPROVAL

Not Required.

ACKNOWLEDGEMENTS

The authors would like to thank Dr. Kuldeep and Dr. Arvind Singh, 1

st

year Residents, Department of Cardiology, KEMH; Dr. Yogesh Naik, Assistant Professor, Department of Anaesthesia, KEMH for their support throughout the treatment and co-operation.

REFERENCES

  1. Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: A distinct clinical and electrocardiographic syndrome. A multicenter report. J. Am Coll Cardiology 1992: 20: 1391-1396.
  2. Antzelvich C, Brugada P, Borggrefe M, Brugada J, Brugada R, Coraddo P, et al. Brugada Syndrome: Report of the second consensus conference. Endorsed by the Heart Rhythm Society and the European Heart Rhythm Association Circulation 2005: 111: 659-70.
  3. Diego J M, Condiero J M, Goodrow R J, Fish J M, Zygmunt A C, Perez G J, et al. Ionic and cellular basis for the predominance of the Brugada Syndrome phenotype in males. Circulation 2002: 106: 2004-11.
  4. Chen Q, Kirsch G E, Zhang D, et al. Genetic basis and molecular mechanism for idiopathic ventricular fibrillation nature. 199: 392: 293.
  5. C R Bezzina, W Simizu, P Yang, Tamara T, Koopmann M Tanck, et al. Common sodium channel promoter haplotype in Asian subjects underlies variability in cardiac conduction. Circulation 2006: 113: 338-344.
  6. Gumpanart Veerakul M D, Koonlawee Nademanee M D. Brugada Syndrome: two decades of progress. Circ. Journal 2012: 76: 2713-2722.
  7. Phillips N, Priestly M, Denniss A R et al. Brugada type electrocardiographic pattern induced by epidural bupivacaine. Anaesthesia Analogue. 97: 264: 2003.
  8. 8.

    Hideki Itoh

    ,

    Keiko Tsuji

    ,

    Tomoko Sakaguchi

    ,

    Iori Nagaoka

    ,

    Yuko Oka

    ,et al

    . A paradoxical effect of lidocaine for the N406S mutation of SCN5Aassociated with Brugada syndrome. International Journal Of Cardiology. 2007: 121 (3): 239-248.

  9. Benjamin Kloesel, Michael J Ackerman, Juraj Sprung, Bradly J. Narr, Toby N. Weingarter. Anaesthetic management of patients with Brugada Syndrome: A case series and literature review. Can Journal Anaesthesia / Can Anaes 2011. 58: 824-836

    .

  10. Nicholas Theododu, Joseph E. Cillo. Brugada Syndrome (Sudden Unexpected Death Syndrome): Perioperative and Anaesthetic Management in Oral and Maxillofacial Surgery. J Oral Maxillofac Surg. 2009: 67 (9): 20121-25.

Early- Accurate Diagnosis and Early Intervention in Cerebral Palsy

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This paper focuses on Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy; Advances in Diagnosis and Treatment. It was said that Cerebral palsy could be diagnosed as early as 12-24 months, but an infant can show clinical signs of CP as early as the 6th month of age. It is also known to be one of the most common physical disabilities in early childhood. Most parents tend to notice the lack of movement in motor activities which causes concern for them. The reasoning that babies are born with cerebral palsy is unknown but some risk factors can often be considered. Some of those risk factors include conception, issues during pregnancy and/or birth, and the postneonatal period. When diagnosing an infant and/or toddler with CP, a combination of numerous assessments (usually done by using clinical reasoning and standardized tools) is recommended (“Early, accurate diagnosis and early intervention in cerebral palsy: Advances in diagnosis and treatment”, 2019). The article also stresses how early intervention is important because it optimizes and promotes learning and neoplastic, prevents impairments that can interfere with learning, and promotes coping methods for parents and/or caregivers of children who are being diagnosed.

This research article focuses on accurately diagnosing CP and early intervention methods to optimizing neuroplasticity and function and summarizing the best available evidence about cerebral palsy so that early intervention could be followed. Three tools were said to be the best at predicting Cerebral Palsy. Those three tools were: Neonatal magnetic resonance imaging (MRI), Prechtl Qualitative Assessment of General Movements (GMs), and the Hammersmith Infant Neurological Examination (HINE). These tools were all used after 6 months of age. Before 6 months of age, a variety of motor assessments and neuroimaging (also known as MRI) were conducted on the infant. In situations where the parents did not feel as if it were safe for an Infant to have an MRI done, or could not afford one, there were other means to test and accurately diagnose CP.

