Mr. Charles Lamont is a 64-year-old patient who is visiting his primary care physician with complaints of vomiting x 3 days and inability to keep anything down.

A 51-year-old male presents to your office with left lower abdominal pain, diarrhea, nausea, and vomiting. He states that he has a decreased appetite along with a low-grade fever and chills.
November 13, 2019
Module 6 Teena Kissee Case Study I What are the potential ICD-10 codes in this case? 1. a. 2. How can the NP determine if the patient v/s an established patient at the clinic?
November 13, 2019

Mr. Charles Lamont is a 64-year-old patient who is visiting his primary care physician with complaints of vomiting x 3 days and inability to keep anything down.

Mr. Charles Lamont is a 64-year-old patient who is visiting his primary care physician with complaints of vomiting x 3 days and inability to keep anything down. His wife is waiting for him in the lobby. She is hoping that Mr. Lamont will tell the physician about his recent bout of coughing and shortness of breath. He smokes 1½ packs of cigarettes per day. His wife has been encouraging him to stop, but he has not shown any interest in quitting. Laura, the registered nurse, takes Mr. Lamont into an examination room. Laura asks him about his overall health and he tells her about a nagging cough and feeling of dizziness when he tries to get up. Laura examined Mr. Lamont and observed dry, scaly skin, an inflamed hemorrhoid, and tremors to his fingers and toes. The patient also vomits after drinking a cup of apple juice. He also reports pain in his feet. Laura instructed the UAP to takes Mr. Lamont’s vital signs with the following results: blood pressure, 156/94 mm Hg sitting; temperature, 98.8° F orally; radial pulse, 52 beats/min and irregular; respirations, 25 breaths/min and regular; and pulse oximetry 87%. Laura retakes the pulse prior to documenting and reporting the findings to the physician. She also documents the vital signs in the computerized medical record.Mr. Lamont calls Laura, the nurse, and tells Laura that as he attempted to get up and go to the bathroom he felt dizzy and had to sit down. Laura also observed that Mr. Lamont was tachypneic. Laura takes Mr. Lamont’s blood pressure and gets the following results: B/P lying 150/90 mm hg, sitting 130/80 and standing 110/70. His pulse increased to 104 beats per minute; resp 28 bpm. Laura called the physician to report the findings using SBAR communication technique before documenting them in the electronic health record. The patient’s wife overheard the nurse reporting to the physician that Mr. Lamont has orthostatic hypotension, is tachycardic, and tachypneic. The wife asked the nurse what those terminologies mean?

a. What is the definition of orthostatic hypotensionb. What may be some causes of orthostatic hypotension?c. What are clinical signs and symptoms of orthostatic hypotensiond. How is orthostatic hypotension assessed?e. What is the nurse’s priority intervention for patient with orthostatic hypotension?f. What is a nursing diagnosis for patient with orthostatic hypotension?g. How should the nurse describe to the patient’s wife the following:i. What is tachycardia?ii. What is tachypneaiii. What is the purpose of measuring pulse oximetry?iiii. What can affect the accuracy of pulse oximetry

 

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