Medicine Cabinet Template. Your Name. Washington State University College of Nursing

Transcription

1 Medicine Cabinet Template 1 Running head: MEDICINE CABINET TEMPLATE Medicine Cabinet Template Your Name Washington State University College of Nursing

2 Medicine Cabinet Template 2 Abstract Abstracts are one paragraph of a self-contained summary of the most important elements of the paper. No more than 120 words. Do not indent the first line (block format). It always starts on page 2 under the Abstract heading. All numbers in the abstract should be typed digits rather then words, unless it begins a sentence.

3 Medicine Cabinet Template 3 Title of Paper Here Introduction to the paper should go here Holistic Interview Family History and Support System Includes members of immediate family and significant others, their health, and relationship with the patient. Review the patients past family medical history-include medical history for siblings, parents and grandparents. Ask about family history of diabetes, cancer (include cancers of the blood and reproductive organs), asthma (or other lung disease), kidney disease, GI problems, neurological disorders, bleeding disorders, or musculoskeletal problems or injuries. This is important because the family has an effect on the patient s health and emotional concerns and support issues. Think of this as a mini biography-include age of patient, place of residence, place of origin, education, past family and social history-marriages, divorces, childbirth, deaths; include hobbies, membership in organizations, etc.. Include substance use (alcohol, tobacco, other illicit drugs) current or past. Environment This section includes living conditions and safety hazards in the house. Does their environment promote and support healthy habits or is it full of distractions, (e.g., is there cholesterol loaded junk food in their cabinets). Is the family unit creating a supportive environment for successful health promotion? Are there safety rails in the bathrooms? Are there steps the patient has to negotiate into the house or within the house? Is the home or living areas clean or cluttered? Is the home in need of repair?

4 Medicine Cabinet Template 4 Does the patient use/need glasses or hearing aids? Does the patient drive a vehicle? Does the patient get any assistance from outside of the house? For instance, is there a housekeeper or chore worker? What does pt s daily life consist of? Local community resource such as; respite care, hospice. Financial How does the patient support him/her self or family? Being sensitive to the fact that this may be an area where the patient is not willing to share information, what is the cost of the medications the patient is taking, and how much is out of pocket? Would the patient qualify for a Drug card? Is this another area where you could target teaching, to educate the patient about medication assistance programs available? Does he have insurance? Are they on Medicaid/Medicare? Are there financial issues and concerns that outside resources could help with? If so what would you recommend to the patient, for resources and assistance from within the community? Religion: Does the person view spirituality as a part of their health? If the patient does not indicate that this is intrusive, explore their religious belief system, and address any concerns that might challenge the prescribed regimen of care. Education and Occupation Review patients education and occupation here. Include patient s thoughts about why they chose to retire (if they are retired) when they did or if they are on disability. Possibly even why they chose the occupation they did. Emotional and Social

5 Medicine Cabinet Template 5 Review patients social support system-family, friends, organizations, clubs, etc. Is there any history of depression or other mental illness. Is the family environment supportive of a healthy lifestyle? Consider evaluating your patient s readiness to learn reporting it here. Is the patient willing to hear feedback and to be advised and educated about their disease process and medications? Patient s strengths Ask the patient what he/she considers their strength? Also, what are their biggest challenges in their own minds? It can be personal qualities, education, family, work experience, health practices. Past Medical History Identify significant events that stand out in the patient s mind. This is especially important if your patient has reduced trust of the medical community. Was there a significant event that broke their trust? Do a complete review of systems-cardiovascular, respiratory, GI, renal, neuro, musculoskeletal, psychosocial, and EENT. This is where you discuss past surgeries, major illness and disease. History of Acute Illness You will use subjective data, written in the patent s words. This is where you let the patient tell you what is important to them about their illness. You will get clues from their statements about what issues most concern them. This will give you an identification of teaching opportunities. If possible use active listening to gain this information. Information from the patient or family members would constitute subjective data.

6 Medicine Cabinet Template 6 After speaking to the subjective data, identify objective data. If taken from the chart then state, As found in patient s chart. If the patient has kept records of their laboratory data identify that as the source. Physical assessment Height: ## inches. You should measure this Weight: ### pounds or ## kilograms. Was this a patient stated weight or was it measured (try to measure it)? Environmental or Drug Allergies: Report the type of reaction for any allergies you identify as being present. Blood Pressure: ###/##. Discuss whether this is a normal or abnormal finding, and if abnormal is it consistent with the patient PMD findings? Is it part of the acute disease process? TPR: Identify abnormal findings and suggest why, if these vital signs are normal state this. HEENT: Assess eyes, ears, nose, throat, lymph nodes, etc. Identify any abnormal findings. Respiratory: Identify abnormal findings and suggest why, if these are normal state this. Explain or discuss any abnormal findings. Cardiovascular: Is it regular? Is the rate and rhythm normal? Do you hear a murmur? Carotid or Renal bruits (for patient with CVD or CVD risk factors). Ankle-Brachial index. Explain or discuss any abnormal findings. Assess and rate peripheral pulses.