Clinicians made an explanation that early diagnosis is not always clear. Infants are constantly growing and changing so their voluntary motor repertoires are expanding and changing. So, determining if an infant’s motor dysfunction is limiting their mobility can be difficult at times. Often clinicians said that False negatives can occur giving the parents false reassurance about their infant’s motor development. This happens when some infants only have a mild form of CP. With mild forms of CP, they are still able to achieve some of their motor milestones on time, offering false reassurance to parents that their infant does not have cerebral palsy.

This clinical study was conducted by collecting and analyzing data using infants that were before 6 months of age and after 6 months of age who had a detectable and nondetectable risk of cerebral palsy. Clinicians started by identifying the risk and then deciding if the risk were concerns or warranted an investigation or not. Once the data needed was collected, through MRIs, Gm’s, and AIMS (Alberta Infant Motor Scale), assessments were combined to indicate if the infant had a high risk of CP, it was unclear, or if they did not have CP at all. When data was being collected and analyzed, a sequence of actions through case studies was being performed.

After the case study was performed, it was clear that infants who were 6 months of age and older had lower scores when it came to their clinical neurological examination, neurological imaging, and motor testing. From those assessments, it was determined that those who scored lower were definitely at a higher risk of being diagnosed with cerebral palsy. Infants who scored less than forty on their Hammersmith Infant Neurological Examination and magnetic resonance imaging were likely to be considered non-ambulant. Infants who scored greater than or equal to forty were at a higher risk of having CP and also likely to be ambulant.

After reviewing the article, one problem that I found during this case study was that clinicians acknowledged that people were receiving false positives and false negatives due to some of their findings. In instances that this happened, the infant was re-diagnosed as having a neurological disability and not a normal developmental disability. False-positive and false negatives prolong the diagnoses process and put off getting an intervention to help parents assist in their infant’s development.

The article that I chose inspired me in a few ways neuromotor system. The earlier you can receive a diagnosis, and get help, the earlier you can offer support for the parents and caregivers. As mentioned before, I would love to find out how or what causes damage to the brain cortex and to see an MRI of someone who has been diagnosed with having CP.  I would also like to do more research on CP to get a better understanding of what can be done to help relieve some of the pain that comes from CP and if medical marijuana would help those who suffer from pain that cerebral palsy causes.

I would love for future researchers to continue to study cerebral palsy to be able to diagnose CP earlier than 6 months of age. This scholar article mentioned that there is pregnancy, perinatal, and postneonatal risk that can lead to CP. I would love to know if there is a way that an infant can be diagnosed as having CP through ultrasound while still in the womb. Or for researchers to come up with a way that the brain cortex would be repaired or cured.


References:

can you tell me if there is current research on using psychological testing to ensure better quality selection in organizations like ours e.g. police forces, defence forces etc.If we were to use psychological testing would it make us more or less attractive to potential applicants?

/in /by

can you tell me if there is current research on using psychological testing to ensure better quality selection in organizations like ours e.g. police forces, defence forces etc.If we were to use psychological testing would it make us more or less attractive to potential applicants?

 

Head of HR, State Police Department

We have been thinking about using psychologi;cal testing for selecting entrants to the police force for many years, but never really followed it up. Given your work,

can you tell me if there is current research on using psychological testing to ensure better quality selection in organizations like ours e.g. police forces, defence

forces etc.
If we were to use psychological testing would it make us more or less attractive to potential applicants?
Word length 2000-2500
Structure of Assignment 1: Annotated bibliography
• Introduction: A brief introduction to your assignment, describing the topic and how you have approached it. (approx. 100-150 words)
• Bibliography: An annotated bibliography of approximately 150 words for each of the 9 peer reviewed academic research articles. (approx.1300 – 1500 words)

ANNOTED BIBLIOGRAPHY
1. Oliva, J. R., & Compton, M. T. (2010). What do police officers value in the classroom? A qualitative study of the classroom social environment in law

enforcement education. Policing: An International Journal of Police Strategies & Management, 33(2), 321-338.
2. Cochrane, R. E., Tett, R. P., & Vandecreek, L. (2003). Psychological Testing and the Selection of Police Officers A National Survey. Criminal Justice and

