ANALYZE AND IDENTIFY THE TYPE OF (1) ASSESSMENT NEEDED, (2) THE SUBJECTIVE, AND (3) THE OBJECTIVE DATA OF EACH SCENARIO. CASE SITUATION #3: You have a 48-year-old male patient who comes in stating, “I feel like I can’t breathe.” Patients’ respirations are 28 breaths per minute and their heart rate is 115 beats per minute. The patient then grabs his chest and says, “My chest hurts so bad, please help!” You ask the patient to rate the pain on a scale from 0-10, 10 being the worst pain ever. The patient replies, “10, it hurts so badly!” You then ask the patient to describe what the pain feels like, the patient reports that his pain feels like pressure. Your patient then starts to become diaphoretic and pale. You take an EKG that shows Sinus Tachycardia. The pulse oximeter shows 100% on room air and the patients’ blood pressure is 120/80 mmHg

ANALYZE AND IDENTIFY THE TYPE OF (1) ASSESSMENT NEEDED, (2) THE SUBJECTIVE, AND (3) THE OBJECTIVE DATA OF EACH SCENARIO. CASE SITUATION #3: You have a 48-year-old male patient who comes in stating, “I feel like I can’t breathe.” Patients’ respirations are 28 breaths per minute and their heart rate is 115 beats per minute. The patient then grabs his chest and says, “My chest hurts so bad, please help!” You ask the patient to rate the pain on a scale from 0-10, 10 being the worst pain ever. The patient replies, “10, it hurts so badly!” You then ask the patient to describe what the pain feels like, the patient reports that his pain feels like pressure. Your patient then starts to become diaphoretic and pale. You take an EKG that shows Sinus Tachycardia. The pulse oximeter shows 100% on room air and the patients’ blood pressure is 120/80 mmHg

