Data Form for Pathophysiology Case Study

This document is a data form for a pathophysiology case study in the field of nursing. It includes identifying data, past medical/surgical history, recent medical history, home medications, physical assessment, laboratory data, diagnostic tests and procedures, intake and output, and routine/PRN medications. The form is designed to gather relevant information for the nursing process.

1
University
School of Nursing
UNRS 367
Data Form
for
Pathophysiology Case Study
Prof. MAEd, MA, PHN, MSN,
Monrovia (LVN-BSN Program)
Student: _________________________
Date: ___________
University
UNRS 367 / J. David

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School of Nursing: Pathophysiology
Nursing Process Data Form
Student: ___________________________________ Date of Care: __________________
Patient Initials: Ronald M Mercy -- Age: 68_ Gender: male Allergies: 1. Profolol 2. Niacin _
Primary Language: _English__ Ethnicity: white Religion: Christian
Marital Status: Married Occupation: _Retired (Worked for SBC-a telephone company)
Insurance: none
Family Composition: has 3 children
Home/Living Situation: temperature of 101.8 F
Date/s of Care: Date of Admission: 2/25/2019 Date/s of Surgery: 11/14/2017
Physician(s)/Specialty: Dr. Shinde-garg
Raquel Herrera- diabetic retinopathy
Admitting Diagnosis/es: Acute exacerbation of COPD
Surgical Procedure(s) this hospitalization: Tracheostomy temporary
1. Past Medical/Surgical History/Chronic Conditions:
Ronald M Mercy has experience in several past medical conditions. He was first diagnosed with
Chronic obstructive pulmonary, DM 2 dyslipidemia, anxiety disorder and hypertension on
2/10/2011. Thereafter he was screened for colon cancer stage 3 on 04/06/2011 and DM 2
diabetic chronic disease on 07/01/2012. Ronald was found to be having coronary artery disease
on 06/06/2015. On 05/18/2016, chronic respiratory failure was discovered and he needed home
oxygen supplement. An abdominal sonogram was done on 2/12/2016 and was diagnosed with
atherosclerosis of aorta on 10/05/16. Ronald was further diagnosed with malnutrition on
UNRS 367 / J. David
A. Identifying Data
B. Biological

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10/30/17, atrial fibrillation on 11/06/17, critical illness myopathy 11/14/17 and a week later
(11/21/14) diagnosed with emphysema. On 11/07/2018, he was found to be having a history of
squamous cell carcinoma in situ and skin cancer. He was further diagnosed with impingement
syndrome of bilat shoulders on 11/13/ 2018.
2. Recent Medical History/Reason for Admission/Course of Hospitalization:
The patient presented a recent medical history of shortness of breath, nausea, coughing, chest
congestion, rhinorrhea and fever (where he reports a temp 101.8 F at home). He was on
albuterol but when the symptoms progressively worsen he came to the emergency department
for further evaluation. The patient received azithromycin, solumedrol 125mg, magnesium sulfate
2mg and Atrovent, 2 rounds of albuterol which lead to improvement of SOB. His wheezing also
improved. Mild atelectatic were seen on both bases but lung fields were clear. Ekg done, normal
ECG.
3. Home Medications:
Generic/Trade Name Dose Frequency Purpose
triamcinolone 40mg 1
prednisolone 20 mg * 3 Tds
Fluticasone 50 mcg 1
Insulin NPH human 70 units 2 To control blood
sugar
Insulin regular
human
30 units 2 To control blood
sugar
Melatonin 5 mg 1
multivitamin 300mcg 1
Metformin 500 mg *2 2
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Metoprolol tartrate 25 mg 2
Tamsulosin 0.4 mg 1
Atorvastatin 80 mg 1 To lower cholesterol
and keep arteries
open
Lisinopril 10 mg 1
Tiotropium 2.5 mcg 2
Fenofibrate 160 mcg 1
Aspirin 81 mg 1
Albuterol 90 mcg *2 puffs 6 For SOB or
wheezing or cough
4. Definition of Medical Diagnosis with patient’s signs & symptoms at the time of admission:
Acute exacerbation of COPD is when the signs and symptoms of COPD suddenly worsens and
lasts for several days. These clinical manifestations include shortness of breath, fever, coughing.