Behavior, 30(5), 511-537.
3. Ho, T. (2001). The interrelationships of psychological testing, psychologists’ recommendations, and police departments’ recruitment decisions. Police

Quarterly, 4(3), 318-342.
4. Lee, C. (2006). Psychological testing for recruit screening. TELEMASP Bulletin, 13(2), 1.
5. LoBello, S. G., & Zachar, P. (2007). Psychological test sales and internet auctions: Ethical considerations for dealing with obsolete or unwanted test

materials. Professional Psychology: Research and Practice, 38(1), 68.
6. Miller, C. E., & Barrett, G. V. (2008). The coachability and fakability of personality-based selection tests used for police selection. Public Personnel

Management, 37(3), 339-351.
7. Furnham, A., & Jackson, C. J. (2011). Practitioner reactions to work-related psychological tests. Journal of Managerial Psychology, 26(7), 549-565.
8. Dantzker, M. L., & McCoy, J. H. (2006). Psychological screening of police recruits: A Texas perspective. Journal of Police and Criminal Psychology, 21(1), 23-

32.
9. Carless, S. A. (2006). Applicant reactions to multiple selection procedures for the police force. Applied Psychology, 55(2), 145-167.
• Analysis: An analysis of the overall bibliography comparing and contrasting the articles in terms of key themes, commonalities and differences in their

research approaches, and their contributions to practice and a synthesis of your findings. (approx. 800 – 1000 words)
• Conclusions and recommendations: A concluding section that draws together your ideas from the articles (based on your analysis and synthesis) and provides

clear and logical recommendations for practice that address the issue(s) raised in the initial HR problem (approx. 300 – 400 words)
Reference list ( APA or Harvard)
ADDITIONAL ARTICLES
1. Haarr, R. N. (2005). Factors affecting the decision of police recruits to “drop out” of police work. Police Quarterly, 8(4), 431-453.
2. White, M. D., & Escobar, G. (2008). Making good cops in the twenty-first century: Emerging issues for the effective recruitment, selection and training of

police in the United States and abroad 1. International Review of Law Computers & Technology, 22(1-2), 119-134.
3. Lough, J., & Von Treuer, K. (2013). A critical review of psychological instruments used in police officer selection. Policing: An International Journal of

Police Strategies & Management, 36(4), 737-751.
4. Super, J. T. (2006). A survey of pre-employment psychological evaluation tests and procedures. Journal of Police and Criminal Psychology, 21(2), 83-87.
5. Arrigo, B. A., & Claussen, N. (2003). Police corruption and psychological testing: A strategy for preemployment screening. International Journal of Offender

Therapy and Comparative Criminology, 47(3), 272-290.
6. Furnham, A. (2008). HR professionals’ beliefs about, and knowledge of, assessment techniques and psychometric tests. International Journal of Selection and

Assessment, 16(3), 300-305.
7. Carless, S. A. (2009). Psychological testing for selection purposes: a guide to evidence-based practice for human resource professionals. The International

Journal of Human Resource Management, 20(12), 2517-2532.
8. Cordner, G., & Cordner, A. (2011). Stuck on a Plateau? Obstacles to recruitment, selection, and retention of women police. Police Quarterly, 14(3), 207-226.
9. Ryan, A. M., & Tippins, N. T. (2004). Attracting and selecting: What psychological research tells us. Human Resource Management, 43(4), 305-318.
10. Dantzker, M. L. (2011). Psychological preemployment screening for police candidates: Seeking consistency if not standardization. Professional Psychology:

Research and Practice, 42(3), 276.
11. Sanders, B. A. (2003). Maybe there’s no such thing as a “good cop”: Organizational challenges in selecting quality officers. Policing: An International Journal

of Police Strategies & Management, 26(2), 313-328.
12. Klehe, U. C. (2004). Choosing how to choose: Institutional pressures affecting the adoption of personnel selection procedures. International Journal of

Selection and Assessment, 12(4), 327-342.
13. Terpstra, J., & Schaap, D. (2013). Police culture, stress conditions and working styles. European journal of criminology, 10(1), 59-73.