7 Medicine Cabinet Template 7 Abdomen: Look, listen and feel in that order. Do you hear bowel tones in all quadrants and do they sound normal, high pitched or tinkling? Is the abdomen soft and nontender? Any hepato-spenomegaly? Explain or discuss any abnormal findings. Extremities: Can you appreciate any pedal edema? Nail Clubbing? Are there any wounds or lesions? Any skin discoloration? Evaluate strength and sensation in each limb. Explain or discuss any abnormal findings. Sensorium: Perform a Mini-Mental Status Exam. Is their sensorium intact? Are they alert and oriented to person place and time? Are there any memory deficits? Explain or discuss any abnormal findings. Hearing: Normal or abnormal? This can be subjective or objective but state which it is. If hearing loss is present ask patient if they know what caused it. Do they wear hearing aids? Are they in good repair? Vision: Do they wear glasses? Are they in good repair? When was their vision last checked? Pain: Assess any areas of reported pain. Document the areas and physical findings. Rate the pain on 0-10 pain scale. Document your discussion of pain issues with the patient and any suggestions you made for comfort. Oral/Dental: Any dentures or bridges? Are there any lesions? Does the patient keep regular dental health maintenance appointments? Nutrition: Do a 24-hour Diet Recall. Address any concerns about patient s diet. What are the normal eating habits and routines for the patient? Do they have someone come in to prepare meals or draw up insulin? What changes would you recommend? Why? Pathophysiology

8 Medicine Cabinet Template 8 List Disease state- Identify pathophysiology of each disease state. Include a description of the disease process in relation the patient. For example, compare and contrast the specific manifestations for this disease(s) with those this patient has and do this for each patient problem. For example: Primary Hypertension Discuss the pathophysiology of the disorder then relate that discussion to the patient findings. Diabetes Mellitus: Discuss the pathophysiology of the disorder then relate that discussion to the patient findings. Medications List each drug separately and address the following information. You need to explain why the patient is taking the drugs they are using. Include any OTC meds including vitamins and supplemental medications, and pay attention to the potential interactions of these with their prescription drugs (for example, antacids can interfere with absorption of antiretroviral medications, iron preparations, tetracyclines ). Ascertain whether their physician is aware of these. Discuss the pharmacodynamics/method of action for each drug listed and the dosages, implications and interactions, and note whether the patient is taking them as prescribed. If not, then identify why not. How they should be taken? Identify any symptoms you think might be a side effect..does the medication cause complications in this patient? What precautions should be taken while on this medication (for example, Mylanta preparations should be given with caution to patients with any degree of renal insufficiency)? Who administers these meds

9 Medicine Cabinet Template 9 (him/herself, spouse, and nurse)? Does his/her medical condition affect his/her medicine intake? Is there a nurse that visits him/her to monitor his/hers compliance? How are the medications stored? This is a great opportunity to address learning needs and what you have talked with the patient regarding medication issues. Nursing Diagnosis (NANDA): List the nursing diagnoses for this patient, they should include both physical/medical problems and health promotion (two of these will be the focus of your teaching plan). Teaching plan for top two problems (one physical/medical and one health promotion) The problem list/ nursing diagnosis or concerns and medication concerns give you your rationale for choosing the two as the top 2 problems. Give your rationale for the plan. If pt. is not adherent to his meds what can be done to help him. Be specific. If a medication causes side effects, what precautions should be taken? If you feel that a patient is at risk for any complications, explain to him/her first signs and symptoms of it. Summary At the end explain how this project helped you in your professional growth. Was this educational? Give an overview of the learning process.

10 Medicine Cabinet Template 10 References Authors: Authors are listed in the same order as specified in the source, using surnames and initials. Commas separate all authors. When there are seven or more authors, list the first six and then use "et al." for remaining authors. If no author is identified, the title of the document begins the reference. Year of Publication: In parentheses following authors, with a period following the closing parenthesis. If no publication date is identified, use "n.d." in parentheses following the authors. Source Reference: Includes title, journal, volume & issue number (volume # is in italics and issue number is in parentheses), pages (for journal article) or title, city of publication, publisher (for book). Italicize titles of books, titles of periodicals, and periodical volume numbers. **Make sure that you consult your APA manual References should be in alphabetical order and double spaced with a hanging indent on every line after the first line. Journal article

11 Medicine Cabinet Template 11 Murzynski, J., & Degelman, D. (1996). Body language of women and judgments of vulnerability Book to sexual assault. Journal of Applied Social Psychology, 26, Paloutzian, R. F. (1996). Invitation to the psychology of religion (2nd ed.). Boston: Allyn and Bacon. Web document on university program or department Web site Degelman, D., & Harris, M. L. (2000). APA style essentials. Retrieved May 18, 2000, from Vanguard University, Department of Psychology Web site: *(note that the hyperlink has been removed: right click on the URL and then click on remove hyperlink ) Stand-alone Web document (no date) Nielsen, M. E. (n.d.). Notable people in psychology of religion. Retrieved August 3, 2001, from Stand-alone Web document (no author, no date) Gender and society. (n.d.). Retrieved December 3, 2001, from Journal article from database Hien, D., & Honeyman, T. (2000). A closer look at the drug abuse-maternal aggression from link. Journal of Interpersonal Violence, 15, Retrieved May 20, 2000, ProQuest database.

12 Medicine Cabinet Template 12 Abstract from secondary database Garrity, K., & Degelman, D. (1990). Effect of server introduction on restaurant tipping. Journal of Applied Social Psychology, 20, Abstract retrieved July 23, 2001, from PsycINFO database. Journal article, Internet-only journal Bergen, D. (2002, Spring). The role of pretend play in children's cognitive development. Early Childhood Research & Practice, 4(1). Retrieved February 1, 2004, from Article or chapter in an edited book Shea, J. D. (1992). Religion and sexual adjustment. In J. F. Schumaker (Ed.), Religion and mental health (pp ). New York: Oxford University Press.