Charting packet

Requirements: answer all the questions
Hlth 243/F23/charting#1/ela Due: Wed, 10/4/23 @ 0900 __________/15 points Page1 Charting packet #1 Instructions 1. Consider this encounter with your pt from a space of empathy and service. 2. Given the information provided, complete the following critical thinking activity: a. Chart chief complaint – clear and concise b. Signature and title at the right-hand margin once completed c. If you do not know some detail, indicate what you would do in the clinic? d. Each charting notation must be handwritten and legible. Computer generation is not acceptable. 3. Pt Interview questions: a. For each, write out 4-5 clarifying questions you would ask your pt to obtain data for your provider’s evaluation b. Think of previous coursework (Disease & Path, Micro etc.) when constructing these questions 4. Lens work: Clinical Reasoning activity a. Refer to the PATIENT STATUS” handout for ideas for each lens box. b. Most of these boxes will require you to consider the holistic care of patients. c. Sufficient responses will be more than just a couple of words. This is where you try to figure out more pieces of the puzzle. Patient: Leanard R. Showalter (5/5/1995) Mr. Showalter has scheduled an appt due to sinus pain, particularly around his eyes. He is complaining of ringing in both ears, fever, saying that his taste is getting “weird.” He is worried that it is beginning to settle in his throat. He did run a fever last night of 101.8 degrees and took some Tylenol – it did provide some help. Date: Time: Pt Name: D.O.B: LMP: Allergies Meds: (Initial by MA/CMA/RN) ____ No Medication Changes _____ Medication changes as follows: Interview Questions:
Hlth 243/F23/charting#1/ela Due: Wed, 10/4/23 @ 0900 __________/15 points Page2 Complete the following holistic patient care lenses: Pathophysiology: Psychological/Emotional Factors: Situational Awareness: What will your provider need you to get ready? _________/ 5 points Patient: Patient: Alberta Murray (1/31/1953) Mrs. Murray is experiencing shoulder pain today. Her husband has Alzheimer’s and is becoming more combative. This is the same shoulder he wrenched about 3-4 months ago. Pain is 7/10 and it is difficult to move her arm forward or raise it above her head. Date: Time: Pt Name: D.O.B: LMP: Allergies Meds: (Initial by MA/CMA/RN) ____ No Medication Changes _____ Medication changes as follows: Pathophysiology: Psychological/Emotional Factors: Situational Awareness: Therapeutic Communication Needs:
Hlth 243/F23/charting#1/ela Due: Wed, 10/4/23 @ 0900 __________/15 points Page3 Interview Questions: Identify the following as either subjective or objective data: (2 points) _____ Data that the patient describes based on experience, sensations, cultural norms, etc. and is not measurable by the five senses _____ Data that came be obtained through the five senses, measurable and cannot be refuted _____ Blood pressure is 118/68 _____ Pain scale is 6/10 _____ I am having a really bad cough at night _____ SpO2 = 97% _____ The pain is mostly on the left side of my abdomen _____ My sense of smell is not what it used to be _____ CBC = wnl _____ No BM for the past five days _____ Blurry vision _____ Wt: 185.4 pounds _____ Face is flushed and sweaty _____ UA specific gravity of 1.040 _____ Nystagmus _____ Pruritis _____ Peak Flow results: 1) 440 lpm, 2) 450 lpm, 3) 440 lpm _____ Tenesmus _____ Pulse is 88, bounding & irregular _____ Purulent discharge noted with peripheral redness Identify the following medications by specific category (1 point) 1. Lipitor: _______________________________________________________ 2. Lisinopril: _____________________________________________________ 3. Gabapentin: ___________________________________________________ 4. Omeprazole: __________________________________________________ 5. Metformin: ____________________________________________________ 6. Sertraline: ____________________________________________________ 7. Atenolol: _____________________________________________________ 8. Plavix: _______________________________________________________ 9. Coumadin: ____________________________________________________ 10. Zantac: ______________________________________________________
Hlth 243/F23/charting#1/ela Due: Wed, 10/4/23 @ 0900 __________/15 points Page4 Drug Classifications Match the classification of drug to the correct definition. 2 points # Classification Definition Analgesic 1. reduces fever Anesthetic 2. lowers blood glucose levels Antacid 3. treatment of manic-depressive episodes Antianxiety 4. increases urinary output Antiarrhythmic 5. relaxes blood vessels, lowers blood pressure Antibiotic 6. loosens/promotes bowel movements Anticholinergic 7. acts to prevents action of histamines Anticoagulant 8. destroys or inhibits growth of microorganisms Antidepressant 9. relieves pain without loss of consciousness Antidote 10. neutralizes acid Antiemetic 11. dilates bronchi Antihistamines 12. prevents/controls coughing Antimanic 13. produces lack of feeling, either local or general Antihypertensive 14. controls/stops bleeding Antineoplastic 15. produces calming effect without sleep Antipyretic 16. reduces nasal congestion and swelling Antitussive 17. counteracts effects of a poison Diuretic 18. prevents/controls clotting Hypoglycemic 19. facilitates removal of bronchopulmonary secretions Sedative 20. controls cardiac arrhythmias Contraceptive 21. prevents/relieves symptoms of depression Hypnotic 22. prevents/relieves nausea and vomiting Bronchodilator 23. constricts vessel and elevates blood pressure Decongestant 24. reduces mental anxiety and tension Expectorant 25. prevents replication of neoplastic cells Hemostatic 26. controls high blood pressure Laxative 27. blocks parasympathetic nerve impulses Vasodilator 28. device/method that prevents conception Vasoconstrictor 29. produces sleep

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