5. Physical Assessment:
Ht 1.778 m Wt 94.6 kg BSA BMI 29.92 kg/m²
VITAL SIGNS/HEMODYNAMICS:
Time Temp F/C Pulse (apical/radial)
BPM
Resp/min BP in mmHg
R or L
Pulse Ox %
12.10 98⁰ F (36.7
⁰C)
101 21 105/64 96%
/
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PAIN ASSESSMENT:
Patient denies feeling pain
Time Pain Tool
Used
Pain
Rating
Pain Description
(OLDCART)
Functional
Pain Goal
pain medication
(or other care)
Response To
Intervention
LABORATORY DATA:
TEST NORMAL
VALUE
RESULTS RESULTS RATIONALE FOR ABNORMALS
CHEMISTRY Date / Time
2/25/2019
Date / Time State the reason why this pts. lab
values are abnormal
Na 135 – 145
mE/L
135 normal
K 3.5- 5.0
mE/L
4.6 normal
Cl 101-111
mE/L
98 normal
Mg
HCO3-
Glucose 70- 140
mg/dL
125 normal
BUN 16
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Creatinine 1.30 mg/dL 1.40 Diet changes
T. Protein
Albumin
Uric Acid
Calcium 8.8 11/282017
Phosphorus
Bilirubin 1.0 mg/dl 0.8 No much variation
Alk Phos 43 11/09/2017
ALT (SGPT) 63 U/L 66 Heart infections
AST (SGOT) 34 U/L 39 Heart infections
LDH
Cholesterol
LDL
HDL
Troponin 0.03 mg/mL 0.02
CPK isos
MM, MB, BB
CBC Normal Date/Time Date/Time Rational for Abnormals:
Hgb 14.0 – 18.0
g/dL
17 Normal
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Hct 42.0 – 52.0 53.1
WBC 4.0 – 11.0
*1000/mcl
7.1 Normal
RBC 4.70 – 6.10
Mill/mcL
5.61 Normal
Diff
Plates 130- 4000 *
1000/mcL
224 Normal
PT/INR 0.8-12 0
PTT
Other Normal Date/Time Date/Time Rationale for Abnormals:
C & S
Cultures
ARTERIAL BLOOD GASES:
ABGs RESULTS
Date / Time:
RESULTS
Date / Time:
pH 7.34 2/25/2019
pO2 68 2/25/2019
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O2 Saturation 96% 2/25/2019
pCO2 69 2/25/2019
HCO3 34 2/25/2019
Overall Interpretación: Respiratory acidosis
DIAGNOSTIC TEST & PROCEDURES:
(Include 12 Lead EKG, CXR, Cardiac Cath, CT, MRI, Ultrasound, Endoscopy, Echocardiogram, etc)
Test: Pt. Results:
(Date/Time)
Normals:
(referenced)
Rationale For Test Being
Performed On This
Patient:
Rationale for Abnormal
Test Results:
CXR Mild atelectatic
changes were
seen at both
bases of lungs
Clear lung
fields with no
atelectatic
bases
To check for
pneumonia
Partially collapsed
lungs
Influenza A
virus
Negative negative To confirm presence
of influenza virus
Normal
colonoscopy
Done on
4/6/2011
Stage 3 cancer
No cancer To diagnose cancer or
check the stages
Presence of stage 3
cancer
Ekg
2/25/19
Normal ECG
Normal ekg Done to detect heart
rhythm problems and
heart attack
Normal
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INTAKE AND OUTPUT Past 24º Balance ___+/-____________
Does the patient have a positive or negative fluid balance as of this date? How much?_250__ML
Intake 1º 12º Output 1º 12º
PO / Enteral 250 Source: 0 ml
IV 0 ml 0ml
Blood Products none none
Medications
IV Solutions/Parenteral Nutrition/Blood Products :
Name of Infusant: Rate: Site:
(describe the appearance)
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IV Solution: none
Not given none
Lipids/TPN: potassium
chloride
Oral liquid Clear
Blood Products: none
None None
Routine/PRN Medications
List all the patient’s medications ordered. Why would THIS patient have this medication
specifically? Consider diagnosis, medical history, lab values, procedures when discussing the
rationale for each medication.
