Develop evidence-based plans of care integrating findings, diagnostic tests, and health promotion strategies across the lifespan.

Develop evidence-based plans of care integrating findings, diagnostic tests, and health promotion strategies across the lifespan.

4 pages

Assignment Content

  1. Competency

    Develop evidence-based plans of care integrating findings, diagnostic tests, and health promotion strategies across the lifespan.

    Student Success Criteria

    View the grading rubric for this deliverable by selecting the “This item is graded with a rubric” link, which is located in the Details & Information pane.

    Scenario

    Steve is a 27-year-old male who presents to the clinic with intractable pain. One year ago, Steve was riding a bicycle to work and was hit by a car and thrown. His right leg was severed below the knee requiring a right transtibial amputation. He complains of severe pain below the right knee that is uncontrolled with over the counter analgesics. He walks with crutches at home and does not yet have a prosthetic.

    He is married and lives with his wife and 2 children, ages 3 and 7. He had previously worked as a computer programmer but is now on disability from work and collecting unemployment.

    He had no contributory medical or surgical history prior to the accident. Both of his parents are alive and well. He is an only child.

    He reports drinking 2-3 beers a night and 1 pack of cigarettes daily. He denies recreational street drugs.

    He reports currently taking Ibuprofen 600 mg every 4 hours for pain as needed and alternating with Tylenol 650 mg every 6 hours for pain. He is not allergic to any medications.

    Your physical exam revealed:

    General: In no acute distress. Trying to smile, but obviously in pain. Alert and pleasant.

    Vital Signs: T: 98.0; P: 78; RR: 18; B/P: 118/82. Weight was not checked because he could not stand on scale.

    Skin: Good color, no lesions or discharge.

    HEENT: Moist mucous membranes without ulcerations; nares patent bilaterally without drainage. Conjunctivae clear without erythema or discharge.

    Neck: No lymphadenopathy. Thyroid nonpalpable.

    Cardiovascular: Regular rate and rhythm. S1 and S2 are normal.

    Respiratory: Chest is clear to auscultation.

    Abdomen: Soft, nontender, bowel sounds present.

    Musculoskeletal: Full ROM in upper extremities. Right BKA stump is wrapped with an Ace bandage. Upon inspection, incision is reddened but healing.

    Genital: He has normal genitalia. There is no evidence of swelling. Testicular exam is normal and there is appropriate hair growth.

    Instructions

    Using advanced clinical reasoning to analyze and interpret the assessment findings, develop a written comprehensive plan to discuss with Steve to be sure he understands and agrees to the steps ahead. The comprehensive plan should include:

    • A summary of the patient’s story and physical findings.
    • Differential diagnosis.
    • Determination if diagnostic tests, referrals, and return visits are needed with included rationale.
    • Recommended health promotion strategies.
    • Summary of the case.

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