Sample Annotation
The citation goes first and is followed by the annotation. Make sure that you follow the required citation style (APA or Harvard). The summary needs to be concise

(please note the following example is entirely fictitious).
In the sample annotation below, each element is numbered (see Key). These numbers are to aid your understanding and should not appear in your written assignment.
(1) Trevor, C.O., Lansford, B. and Black, J.W., 2004, ‘Employee turnover and job performance: monitoring the influences of salary growth and promotion’, Journal of

Armchair Psychology, vol 113, no.1, pp. 56-64.
(2.) In this article Trevor et al. review the influences of pay and job opportunities in respect to job performance, turnover rates and employee motivation. (3) The

authors use data gained through organisational surveys of blue-chip companies in Vancouver, Canada to try to identify the main causes of employee turnover and whether

it is linked to salary growth. (4) Their research focuses on assessing a range of pay structures such as pay for performance and organisational reward schemes. (5) The

article is useful to my research topic, as Trevor et al. suggest that there are numerous reasons for employee turnover and variances in employee motivation and

performance. (6) The main limitation of the article is that the survey sample was restricted to mid-level management, (7) thus the authors indicate that further, more

extensive, research needs to be undertaken to develop a more in-depth understanding of employee turnover and job performance. (8) This article will not form the basis

of my research; however it will be useful supplementary information for my research on pay structures. Key
(1) Citation
(2) Introduction
(3) Aims & Research methods
(4) Scope
(5) Usefulness (to your research/ to a particular topic)
(6) Limitations
(7) Conclusions
(8) Reflection (explain how this work illuminates your topic or how it will fit in with your research)

http://www.lc.unsw.edu.au/onlib/annotated_bib.html
http://olinuris.library.cornell.edu/ref/research/skill28.htm

1. Evaluate the research questions using the Research Questions and Hypotheses Checklist as a guide(please see uploaded guide)

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1. Evaluate the research questions using the Research Questions and Hypotheses Checklist as a guide(please see uploaded guide)

2.Identify the type of qualitative research approach used and explain how the researchers implemented the design
3. Analyze alignment among the theoretical or conceptual framework problem purpose research questions and design
THIS IS THE ARTICLE. I WILL UPLOAD
Phenomenology
Palacios-Cena D. Gomez-Calero C. Cachon-Perez J. Brea-Rivero M. Gome-Perex D. & Fenandez-de-las-Penas C. (2014). Non-capable residents: Is the experience of dependence understood in nursing homes? A qualitative study. Geriatrics & Gerontology International 14(1) 212219. doi:10.1111/ggi.12066

FREE AND FAIR TRADE OR BUDGETARY ISSUE

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Instructions
For this assignment, respond to one of the following options:

Option 1: Find a recent article (less than one month old) from a reputable news source concerning a Free and Fair Trade issue between at least two countries.

  • Summarize the article.
  • What is the issue?
  • Explain why this issue is important to the global community.
  • Evaluate the source.
  • What is your opinion?

Option 2: Find a recent article (less than one month old) from a reputable news source concerning a proposed budgetary change.

  • Summarize the article.
  • What is the issue?
  • Explain who is affected most from the change?
  • Evaluate the source.
  • What is your opinion?

Writing Requirements (APA format). Refer to the APA manual.

  • Length: 3 full pages (not including the title or references page)
  • 1-inch margins
  • Double-Spaced
  • 12-point Times New Roman font
  • Title and Reference page required
  • APA cite article with link
  • Scan copy of article required

What are the probabilities of success of various treatment options?

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What are the probabilities of success of various treatment options?

Let’s have a debate!!! Is nursing theory important to the nursing profession? If you believe that it is important, explain why it is useful. If you do not believe that it is useful, explain why nursing theory is not necessary to the profession? Be sure to provide an example that demonstrates your opinion and a scholarly reference (not using the required textbook or lesson) which supports your opinion.

The diversity movement suggests that there is strength in our differences and that our differences enhance each other. At the same time, the movement insists that our differences should not have economic, social, or political consequences. We are entitled to the same access to resources and opportunities regardless of our differences. The human suffering from Hurricane Katrina and the images of victims has stimulated the debate about differential access to resources.
Read the report Women in the Wake of the Storm: Examining the Post-Katrina Realities of the Women of New Orleans and the Gulf Coast. On the basis of your reading, create a report, answering the following:
• Discuss the prominent dimensions of diversity revealed as a result of the Hurricane Katrina disaster.
• Discuss factors that specifically influenced women’s vulnerability to Hurricane Katrina. While answering, consider the primary dimensions mentioned in the lectures as well as the secondary dimensions such as parental and marital status, income, educational level, military experience, geographic location, work background, and religious beliefs.
• Describe the implications for healthcare organizations as a result of the disaster.
• Discuss at least of two of the policy implications that are outlined in the report. If you were given the task to add another policy recommendation what would it be and why?