Medication: prednisone Dose: 40 mg Route: po Frequency: daily
Classification: Corticosteroids
Action: Reduces the response of immune system to allergic conditions
Safe dose range for age/wt: 5mg-60mg/day
Rational for use in THIS
patient:
Reduced the inflammatory reactions
Desired Effect: Opening and expansion of the airways
Side Effects: Insomnia, diarrhea, vomiting, constipation, decreased appetite,
increased blood pressure, restlessness, and vertigo
Toxic Effects: Cataract, worsening diabetes, growth of facial hair, glaucoma,
worsening diabetes, moon face, obesity, convulsion, anaphylaxis,
anaemia, pancreatitis, hypothyroidism, allergic dermatitis
Nursing Implications: Monitor the side effects of the drugs
Pt/Fam teaching needs: Educate the patient on the side effects of the drugs
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Medication: azithromycin Dose: 500 mg Route: iv Frequency:
Classification: Aminoglycosides
Action: Inhibit bacterial protein synthesis, reduces the formation of the
biofilm,
Safe dose range for age/wt: 500 mg/day
Rational for use in THIS
patient:
Its ability to modulate host responses facilitates its long-term
therapeutic benefits in exacerbations of chronic obstructive
pulmonary disease (COPD)
Desired Effect: Prevent bacterial infections
Side Effects: Nausea, vomiting, stomach, cramping, and loss of appetite
Toxic Effects: Troubled breathing
Nursing Implications: To monitor for the side effects of this medication
Pt/Fam teaching needs: Teach the patient on the correct dosing of the drug to avoid toxic
effects
Medication: albuterol Dose: Route: nasal Frequency: 3
Classification: bronchodilators
Action: Relaxes bronchial muscles
Safe dose range for age/wt: 90mcg/ actuation. 2.5mg nebulized
Rational for use in THIS patient: To alleviate asthma symptoms
Desired Effect: To treat bronchospasm
Side Effects: Tremor, insomnia, nausea, fever, vomiting, headache, cough,
otitis media, urinary tract infection, dry mouth, chills,
difficulty in speaking
Toxic Effects: Fatal, serious adverse effects results
Nursing Implications: Advise the patient not to take more than the recommended
dose
Pt/Fam teaching needs: Educate the patient on how the right dosage of the drug and
also on the side effects
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Medication: aspirin Dose:81mg Route: po Frequency:1
Classification: Salicylate; NSAID
Action: Used to reduce fever and alleviate pain that is mild to moderate
Safe dose range for age/wt: 81mg
Rational for use in THIS patient: To reduce fever and also prevent blood clots
Desired Effect: To reduce fever
Side Effects: Heartburn, stomach upset
Toxic Effects: Confusion, burning pain in stomach, mood changes, rapid
breathing, fainting, seizures.
Nursing Implications: Make sure the patient takes the right dosage of the medication
Pt/Fam teaching needs: Teach the patient about the medication, why he is given and the
side effects that may occur
Medication: atorvastatin Dose: 80mg Route: oral Frequency: 1
Classification: statins
Action: Reduces the amount of cholesterol produced by the liver
The safe dose range for age/wt: 80mg/ day
Rational for use in THIS patient: Decrease the risk of heart disease
Desired Effect: Less cholesterol in the body
Side Effects: Confusion but rare
Toxic Effect: Peripheral neuropathy, myopathy, acute renal failure
Nursing Implications: Advise the client to avoid alcohol during this medication regime
Monitor for adverse drug reaction
Pt/Fam teaching needs: Teach the patient the correct prescription of the drug.
Educate him on the side effects of this medication and to report
in case of any problem arising.
