CLASS NAME: PRACTICUM IMMERSION
ASSIGNMENT: CASE PRESENTATION “IRON DEFICIENCY ANEMIA”
NOT TO WRITER: MY CHOICE OF PRESENTATION TOPIC IS “IRON DEFICIENCY ANEMIA”. Below is information on patient and what was done for patient at the clinic. Presentation instructions is also included. I will also attach the case presentation instruction plan to this order.
Info of patient that I am using: 36 year old female with history of anemia and B12 deficiency (Note pt is already on weekly b12 IM injections). She presented to the clinic complaining of excessive and frequent menstruation, fatigue, and weakness.
-Patient is alert and oriented x 4.
• Initial encounter – Patient presented with recent increased menorrhagia, fatigue and weakness. Intervention included drawing blood work to determine patient’s blood levels to help determine best way to treat patient.
-Blood work ordered during initial encounter included CBC with diff, CMP, Ferritin, B12, Folate, Retic count, LDH and hemoglobin electrophoresis.
– Her vitals during the initial visit height- 63 in, weight 155 lb, BMI 27.46, 119/67 mmHg, 98.6 °F, 83 bpm, 18 RR
• Next encounter was after a week when blood work resulted.
Remarkable results is as follows Hemoglobin 8.6, Hematocrit 30.7, Ferritin 3, MCH 18.7, MCHC 28.0, MCV 66.7, RDW 17.2,
-Her vitals during the next visit height- 63 in weight- 155 lb, BMI 27.46, 120/80 mmHg, 98.2 °F, 85 bpm, 18 RR, 98 %
Chief complains: Menorrhagia, fatigue, and weakness.
Diagnoses: (D50.9) Iron deficiency anemia, unspecified, (N92.0) Excessive and frequent menstruation with regular cycle, (R53.83) Other fatigue.
Orders: medication for Iron deficiency Anemia: Sodium Ferric Gluconate Complex in Sucrose (Ferrlecit) 12.5 MG/ML Intravenous Solution. This will be administered weekly for a few weeks.
Subjective
Subjective note
REVIEW OF SYSTEMS: General: No weight change, Reports weakness and fatigue, generally well. Head: no headaches, no vertigo, no injury. Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain. Ears: No change in hearing, no tinnitus, no bleeding, no vertigo. Nose: No epistaxis, no congestion, no obstruction, no discharge. Mouth: No dental difficulties, no gingival bleeding, no use of dentures. Neck: No stiffness, no pain, no tenderness, no noted masses. Breast: No noted lumps, no tenderness, no swelling, no nipple discharge. Chest: No dyspnea, no wheezing, no hemoptysis, no cough. Heart: No chest pains, no palpitations, no syncope, no orthopnea. Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena. GU: No urinary urgency, no dysuria, no change in nature of urine. Gyn: No change in menses, no dysmenorrheal, no vaginal discharge, no pelvic pain. Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesia or numbness. Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia. Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
Objective (normal )
Objective note
GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, oriented x 3 and appears to be in no acute distress. HEAD: Symmetric, Normocephalic. EYES: PERRL, EOMI. Fundi normal, vision is grossly intact. EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. NOSE: No nasal discharge. THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses. No hepatosplenomegaly. MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait. BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm. EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. SKIN: Skin normal color, texture and turgor with no lesions or eruptions. PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal..
Plan
Plan note
Ferrlecit 62.5mg ivpb x 1 well tolerated
Vit B12 1000mcg IM x 1
RTC 1 week
Introduction
By the end of this assignment, a learner will be able to:
• Support a diagnosis or treatment plan with scientific research, advanced concepts, quality care principles, and/or mathematics. (CO1 and CO2)
• Present a case that demonstrates your advanced skills in physical assessment, pharmacology, and therapeutic nursing interventions in the care of patients. (CO7)
• Analyze client outcomes to evaluate the effectiveness of treatment. (CO3)
• Identify the need for change in a patient’s health-care plan that will either increase the effectiveness of the treatment, increase the safety of the treatment, and/or decrease the cost of the treatment without decreasing the treatment’s effectiveness. (CO5)
Presentation Instructions
Your completed presentation must contain at least 15 slides and the presentation itself should span 15–20 minutes.
I. Topic Selection
Begin your presentation by stating either:
• A diagnosis and treatment plan you made or witnessed during your practicum.
• A health-care service involving either health promotions, disease prevention, health protection, anticipatory guidance, or disease management that you provided or witnessed during your practicum.
II. Research
Support this diagnosis or the provided health-care service with:
1. At least four references (for example, Buttaro, Grubbs, Bickley, and a medical journal)
2. A research article
The research article should meet the following requirements:
• Supports the diagnosis and/or treatment
• No more than 5 years old
• Qualitative or quantitative
• Research study (for example, population, sample size, results, conclusion, and so on)
Your presentation must contain a slide detailing how the research article you chose and presented defends or supports the diagnosis and treatment or provided health-care service.
III. Analysis
Analyze the outcomes to evaluate the effectiveness of the diagnosis and treatment plan/provided health-care service.
IV. Reflection
Identify how the treatment plan or health-care service could have been altered in a way that either increased the effectiveness of the treatment, increased the safety of the treatment, and/or decreased the cost of the treatment without decreasing the treatment’s/health-care service’s effectiveness.
V. Posing Questions
At the conclusion of your presentation, pose two discussion questions for your classmates to answer.
VI. Citations
Include a References page in APA style at the end of your slideshow.
Case Presentation Rubric
Criteria Ratings
Introduction Greets audience; introduces self and interest in topic. Reviews objectives.
Discussion of topic with CC, subjective data, objective data (physical assessment), diagnosis, differential diagnosis, risk factors, treatment plan Discussion includes all required areas of content. Knowledge of topic is evident in organized presentation
Research article used to support diagnosis by student referencing and providing evidence on a slide. Also cites four additional resources in APA format. Supports diagnosis with research article provided, cites four additional resources, and has no errors in APA.
Conclusion and summary Conclusion and summary with recommendations; provides two questions for classmates.
Verbal presentation and professionalism Good eye contact and dialogue that flows and is easy to understand. Presentation is within time frame. Professional attire; presentation setting is not distracting.
Visual presentation No errors in spelling, vocabulary, or punctuation. Appropriate font size. At least 15 slides. Creative.
PLACE THIS ORDER OR A SIMILAR ORDER WITH NURSING TERM PAPERS TODAY AND GET AN AMAZING DISCOUNT
The post IRON DEFICIENCY ANEMIA appeared first on Nursing Term Papers.
