NSG 6435 Week 7 Assignment

NSG 6435 Week 7 Assignment 1 – Comprehensive case study

Assignment 1: Comprehensive Case Study

General Guidelines for Comprehensive Case Study – Week 7 Assignment 1

Your case study should not be just a SOAP note of a patient encounter—it should be a comprehensive evaluation of an iHuman patient case.

You will complete a Comprehensive SOAP note on the approved Pediatric SOAP Note template based on the findings of the iHuman case – then major research and discussion of the disease process are presented.

This case study should be a summative evaluation supported by a minimum of 5 evidence-based articles.

Evaluation of the case study should be no more than 3-4 substantive paragraphs.A minimum of five evidence-based sources (in addition to your text) should be used for your case study. NSG 6435 Week 7 Assignment .

Course texts will not count as a scholarly source; if using data from websites you must go back to the literature source for the information-no secondary sources are allowed, ie, Medscape, UptoDate, etc.

This week, complete the iHuman case titled “Tommy Acker, Child Abuse”.Click here for information on how to access and navigate iHuman.

Name your SOAP note document SU_NSG6435_W7_A1_lastname_firstinitial.doc

i-Human

i-Human is an interactive cloud based system that provides comprehensive learning that integrates clinical experience.The i-Human system helps students develop patient assessment and diagnostic reasoning skills at various levels of education.NSG 6435 Week 7 Assignment .Students will receive online guidance, feedback, and coaching during the learning process.

Student Login Instructions for i-Human

Logging in to i-Human:

Log on at:

http://toolmanagement.next.ecollege.com/tools/thirdparty/blti.ed?launch=LS:iHuman:Patients

Next Steps:

1) If you were unable to attend a Student Orientation Webinar, please watch this introduction

video: https://vimeo.com/185046053/228aea3fc9

2) Additional tutorial videos can be found on the i-Human home screen under the title “Player

Screencast Tutorials”

3) After attending the webinar or viewing the tutorial you are ready for your first practice

case.

4) The i-Human Student Support Center (link on the home screen under the videos) is a

resource for our most frequently asked questions.The Student Manual is also located here. NSG 6435 Week 7 Assignment .

5) If you are having any issues that are not answered through the webinars, videos or support

center, you can email: [email protected]

Solution also available for:

NSG 6435 Week 7 Assignment 2

Assignment 2: SOAP Note

Each week, you are required to enter your patient encounters into eMedley.Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience.You will also need to include a minimum of one complete SOAP note using the Pediatric SOAP Note template.The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Dropbox.When submitting your note, be sure to include the reference number from eMedley. NSG 6435 Week 7 Assignment .

Submission Details:

enter your patient encounters into eMedley and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG6435_W7_A2_LastName_FirstInitial.doc.

complete a Comprehensive SOAP note on the approved Pediatric SOAP Note
template based on the findings of the iHuman case – then major research and
discussion of the disease process are presented.

This case study should be a summative evaluation supported by a minimum of 5
evidence-based articles.

Evaluation of the case study should be no more than 3-4 substantive paragraphs- A
minimum of five evidence-based sourm (in addition to your text) should be used for
your case study. NSG 6435 Week 7 Assignment .

Course texts will not count as a scholarly source; if using data from websites you must
go back to the literature source for the infon’nation-no secondary sources are allowed,
ie, Medscape, UptoDate, etc-

Name: Tommy Acker
Age: 26 months
Sex: M
Height: 2′ 4″
Weight: 22 pounds (BMI 19.7)
Temperature: 97.9 F (oral)
Pulse: 160 bpm – regular
Blood pressure: 68/40 mmHg
Respiratory rate: 50 bpm
SpO2: 93% on room air

Expression: Listless, poor eye contact
Skin: Pale, cool, clammy
Initial position: Lying still on exam table; sucking thumb
Evaluation of Tommy’s height, weight, and BMI:

Height: 28″ = significantly lower than the 5th percentile

Weight: 22# = less than 5th percentile

BMI: 19.7

Key findings
Abdominal pain following a minor fall MSAP
Poor appetite Related
Vomiting x one episode Related
Lethargic Related
Sweaty Related
Rapid breathing/tachypnea Related
Decreased urination; dark, strong-smelling urine Related
Listless, ill appearance Related
Decreased level of responsiveness Related
Tachycardia Related
Hypotension Related
Abdominal distension; epigastric bruising Related
Diffuse abdominal tenderness, guarding, and rebound tenderness Related
Dental caries Related
Down syndrome; global developmental delay Unknown
Atrial-septal defect; status-post surgical repair Unknown
Low-income, single parent with multiple young children Unknown
Small for age; Down syndrome features Unknown
3/6 systolic murmur Unknown
Reducible 2.0 cm umbilical hernia Unknown
Fading (old) ligature marks Unknown
Diaper rash Unknown
Congestive heart failure per history; resolved post cardiac surgery Resolved/PMH. NSG 6435 Week 7 Assignment .

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Problem statement
Tommy, a 26-month-old male with Down syndrome, was brought into the ED by his mother who reports he has been “complaining” of abdominal pain x 2 days, had emesis x 1, is lethargic, sweating,
breathing rapidly and has diminished urine output. All symptoms started soon after his “falling out of the bed during his nap.” She denies associated head trauma but claims he is not eating or
drinking. She denies prior injuries that required medical attention. PMH is notable for post atrial-septal defect repair with transient CHF as an infant. NSG 6435 Week 7 Assignment .The child appears listless and pale. Exam
reveals hypotension, tachycardia, tachypnea, and signs of dehydration. The abdomen is grossly distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is
firm to palpation with diffuse tenderness, guarding and rebound tenderness. A reducible 2.0-cm umbilical hernia is present.

Differential diagnosis: volvulus vs blunt abdominal trauma vs Hirsch sprung disease vs Henoch schon lein purpura vs child abuse vs traumatic brain injury vs incarcerated hernia vs SIRS

Lab and/or Diagnostic Tests:
Complete blood count: WBC: 19000; HgB: 9; platelets: 60; neutrophils: 81; lymphocytes: 17; monocytes:1; segmented neutrophils: 77
Comprehensive metabolic panel: Sodium: 150; potassium: 6;calcium:7;chloride: 90;carbondioxide: 12; glucose: 130; BUN: 130; creatinine: 2; albumin 2.5; protein total: 4.5; ALP: 25
Lipase: 60
Lactic acid: >4
VBG: venous pH: 7.2; PvO2<65%
PT/INR: 16.5/2.0
UA: Protein 4
Amylase: 115
CT scan of abdomen/pelvis with IV contrast: CT scan of abdomen with oral contrast demonstrates a large central area of edema inclusive of

collections of blood. Marked bowel distension. Findings consistent with duodenal hematoma

Skeletal survey: Upright AP chest and abd x-ray showed acuterib Fx left 8th; healing rib Fx right 4th and 5th; old rib Fx right 9th and 10th.
CT of brain within normal.

Final diagnosis: blunt abdominal trauma, child abuse, SIRS

Patient disposition: admit to pediatric ICU.
Contact social worker and local police. Moms boyfriend admitted to punching tommy in the stomach and throwing him to the bed. NSG 6435 Week 7 Assignment.