Medication: fenofibrate Dose:160mg Route: oral Frequency: 1
Classification: fibrates
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Action: Increases the natural substances that break down fats in the body
Safe dose range for age/wt: 160 mg daily
Rational for use in THIS patient: Treatment of dyslipidemia
Desired Effect: To regulate the amount of lipid
Side Effects: Abdominal pain, headache, nausea, respiratory disorder
Toxic Efect: Peripheral neuropathy
Nursing Implications: Ensure the drug is not taken with atorvastatin since it is
contraindicated
Advise the client to avoid alcohol during this medication regime
Monitor for adverse drug reaction
Pt/Fam teaching needs: Teach the patient the correct prescription of the drug.
Educate him on the side effects of this medication and to report
in case of any problem arising.
Medication: insulin Dose:160mg Route: parenteral Frequency:3
Classification: Anti-diabetic
Action: Control blood sugar during meals and correct the blood sugar.
Safe dose range for age/wt: adjusted
Rational for use in THIS patient: Patient have DM 2 hence this will control it
Desired Effect: To control diabetes
Side Effects: High blood pressure, hyperglycemia
Toxic Effects: Low blood sugar, hypoglycemia, hypokalemia
Nursing Implications: Ensure the right drug and dose for the insulin therapy
Pt/Fam teaching needs: Teach the patient how to self-administer insulin, the right dose
and when to administer
**Continue to copy the above chart as often as needed to include ALL Routine
& PRN
meds**
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INTEGUMENTARY:
Skin: Color normal Turgor: intact Temp Moisture warm and dry
Lesions none
Incisions tracheostomy temporary Dressings none
Varicose Veins none Scars minimal Nails well kept
Pressure Ulcer: Location none Stage None Characteristics
Unusual Pigmentations/Tattoos/Piercings no tattoos
Drainage/ Suction none
Dressings (describe each by site, size, appearance, characteristics, drainage, etc.) ____not
applicable_
Note: *Labs & Medications for the integumentary system must be addressed here
MUSCULOSKELETAL:
Activity Level normal ROM Gait/Mobility normal Posture norma
MuscleTone/Strength negative for myalgia
Any Contractures none
LUE normal RUE normal LLE normal RLE normal
Assistive Devices none Prosthesis/es none
Other Devices none
Frequent position of pt. on your shift left lateral
UNRS 367 / J. David
Head-to-Toe Assessment

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Note: *Labs & Medications for the musculoskeletal system must be address
NEUROLOGICAL:
Level of consciousness, alertness, orientation, cognition memory (short/long
term) patient is well oriented to time, place and person
Sleep/rest patterns normal
Speech no speech difficulty
Sensory (taste, smell, touch) normal
Motor (fine/gross) normal
Vision normal
Hearing normal
Reflexes
Cranial Nerves (All must be included, how tested & results)
CN I – Olfactory- no change in smell noted
CN II – Optic- vision was well functioning
CN III – Oculomotor- trying to note any evidence of ptosis but not found
CN IV – Trochlear – normal functions found
CN V – Trigeminal – sensory and motor reflexes functioned well when tested
CN VI – Abducens -normal response found
CN VII – Facial – found normal
CN VIII – Vestibulocochlear- no defects in hearing
CN IX – Glossopharyngeal - normal
CN X – Vagus – functions normally
CN XI – Accessory – can be tested by asking the patient to turn the head one side and
resist being pushed the other side. This was found normal
CN XII – Hypoglossal- can be tested through inspection of the tongue. Found normal.