Medical Indications: The Principles of Beneficence and Nonmaleficence
1. What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
2. What are the goals of treatment?
3. In what circumstances are medical treatments not indicated?
4. What are the probabilities of success of various treatment options?
5. In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
Patient Preferences: The Principle of Respect for Autonomy
1. Has the patient been informed of benefits and risks, understood this information, and given consent?
2. Is the patient mentally capable and legally competent, and is there evidence of incapacity?
3. If mentally capable, what preferences about treatment is the patient stating?
4. If incapacitated, has the patient expressed prior preferences?
5. Who is the appropriate surrogate to make decisions for the incapacitated patient?
6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
Quality of Life: The Principles of Beneficence and Nonmaleficence and Respect for Autonomy
1. What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
2. On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
3. Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
4. What ethical issues arise concerning improving or enhancing a patient’s quality of life?
5. Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
6. What are plans and rationale to forgo life-sustaining treatment?
7. What is the legal and ethical status of suicide?
Contextual Features: The Principles of Justice and Fairness
1. Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
2. Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
3. What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
4. Are there financial factors that create conflicts of interest in clinical decisions?
5. Are there problems of allocation of scarce health resources that might affect clinical decisions?
6. Are there religious issues that might influence clinical decisions?
7. What are the legal issues that might affect clinical decisions?
8. Are there considerations of clinical research and education that might affect clinical decisions?
9. Are there issues of public health and safety that affect clinical decisions?
10. Are there conflicts of interest within institutions and organizations (e.g., hospitals) that may affect clinical decisions and patient welfare?

topic 7 dq 2 | hrm 645

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Topic 7 DQ

2What are legally required benefits and why are they required by law? Can any of these benefits be waived? Provide an example. Provide one additional benefit that should be made into a legally required benefit.

Topic 8 DQ 1

How could Christian perspectives prevent an employee from performing their required duties? As an HR representative, what legal and ethical responsibilities do you have to ensure all employees views and beliefs are being considered? Provide an example.

opic 8 DQ 2

Equal Employment Opportunity (EEO) and Affirmative Action (AA) are not required in today’s evolved organizational climate. EEO and AA enforce quotas on organizations that must be met during the hiring process, thus hiring unqualified applicants. Evaluate this statement. Do you agree or disagree? Explain.

Topic 7 DQ 2

You are going to present data that has been collected to your administrative group. The focus is on outcome measures and the data collected is unplanned readmission rates at two different hospitals. What format would you choose to display your data and why? What information would you include with the data?

Topic 8 DQ 1

What two elements do you believe play the most significant role in sustaining change and why? Support your answer with one or two references.

Case study of patient care in radiography

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This investigation will consider the needs of a 24-year-old female patient who has been referred for an abdominal X-ray. The patient arrived from the emergency department on a trolley with suspected perforation. She appears to be in a lot of pain, is on oxygen and has been vomiting. She speaks Bengali with little English. She is accompanied by a nurse and her older brother who speaks English. This report aims to identify needs and requirements to form the most suitable plan of care for the patient, whilst in the radiography department. The following objectives will be taken into consideration; the needs of the patient, legal requirements and the role as a healthcare professional. Areas that will be considered in this investigation are communication, consent, patient dignity, health and safety, patient management and inter-professional collaboration. Patients beliefs, ethical issues and confidentiality need to be taken into account when planning patient care, as care needs to be tailored for each individual person who uses hospital services. In this investigation all the issues mentioned will be addressed and a care plan will be made for this patient.

