Physical Assesment Case Study Research Paper Example | Topics and Well Written Essays - 1000 words

Physical Assesment Case Study - Research Paper Example Client was awake, alert and coherent. Physical assessment revealed erythematous plaques covering both cheeks, and at the bridge of her nose, without affecting the nasolabial folds or any other part of her body. Aside from that, her head was found to be normocephalic with no signs of trauma or other deformities. She had clear white sclera and clear conjunctiva; her pupils were reactive to both light and accommodation. Erythema was noted on the posterior wall of her pharynx, and ulcers were found on both of her buccal mucosa. Her neck showed no swelling or bumps, and no traces of lymphadenopathy or thyromegaly. Patient had no trouble achieving full range of motion in her joints with no obvious swelling or deformities. Patient’s vital signs showed a normal heart rate at 62 beats per minute, normal respiratory rate at 12 breaths per minute, a normal blood pressure of 112/66 mmHg, and an elevated temperature of 100.3 degrees Fahrenheit. Interview and Health History Patient reported that the rash was first noticed after a week outdoor hiking and camping in the Appalachians. She denies exposure to any new skin products, usage of medications, environmental exposure, and food allergies. She has not taken any medication for the rash. She denies experiencing headache, sore throat, ear pain, nasal congestion, chest pain, shortness of breath, cough, pain during urination, urination and diarrhea. She reports no stiffness in the joints or difficulty in getting up in the morning. The only surgical procedure that the patient has undergone was a tonsillectomy at age 9 due to her chronic strep throat infection. Other than that, she has not had any other diseases needing hospitalizations as an adult. An investigation into her family history revealed that her mother had rheumatoid arthritis She does not engage in smoking or recreational drug use, but admits to taking a glass of wine almost every night with dinner. Nursing Care Plan Based on the information, the patientâ€⠄¢s main concern is the rash on her face and what it means. Considering the location, the shape, and the other symptoms, it could be a malar rash pointing to Systemic Lupus Erythematosus, but since it is yet to be diagnosed, the more pressing concern is her fatigue. This can be caused by not enough energy being produced to cope with the inflammation going on with her rash, the erythematous posterior wall of her pharynx, and her fever. Her weight loss could also be an effect of this. Fatigue is defined as â€Å"an overwhelming sense of exhaustion and decreased capacity for physical and mental work at the usual level† (Doenges, Moorhouse, & Murr, 2010). The patient verbally reports feeling fatigue after the rash appeared (Sommers, Johnson, & Beery, 2010; Smeltzer & Bare, 2011; WebMD, 2011). In a nursing care plan to take care of the client’s fatigue, the desired outcomes would be that the client will: - Report improved sense of energy - Identify the basis of fatigue and individual areas of control - Perform ADLs and participate in desired activities at level of ability - Participate in recommended treatment program with sufficient energy (Source: Doenges, Moorhouse, & Murr, 2010; Sommers, Johnson, & Beery, 2010) Nursing interventions to help with the patients fatigue are: Intervention: Identify the presence of physical and/or psychological conditions (e.g. infection, nutritional deficiency, depression, trauma, autoimmune disorders, substance use/abuse,

Information Technology Project Management System thinking Essay

Information Technology Project Management System thinking - Essay Example Although Smith says that their 6000-plus health care workers participated in the system's development and implementation, I have found no details on just how this came about. Baker describes the need for the staff to have an ID and password before they could treat hospital patients. Improvement in services, especially pharmacy, is also mentioned, as well as a faster time to get test results in other departments such as X-ray. What isn't mentioned are the obstacles met and resolved during implementation of the new technology. Baker does say that, according to Smith, other systems, not referred to by name, were studied and found to be lacking, and the reason for one failure was because staff usage was voluntary, and not enough people signed up to use it. This is the only reference to an obstacle. Baker says that Smith attributes the success of Epic at ENH to the commitment of management to make it a priority. In fact, most of the credit is given to management, even though cooperation o f staff appeared to be very much a contributing factor. Although Baker did describe the system set up with staff to make the system work, none of the pros or cons faced by them was covered. Comments: In past years, especially before the year 2000, patient record keeping in health institutions focused far more on the financial records of the institution, with computer usage mostly in accounting. Patient tracking did not always exist as a complete package, combining physician, laboratory, hospital, and information records. Because of layoffs in the health field, in clerical as well as medical areas, filing was not always up to date, and records were sometimes missing. This led to medical errors. The computer as an interconnected unit collecting all information on a single patient was not being utilized. As the millennium drew near, the need for updated systems of communication through information technology became evident, and a concerted effort was made to prevent data loss with the advent of Y2K. Even though the anticipated problems never really materialized, the use of electronics became the system of choice for record keeping and intercommunication. The institution of new pro grams and increased computer usage meant setting up training programs for workers who often had no previous computer knowledge. One factor not addressed in Baker's article is whether management explored assistive technology to aid disabled people in an age in which the emphasis is on equal access and function. According to a recent article on access for the disabled, "at the systems (or public technology) level, technology provides access that enhances community integration and equal opportunity. ("Technology for Access and Function," par. 3). In looking to the future of information technology in health care, the events that followed Hurricane Katrina and Rita in Louisiana were unprecedented, and that state finds itself rebuilding its health care system. The Rand Corporation set up an institute for a