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Note: *Labs & Medications for the neurological system must be address
CARDIOVASCULAR:
Heart Sounds normal clear S1/S2 Rate normal Rhythm regular Apical
normal
Pulses: R/L Radial normal Brachial normal Femoral normal DP normal PT
normal
Capillary Refill less than 2 secs Skin color/temp no color change and temp
normal Edema/Location absent
Shunts/Location (bruit, thrill) none
Note: *Labs, Vitals & Medications for the cardiovascular system must be address
PULMONARY:
Respirations :
Rate/Min 18 Rhythm regular Depth normal Effort/Ease no difficulty Pulse Ox
normal
Breath Sounds (all lobes & bilateral comparison) R/L – Crackles (fine, coarse)
Wheezes (inspiration, expiration), Diminished, Absent has wheezes, no rales,
no stridor
Sputum/Secretions no secretions
Oxygen Therapy/Rate: 8.5 mls Via nasal
RT Treatments (type, frequency) daily
Chest Tubes none Suction none Drainage none
Note : *Labs, Vitals & Medications for the pulmonary system must be address
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GASTROINTESTINAL:
Diet good Appetite good Intake% 250 mls N/V
Kcal per day needed receiving 3500
Enteral nutrition: NG Tube n/a G Tube J Tube
Mouth /oral mucosa Teeth/Dentures normal
Abdomen: (soft, distended, ascites, stomas): soft, not tender and not
distended
Bowel sounds: Location normal Activity adequate
Bowel Patterns normal Last BM Stool Characteristics
Note: *Labs & Medications for the gastrointestinal system must be address
GENITOURINARY:
Urine: Output (hourly, 8º, 12º, 24º) 0mls Characteristics none
Patterns of voiding no output Catheter (type) not inserted__
Genitalia: Male
Sexual History (if applicable) N/A
Childbearing History (if applicable):N/A
Note: *Labs & Medications for the genitourinary system must be address
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6. Clinical Manifestation of Current Condition(s):
Expected Manifestations. According
to Literature for Each Medical
Diagnosis and Surgical Procedure.
Must be referenced and cited per
APA
Assessment findings on Day of Care r/t each diagnosis. Include vitals,
labs and physical assessment data
(Date)22/5/2019
Dx #1:
Shortness of breath
Dx #2:
fever
Dx #3:
nausea
Dx #1:
The patient experience shortness of breath and this was evident by
the increase in respiratory rate
Dx #2:
The temperature was 36.7 ⁰C. fever absent
Dx #3:
The patient had fairly improved and could retain feeds
7. Patient Care Needs on your shift: (Discus your focus/concerns /care for the day)
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Ronald is a patient requiring critical care.
During my care of the day, my main focus will be monitoring the vital signs to ensure that
they remain within the normal ranges since any abnormal vital signs will be an indication
of infections.
Ronald worsening symptoms which led to an exacerbation of COPD should also be
managed and medications are administered as prescribed by the physician.
I will have to perform a thorough physical assessment for the patient in order to find out if
there is any other abnormality on the patient.
Moreover, patient education is a vital focus for care. The patient needs to understand more
about his medical conditions and the treatment course that he needs to undergo. This will
greatly help in ensuring that the patient does not become anxious but instead, he will fully
cooperate throughout his care.
8. Pathophysiology (Discuss the pathophysiology of the patient's current
and relevant past medical/surgical problems:
The patient underlying medical diagnosis is an Acute Exacerbation of COPD. This is an
episode whereby the symptoms of COPD worsens as a result of the airways
suddenly becoming blocked. In COPD, chronic inflammation greatly influences the
pathophysiology. Smoking or any other airway irritants make t-lymphocytes,
neutrophils to accumulate in the airways. They then trigger an inflammatory
response making the inflammatory mediators destroy and get rid of inhaled
foreign debris. With the ongoing inflammation, the airways become constricted
as they get narrow and swollen. This leads to the production of excess mucus
making airway clearance difficult. This leads to the development of symptoms
such as coughing, wheezes. When these symptoms worsen, acute exacerbation of
COPD occurs.
Integrate textbook details with specifics of your patient. Make this very specific
to the patient you have cared for
. Cite references per APA (This generally requires 2 pages MINIMUM, double
space)
It is evidently clear that Ronald Mercy is portraying the manifestation of COPD. His
symptoms started worsening before prior to his admission. He is experiencing shortness
of breath which is due to the inflammation that causes the narrowing of the airways.