Communication:

Communication is vital with patients as the procedure needs to be explained and understood before the patient gives consent. The 3-point-check, checking the patients name, date of birth and address could help show how much English the patient understands as well as identifying the patient. Last menstrual period also needs to be checked before an x-ray as it could damage the growth of a foetus. The nurse may have already performed a pregnancy test or made arrangements for communication as the patient speaks little English. Communication with the patient’s brother could also be beneficial as he speaks English and could be used as an interpreter if no professional interpreter is available. Interpreters can also be used to convey non-verbal communication such as body movements and gestures. It is normally preferred that relatives are not used as interpreters due the unknown reliability of translation (Fraser and Cooper, 2009). Consent from the patient is required for anyone to be present in the room. In 2004 the British Red Cross and Department of Health issued multilingual phrasebooks to every UK hospital, which covers 36 languages, including Bengali. The intention was to provide translations of common medical terms and questions that can be used for basic communication with patients. Another issue, which could effect communication, is that the patient is nervous, in pain, on oxygen and is vomiting. This could make it difficult for the patient to talk and cause misunderstanding about what is being said. To ease this the patient will need to be kept calm and comfortable by using simple language to explain the procedure and respecting the patient’s individual beliefs and needs (Department of Health, 2003).

Patient Dignity:

Patient dignity is an important part of health care. This includes patient privacy and patients religious, social and ethical beliefs. Privacy can be maintained by providing private areas the patient to undress and discuss treatment. This may not be necessary for this patient as she may already be in a gown or could be unable to undress herself. Once communication with the patient has been organised, her beliefs need to be made clear as it may make a difference to the way that care is provided. The main religious beliefs that may have an effect in a radiography department are a requirement to be treated by a radiographer of the same sex and prohibition to undress in company of others (Department of Health, 2009). For an abdominal X-ray, any material, like metal, which may affect the image, will need to be removed from the area. This may not be appropriate for the patient. Issues with the sex of radiographers can be overcome if other staffs are available. In circumstances where an image cannot be taken due to patients’ needs and requirements, the patient must be informed of the risks involved and be offered other forms of treatment. As researched by Field and Smith (2008) it may not be appropriate for the brother to be with the patient. The patient’s dignity may be lost if information about delicate issues, such as last menstrual period (LMP), is known by family members.

Consent:

Before the abdomen x-ray can be taken the patients consent is needed. Consent is also needed for the patient’s brother or an interpreter to be in the room and for the radiographer to touch the patient for positioning. For consent to be valid the patient has to be correctly informed and must have the capacity to give consent for the procedure in question (Department of Health, 2009). The patient must not be influenced or pressured into either giving consent or not giving consent. Being pressured or influenced can come from healthcare professionals, family members or friends. This is why the patient’s brother is an unreliable source for translation as he could give false translations if he doesn’t agree with the female patient’s decision. In this case it will be vitally important that good communication is made, as the patient may not understand what is said because she speaks little English. The level of understanding may be impaired due to the patient being nervous, vomiting and on oxygen. Due to this it may not be possible to gain written consent so other forms of consent can be used. Consent can be written or verbal. Written consent is normally preferred as it can be used as evidence if necessary. Informed consent is signalled by the actions and behaviour of an informed patient (Department of Health, 2009). For example if the patient positively responds to requests then it can count as consent. The nurse who has accompanied the patient to the radiography department could be a witness to verbal or informed consent.

Health and Safety:

Health and safety is essential in the NHS. This includes health and safety of workers, patients, visitors and anyone who enters the hospital. As the female patient has suspected perforation, is on oxygen and has been vomiting, it is likely that she is a trauma patient. Anger or aggression is a common way to react to trauma. The communication barriers could worsen this. Anger is a reaction to fear and uncertainty and if not controlled can cause danger to workers and carers in the hospital (Easton, 2009). Control methods include talking to the patient, making sure that she understands what is happening and considering body language, as this could worry the patient or the patient’s brother. Also as the patient is on oxygen and has been vomiting its necessary to ensure that the oxygen tank is functional throughout the procedure and that back-up supplies are available if needed. The patient has been transferred on a trolley so will need to be moved to the table for the abdomen x-ray. As the patient may not be able to move herself, a team of trained staff will be required for manual handling to move the patient. The movement can be done in many ways including log rolling and the use of a slip mat. The team should include about 6 members of staff to ensure that no injury is caused to the staff; i.e. back injury, and to ensure that the patient is supported well. Health and safety standards should be maintained at all times.