Understanding Health Insurance: A Guide to Billing and Reimbursement

14th Edition

ISBN:9781337679480

Author:GREEN

Publisher:GREEN

Chapter7: Cpt Coding

Section: Chapter Questions

Problem 22R

See similar textbooks

Similar questions

READ THE FOLLOWING CASE SCENARIO. ANALYZE AND IDENTIFY THE TYPE OF (1) ASSESSMENT NEEDED, (2) THE SUBJECTIVE, AND (3) THE OBJECTIVE DATA OF EACH SCENARIO. CASE SITUATION #2:Mr. Michael is 51 years old. He was admitted two days ago with chest pain. His physician has ordered the following studies: electrocardiogram, chest x-ray, and complete blood studies including blood sugar. These studies were just posted on the chart. When you talk with him, he states, "I feel much better today- no more pain. It is a relief to get rid of the discomfort." You think he appears a little tired or weary- he seems to be talking slowly and sighs more often than you would think is necessary. When his wife comes to see him, she is cheerful with him but confides in you he seems depressed or something. His vital signs are BT- 98.8°F, BP: 140/90, PR: 74, and RR: 22.
Give a rationale for each nursing diagnosis listed below in regards to the scenario attached Jack Soo Park, a 78-year-old man receiving intravenous (IV) therapy with antibiotics, states, “I’m having trouble breathing. “ Vital signs include 156/88, Pulse 105, Respiratory Rate 30, Temperature 98.4F, and O2 Sat of 94% on 2LNC. It just started a little while ago. Physical examination reveals a bounding pulse; distended neck veins; shallow, rapid respirations; and crackles and wheezes in the lungs. Excess fluid volume is suspected. Further checking reveals an IV fluid-administration error that has resulted in overhydration. Nursing Diagnoses -Impaired gas exchange related to disease condition as evidenced by lung sounds. -Risk for excess fluid volume related to overhydration as evidenced by observation. -Risk for electrolyte imbalance related to excess fluid as evidenced by observation. -Risk for blood pressure instability related to reduced cardiac output as evidence for fluid volume…
Scenario: Upon completing a medical history and physical assessment the nurse learns that the client has an eight-year history of chronic obstructive pulmonary disease (COPD) and continues to smoke ½ pack of cigarettes daily. The client is febrile (101.20 F) and reports experiencing periods of chilling. The client has a productive cough resulting in large amounts of purulent sputum and reports, "All this coughing and difficulty breathing makes my chest hurt." The client's spouse shares that the client hasn't been eating or drinking as well as usual and constipation has been a problem for the last 3 days. Both covid-19 infection and pneumonia are being ruled out as the possible diagnosis. The nurse will identify which assessment and/or history data as supporting a diagnosis of pneumonia? Select all that apply. Cough Anorexia Chest pain Constipation Fever and Chills Purulent sputum History of COPD
Concept Map which consists of: 1 nursing diagnosis 1 Goal 3 Nursing interventions with rationale evaluation Completed medication cards Mr. S.B. has been a smoker for 20 years. He has noticed increased shortness of breath (SOB) for the past week and is complaining of a productive cough with thick whitish phlegm. VSS 99.9F, 92HR, 32R, and 152/90. Pulse oximetry is 90% on room air. Medications: Prednisone 10mg orally dailyProventil MDI 180mcg. 2 puffs inhaled every 6 hours
Case Analysis: You are a daycare provider and find a 3-year-old child who is unresponsive. She had laid down for a nap because she was not feeling well. When you checked on her, she was not breathing and appeared blue. You are by yourself. What will you do?
Scenario Description: Juan Ferguson 50-year-old man with long-term emphysema who has become dyspneic and has been brought to the Emergency Department by paramedics and now is admitted to your floor for admission. He arrives alert and anxious, wheezing and still dyspneic. An IV has been started. Oxygen is started. What is my client’s primary and possible secondary diagnosis? What signs and symptoms would I expect to see with primary and secondary diagnosis? What do I need to assess? What is my top three priority assessments for this client? (Airway, breathing, circulation) What is my focused assessment for this patient and any nursing interventions I may need? What are the signs/symptoms that my client may exhibit if their condition is worsening? Give one or two reasons you would want to contact the healthcare provider?
Scenario: Emily Campbell is a 48 year old female, she came to the Emergency Department with chest pain and some shortness of breath. She was conscious and ambulatory, and was accompanied by her 19 year old daugter. Presenting complaint: "Nurse, I just don't feel quite right. I've had pain on my chest and I've been feeling breathless." Question(s): 1.) What type of health history should the nurse be taking for Ms. Campbell? Elaborate why. 2.) What three vital questions do you need to ask in order to explore Ms. Campbell's symptoms? Explain the significance of each. 3.) Which part of the history assesment tool should you give focus on with regards to Ms. Campbell's case? Give at least 3 and explain.
A nurse is caring for a client who presented to the emergency department with an acute asthma exacerbation. The respiratory rate is 36 breaths/min, and a pulse oximeter is 85% on room air with accessory muscle use to breathe. The nurse placed the client on oxygen 4 liters nasal cannula. The arterial blood gas (ABG) is as follows: pH: 7.28, PaCO2: 50 mm Hg, PaO2: 75 mm Hg, and HCO3: 26 mEq/L. Which of the following treatments is the nurse's highest priority? A) Administer bronchodilators B) Administer sodium bicarbonate Administer methylprednisolone (D) Perform a chest x-ray
Scenario 1: Mr. Pickwick has obstructive sleep apnea, and the doctor has ordered him to be placed on BiPAP at the following settings: mode, S/T; rate, 12 breaths/minute; IPAP = 12 cm H2O; EPAP = 6 cm H2O. You enter his room, identify yourself, and explain everything to him. You also perform a complete assessment. After applying BiPAP, you note a drop in blood pressure and oxygen saturation. 1) What would you recommend to Mr. Pickwick for infection control in the home?
Scenario 1: Mr. Pickwick has obstructive sleep apnea, and the doctor has ordered him to be placed on BiPAP at the following settings: mode, S/T; rate, 12 breaths/minute; IPAP = 12 cm H2O; EPAP = 6 cm H2O. You enter his room, identify yourself, and explain everything to him. You also perform a complete assessment. After applying BiPAP, you note a drop in blood pressure and oxygen saturation. What are possible causes of the drop in blood pressure and Spo2 and what changes or modifications would you recommend?
Think about the priorities inherent in the basic care and comfort needs of clients. After meeting the need for oxygenation, identify and briefly discuss the following: Which need is the next priority for you
Think about the priorities inherent in the basic care and comfort needs of clients. After meeting the need for oxygenation, identify and briefly discuss the following: How a change in health status would affect meeting that basic need.