Ronald also coughs which is due to the irritation of the airways. He had been previously
UNRS 367 / J. David

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diagnosed with asthma which is common as a result of allergens. Cigarette smoking is
one of the most common risks of COPD. Ronald has been a known chronic smoker for 25
years and this might one of the factors which lead to his development of COPD. Copd
however progresses and slowly start to comprise the gas exchange. The arterial blood
gases have been altered and Ronald has chronic respiratory disease. This is a result of
the shortness of breath that he is experiencing. There is also an associated decline in
lung functions. From the assessments done prior to my shift, Ronald had atelectatic
lungs at both bases. This may due to the infections. It is, however, safe that lung fields
are clear. His body mass index is also higher than the normal ranges. The shortness of
breath may be due to the increased narrowing of the airway and a mismatch of
ventilation-perfusion (Vestbo, et.al, 2013).
9. Potential Complications (based on pathophysiology & referenced):
Medical Diagnosis: Potential Complication:
Dx #1 acute exacerbation of COPD Airway blockage
Dx #2 DM2 Diabetic foot
Dx #3 Asthma Collapse of the lungs
10. Nursing / Medical Therapies and Treatments:
(Utilize Potter and Perry& Lewis textbooks. Cite all rational & nursing
implications)
Treatment Rationale for Treatment /
Patient Application
Nursing Implications Frequency
Vitals To help in noting any
abnormality
I ensure that I check the
vital signs of the patient
accordingly
Every 4 hours
Positioning To prevent bed burns I ensured that I repositioned
the patient every two hours
Every two
hours
Patient education To relieve anxiety I did this by ensuring the
patient got a better
understanding of his
medical conditions. All his
questions answered and also
explained his medication
Whenever
need be
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21
regime to him.
Medication
administration
To help alleviate the signs
and symptoms
Ensured that the right
patient gets the right drug
and dose at the right time
As prescribed
by the
physician
documentation This provides evidence for
what has been done. Also to
allow for the continuation
of shifts.
As I nurse, I need to
immediately note down
every procedure that I have
performed for the patient
Every time a
procedure is
performed
This should be a comprehensive list of all the care provided to your patient during your shift. It may be
care offered by other disciplines or by nursing. Examples include ADL’s, ambulation, ROM, feeding, I&O,
Vitals, Med pass, documentation. PT, ST, RT, OT, MD visit, repositioning, dressing changes, pt/family
education, emotional or spiritual care, visit from a chaplain, etc. etc. ALL care provided to a patient
requires some level of nursing assessment and monitoring and has a nursing implication. This chart is
designed for you to explain how busy you were providing outstanding care to your patient.
1. Individual/Family Developmental Stage and Family Dynamics:
(Discuss stages per Ericson and Maslow with rational based on your assessment of pt)
From the assessments, it is clear that Ronald is undergoing the eight stage of Erickson
developmental stages “ego integrity vs despair.” Despite having been diagnosed with several
conditions, he feels like he had achieved a lot in life now that he even had worked to retirement.
He feels that he had been productive and does not regret his past actions. The patient is
undergoing the esteemed stage of Maslow's hierarchy of needs. This is where he feels a sense of
achievement.
2. Cultural Influences/Health Beliefs and Values:
(Provide general information regarding pts identified culture first)
The patient does not have particular cultural beliefs which he holds on.