Patient Management:

The patient will need to be monitored at all times through the x-ray procedure as any changes in her condition could be life threatening. She has suspect perforation. As defined by Oxford (2010), perforation is the creation of a hole in an organ, a tissue or a tube inside the body. A disease, allowing the contents of the intestine to penetrate the peritoneal cavity, can cause this. Basic observation that need to be made while in an x-ray department are pulse, respiration and temperature, as these are easy observations which can be the first signs of changing conditions. The patient is also in a lot of pain. Pain can be assessed by talking to the patient and by watching the way the patient behaves. (Field and Smith, 2008). As the patient has come with a nurse from another hospital department she may have been given pain management such as morphine or paracetamol, and the radiographer should ask the nurse this when the patient first arrives. Other methods of pain management, which include no drugs and can be easily implemented in an x-ray department, include keeping the patient calm, relaxed and distracting the patient from the pain. This can be done by talking to the patient, either with or without the use of an interpreter depending on the needs. If the patient’s condition worsened when in the radiography department the scan may not be possible and emergency action may be necessary. This would involve calling in emergency nurses and doctors to help. The patient would need to be transferred to the relevant part of the hospital for care.

Inter-professional Collaboration:

Inter-professional collaboration is an essential component in healthcare. The College of Nurses of Ontario (2008) believe it means working together with other members of the healthcare team who each make an individual contribution to achieving a common goal or purpose. A number of professions have already been included in the care of the female patient; the nurse who is accompanying her, the doctor who referred her to the x-ray department, porters and possibly many more such as paramedics and triage nurses. The radiographer will need to work with the nurse and the brother to help the patient and possibly with an interpreter to help with translations and communicating with the patient. The referral card will have a doctor’s name and signature, which needs to be checked before the x-ray can be taken. This requires inter-professional collaboration as only certain qualified staff can refer patients to the x-ray department. As the patient is on a trolley and in pain she may not be able to move herself onto the x-ray table. Extra staff will then be required to help with manual handling when moving the patient from the trolley to the table. Porters will be needed to transport the patient after the x-ray has been taken. The x-ray image will need to be sent to colleagues who can then make a plan of care. If surgery is needed then information will need to be supplied to them. Inter-professional collaboration makes healthcare efficient and as radiographers work with every department in a hospital, it is vital that inter-professional collaboration is enforced.

Conclusion:

In summary, it is not only a radiographers duty to take x-ray images of every patient who walks into the department, but also to ensure that their experience is beneficial and satisfactory to their needs. This can take many forms as with the female patient, who speaks little English, her needs required special measurements for communication with possible use of an interpreter, pain control, other forms of consent and precautions about giving details to the patient’s brother. She also requires care as she is wearing an oxygen mask. For this patient, all of her needs and beliefs have to be taken into account, but still whilst working within the law. The radiographer is also obliged to make sure that each patient will be receive the correct care after their visit to the radiography department. For example, information needs to be passed on to relevant professions after the female patient’s abdomen scan is taken. The patient should be able to leave the radiography department feeling that she was welcome in the department and knowing that the hospital staff all cared about her well being. This type of care, which has been tailored to suit the patient’s needs, is not just for patients who cannot speak English or patients who are in pain. Each patient that comes in for a scan needs to be treated individually as everyone has preferences and it is the job of the radiographer to guarantee patient satisfaction on both a healthcare and social level. The patient should always be the priority to anyone in healthcare.

65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing shortness of breath and coughing at least once daily.

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65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing shortness of breath and coughing at least once daily.

65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4 times per week average) serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started no seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.
Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies
NKDA
ROS
Positive for shortness of breath coughing wheezing and exercise intolerance. Denies headache swelling in the extremities and seizures.
Physical exam
BP 171/94 HR 122 RR 31 T 96.7 F Wt 145 Ht 5 3
VS after Albuterol breathing treatment – BP 134/79 HR 80 RR 18
Gen: Pale well developed female appearing anxious. HEENT: PERRLA oral cavity without lesions TM without signs of inflammation no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft non-tender non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema on right no bruising normal pulses. NEURO: A&O X3 cranial nerves intact.
Laboratory and Diagnostic Testing
Na – 134
K – 4.9
Cl – 100
BUN – 21
Cr – 1.2
Glu 110
ALT 24
AST – 27
Total Chol 190
CBC – WNL
Theophylline – 6.2
Phenytoin – 17
Chest Xray Blunting of the right and left costophrenic angles
Peak Flow 75/min; after albuterol 102/min
FEV1 1.8 L; FVC 3.0 L FEV1/FVC 60%
Create a holistic care plan for disease prevention health promotion and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the South University Online Library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition consider visiting government sites such as the CDC WHO AHRQ and Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases Ninth Revision Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
The care plan example provided here is meant only as a frame of reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment diagnosis and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.