1. 19 yr old brought in by

1. 19 yr old brought in by his college roommate abdominal pain, , passing urine a lot, vomiting several times before arriving at the ER, with c/o thirst. He appears flushed, lips mucous membranes dry and cracked poor skin turgor ,fruity breath, type 1 diabetic, skip a few insulin dosages, has problems focusing on the questions asked.b/p 110/60, pulse 110, res 32, temp 100.8, Accu-chek 600 mg/dl. 2. 32 yr old brought in by paramedics after falling from the second story of his home. He was place on a spinal board to immobilize his spine and a neck brace was applied, sterna rubs must be done to arouse patient and there is no response to verbal commands or when his name is called, extends legs stiffly when nailed pressure is applied, b/p 190/60, pulse 50, res 10 with 20 seconds periods of apnea, large laceration to the occipital. Have to do SOAP note and SBAR note on these two case study Subjective – The “history” section HPI: include symptom dimensions, chronological narrative of patient’s complains, information obtained from other sources (always identify source if not the patient). Pertinent past medical history. Pertinent review of systems, for example, “Patient has not had any stiffness or loss of motion of other joints.” Current medications (list with daily dosages). Objective – The physical exam and laboratory data section Vital signs including oxygen saturation when indicated. Focuses physical exam. All pertinent labs, x-rays, etc. completed at the visit. Assessment/Problem List – Your assessment of the patient’s problems Assessment: A one sentence description of the patient and major problem Problem list: A numerical list of problems identified All listed problems need to be supported by findings in subjective and objective areas above. Try to take the assessment of the major problem to the highest level of diagnosis that you can, for example, “low back sprain caused by radiculitis involving left 5th LS nerve root.” Provide at least 2 differential diagnoses for the major new problem identified in your note. Plan – Your plan for the patient based on the problems you’ve identified Develop a diagnostic and treatment plan for each differential diagnosis. Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc. Your treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures. You must also address plans for follow-up (next scheduled visit, etc.). Also see your Bates Guide to Physical Examination for excellent examples of complete H & P and SOAP note formats. The components of SBAR are as follows, according to the Joint Commission: • Situation: Clearly and briefly describe the current situation. • Background: Provide clear, relevant background information on the patient. • Assessment: State your professional conclusion, based on the situation and background. • Recommendation: Tell the person with whom you’re communicating what you need from him or her, in a clear and relevant way SCIENCE HEALTH SCIENCE NURSING NURSING NUR201

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."