UNRS 367 / J. David
C. Psychosocial Subsystem

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3. Individual/Family Challenges VS. Individual/ Family Strengths
Individual/Family Challenges Individual/Family Strengths
1. financial insecurity 1.supportive
2. very emotional 2. loving
3. anxiety 3. caring
4. Individual/Family Coping with the Current Stressors:
Stress is one of the common challenges faced in every day to day life. Ronald as an individual
has become very stressed, especially now that he has been diagnosed with various medical
conditions over the past years. He, however, has managed to cope up with that since he does
not keep things for himself but rather share his problems with others and always ready to get
help. He also has a very loving and supportive family. These are the people he relies on
whenever he is sick. They always take care of him and seek medical attention whenever
necessary. They also take great care of him whenever hospitalized and even after discharge. This
has greatly enabled him to cope up with stressors
1. Spiritual Assessment: {Ref. Taylor (2002); Potter & Perry (2013), Articles for a variety of
spiritual assessment tools that can be used. Student must identify the specific
model/tool/assessment used, the questions asked and the patient’s response including patient’s
own words in quotations}
Spiritual Strengths Spiritual Resources Spiritual Needs
1. healing 1. prayers 1.love
2. comforting 2. devotions 2.belonging
UNRS 367 / J. David
D. Spiritual
Subsystem

23
3. sense of belonging 3. reflections 3.peace
respect
5. Link between spiritual assessment findings and overall health of patient:
Note: This is a great place to integrate the required research article, then link
to specific patient issues
There has always been an association with the spiritual assessment findings and health of
a patient (Koenig, Koenig, King, & Carson, 2012). It is always important for the nurses to
get to clearly understand the spiritual dimensions of an individual. Most patients believe
in the power of prayer and that is why chaplains are brought into the hospital and allowed
to interact with the patients. Most believe that it is through their faith in a religion that
they let their fears go and also start the healing process. The faith and beliefs of a patient
greatly influence the way they cope with stress or difficult times. It is what gives them
the meaning of life. It is therefore important to refer a patient to a chaplain since their
overall health status greatly depends on their stand in the religion where their stand is.
UNRS 367 / J. David

Community Referral, Follow-up Appointments, Medications, Treatments, Equipment, Support
Groups, Home Health Needs and Long Term Care Concerns.
Educational Needs Evaluation of
Teaching
Medications/Treatments/Equipment Referrals / Follow-up
/ Disposition
The patient needs
to learn about his
medical
conditions and
how they
manifested
He also needs
education on his
medication,
especially during
discharge. This
may also include
other education
on how to cope
up with life after
being discharged.
Evaluation can be
done by asking
the patient
questions on
what they have
been thought. If
they can answer
well then that
means they have
clearly
understood what
they have been
educated on.
They may be also
asked to clarify a
certain point or to
repeat what they
have been taught
or even to
demonstrate. If
they do it as
needed, then that
means the point
is home.
No other medications than the ones
prescribed during the hospital
encounter
No referrals were
received. Follow
has to be done since
the patient will need
close monitoring of
his sign and
symptoms.
Provide a list of names and contact information in the patient’s neighborhood, for
necessary support groups or other types of resources that might be required by the
patient upon discharge:
Kim Hussein – community Health nurse
John Kerry – psychologist and counselor
Martin K. – physiotherapist
UNRS 367 / J. David

Ronald A. – pastor
Mercy Tim – area administrator
1. At least one general clinical or specialty article
a) Use articles from peer reviewed professional journals.
b) Must include copy of the article.
2. At least three Evidenced Based Research Article
a) Three research article required for full credit.
b) Include a copy of all the articles used to obtain credit.
c) Write a brief statement on how a research article was applied to nursing care for
this specific patient.
3. Formatting & Appearance of completed work
a. APA format
b. Pagination
c. Title & Running header
d. Margins
e. Quotations
f. References
g. Spelling
h. Grammar
UNRS 367 / J. David
G. References and Reference list per APA
guidelines

References
Ko, F. W., Chan, K. P., Hui, D. S., Goddard, J. R., Shaw, J. G., Reid, D. W., & Yang, I.
A. (2016). Acute exacerbation of COPD. Respirology, 21(7), 1152-1165.
Koenig, H., Koenig, H. G., King, D., & Carson, V. B. (2012). Handbook of
religion and health. Oup Usa.
Sacco, R. G. (2013). Re-envisaging the eight developmental stages of Erik Erikson:
the Fibonacci life-chart method (FLCM). Journal of Educational and
Developmental Psychology, 3(1), 140-146.
Søyseth, V., Bhatnagar, R., Holmedahl, N. H., Neukamm, A., Høiseth, A. D., Hagve,
T. A., ... & Omland, T. (2013). Acute exacerbation of COPD is associated with
fourfold elevation of cardiac troponin T. Heart, 99(2), 122-126.
Thielke, S., Harniss, M., Thompson, H., Patel, S., Demiris, G., & Johnson, K. (2012).
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