Discussion Example of Acute Care Soaps Notes
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
Discussion Example of Acute Care Soaps Notes
EXAMPLE
HPI: 45 y/o female from the Virgin Islands admitted for infected left stump. Transferred to ICU for worsening septic shock with respiratory distress. Last night had active bleeding from stump, surgery at beside. Patient in cardiac arrest x2 with ROSC. 4 units PRBC, 2 FFP, 1 of platelets given.
> PMH: chronic- HTN, PVD, DM, Mitral regurgitation, MI, HFrEF 20-25% (8/17), pulmonary hypertension
> FH: Mother HTN, Father DM.
> SH: Denies use of alcohol, drugs or smoking.
> ALL: NKDA
> MEDS: Metformin 500 mg BID, Metoprolol succinate 100 mg PO daily, aspirin 81 mg PO daily
> Objective
> VS: BP 97/55, HR 98, RR 20, MAP: 69, O2: 100%, Ht: 5’3”, Wt 89 kg, BMI 34.9
> LABS: AST 396/ ALT 63 ^, WBC 14.8 ^, H/H 7.6/30, platelets 350, aPTT 40, Glucose 202 ^, Na 144, K+ 3.9, lactic 10^. BUN 40, creat 3.0. Leg wounds culture: achromobacter. Tracheal aspirate: stenotrophomonas (9/9)
> PE: Anasarca. Mechanical ventilation, diminished breath sounds. Wet gangrene of leg stump debrided. Dry gangrene of right lower extremity. Lines: NG tube, PICC, left IJ.
> Assessment: 1. Septic shock 2. Acute Hypoxic respiratory failure 3. Left stump infection, dry gangrene of RLE 4. Post cardiac arrest 5. Apical thrombus
> Plan :
> 1. Septic shock. Continue vasopressors, levophed currently at 15 mcg/min. Analgesia with fentanyl drip, dilaudid 0.5 mg q4h PRN. Monitor CBC/BMP and lactic levels. Daptomycin to be continued for 6 weeks (from 8/25). Mondays check CKP, ESR, CRP levels while on daptomycin. GI prophylaxis with Pepcid 20 mg IV daily. Glucose checks q8h.
> 2. Acute hypoxic respiratory failure. Continue mechanical ventilation and monitoring of patient oxygenation. Fio2 successfully titrated from 60 to 40%.
> 3. Left stump infection, dry gangrene of RLE. Zosyn 3.375 IV to be continued for 6 weeks from 8/25. Consult ID.
> 4. Pending CT brain post cardiac arrest.
> 5. DVT prophylaxis with heparin drip (apical thrombus). Continue to monitor coagulation levels.
EVIDENCE-BASED PRACTICE FOR NURSES Appraisal and Application of Research
2
THE PEDAGOGY
Evidence-Based Practice for Nurses: Appraisal and Application of Research, Third Edition, drives comprehension through various strategies that meet the learning needs of students, while also generating enthusiasm about the topic. This interactive approach addresses different learning styles, making this the ideal text to ensure mastery of key concepts. The pedagogical aids that appear in most
chapters include the following:
3
Chapter Objectives These objectives provide instructors and students with a snapshot of the key information they will encounter in each chapter. They serve as a checklist to help guide and focus study.
Key Terms
Found in a list at the beginning of each chapter and in bold within the chapter, these terms will create an expanded vocabulary in evidence-based practice.
Critical Thinking Exercises An integral part of the learning process, critical- thinking scenarios and questions are presented by the authors to spark insight into situations you may face in practice.
4
FYI
Quick tidbits and facts are pulled out in chapter margins to highlight important aspects of the chapter topic.
Test Your Knowledge
These questions serve as benchmarks for the knowledge you are acquiring as you move throughout the chapter.
5
Rapid Review This succinct list at the end of the chapter compiles the most pertinent and key information for quick review and later reference.
6
Apply What You Have Learned
With this outstanding feature, you will be challenged to apply your newly acquired knowledge to specific evidence-based practice scenarios and research studies.
7
Case Examples Found in select chapters, these vignettes illustrate research questions and studies in actual clinical settings and provide critical-thinking challenges for students.
8
Keeping It Ethical
Relevant ethical content concludes each chapter to ensure ethics are kept at the forefront of every step of the nursing process.
9
10
World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 info@jblearning.com www.jblearning.com
Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.
Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com.
Copyright © 2015 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.
The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes.
All trademarks displayed are the trademarks of the parties noted herein. Evidence-Based Practice for Nurses: Appraisal and Application of Research, Third Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product.
There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only.
The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein.
Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field.
When consideration is being given to use of any drug in the clinical setting, the healthcare provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used.
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
CLICK ON THE LINK HERE: https://www.perfectacademic.com/orders/ordernow
Also, you can place the order at www.collegepaper.us/orders/ordernow / www.phdwriters.us/orders/ordernow
Do You Have Any Other Essay/Assignment/Class Project/Homework Related to this? Click Here Now [CLICK ME]and Have It Done by Our PhD Qualified Writers!!