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Ruig head: GASTROENTEROLOGY CARE PLAN 1

GastroeterologyCare Pla

Name

IstitutioalAffiliatio

Date

GastroeterologyCare Pla

PatietIitials: &bspI. M&bsp&bsp&bsp&bsp&bsp&bsp&bsp&bsp&bsp&bsp&bsp&bspAge: &bsp&bsp60&bsp&bsp&bsp&bsp&bsp&bsp&bsp&bsp&bspSex: Male

SubjectiveData:

ClietComplaits:

  • The cliet complais of umbilical pai ad vexig pai i the umbilical area.

  • The cliet experieces chroic heartbur-like symptoms after eatig.

  • He experieces chroic tiredess or uexpected fatigue.

  • He experieces abdomial pai ad ueasiess.

  • The patiet also has stomach upset ad ausea.

HPI(History of Preset Illess):

Thecliet complais of acute oset of umbilical pai ad experiece agawig pai i the umbilical area. The pai is curretly draw-outbut the cliet feels uwell, ad does ot vomit. He felt warm adsweaty last ight, which were sigs of fever. However, the symptomslesseed after he sat dow for some times o a chair. The pace ofilless was worse last ight tha it is ow. I the past, symptomswould last from about oe hour or more but resolve uexpectedly. Theseverity of his discomfort was at te last ight but ow it has owreduced to seve. The pai has bee botherig him for the past 24hours ad eve he could ot sleep last ight. The pai was localizedi the umbilical regio last ight ad it is more diffuse ow thalast ight. The pai is geeralized i the abdome ad the clietexperieces heartbur-like symptoms for the past two weeks. Theheartbur icreases after eatig ad resolves suddely withi a fewhours.

PMH(PastMedical History ad hospitalizatios):

Thecliet was treated for hypercholesterolemia, gout ad hypertesio.He atteds the primary care hospital settig for every 3-4 moths fora routie check-up. The cliet had stomach problem but caot recallthe medicatio he was give. He recalls that the primary careprovider did a upper gastroitestial oly. About 20 years back, hehad appedectomy but without ay complicatios. He has bee usig alot of o-steroidal ati-iflammatory drugs (NSAIDs) to cotrol thegouts symptoms. The cliet has had o sigificat illess but alwayshad stomach complicatios. He is treatig heartbur issues with olyover-other-couter medicatios but has had o further examiatio.

Allergies:

Thepatiet does ot have recogized allergies or ay reactio tomedicatios.

Medicatios:

  • The patiet was give to Idoci 50 mg Q 6 hours PRN gout symptoms.

  • He was give Zocor 20 mg QD.

  • Propraolol 50mg BID.

  • PH moitorig (with a probe or ‘Bravo’ capsule) is a effective medicatio for this patiet.

  • The patiet is cocered about the side effects of this medicatios because he is ot compliat with the prescribed medicie. Therefore, he seems to be overusig Idoci to reduce gout symptoms for the past oe moth.

  • He also bee attedig Sait Joh hospital for therapy because he believes he is sufferig from depressio.

  • He has bee takig three capsules for the past oe moth but experieced o sigificat chage.

SigificatFamily History:

Thepatiet has older survivig brother livig with high blood pressuread high cholesterol. There is also sigificat family of goutthroughout that might be that cause for his curret gout issues.

&bspDescriptioof Cliet’s Support System:

Thecliet receives support from his wife, ad some people he used towork with i the school district. The patiet is a retiredschoolteacher but he is livig off a state teacher’s pesio. Thepatiet has effective access to primary care provider ad he has ahealth isurace coverage icludig prescriptio cover. The wife ofthe cliet has osteoarthritis of both hips ad kees but she ru agrocery stores, which helps to sustai them. They have commuitysupport groups with adequate resources but does ot have access toall the resources. The patiet lives good life ad does ot haveudue stress thus he hopes that he will recover if health careproviders do somethig. Therefore, he is ot sufferig from socialisolatio ad wishes to ivolve i the commuity work oce he getswell. This is because he believes that commuity ivolvemets willhelp him cure from depressio.

Behavioralor Noverbal Messages:

Thepatiet gets axious faster but he does ot show it. He likes workigad also walkig oe or two days weekly. The patiet also driks wieevery ight but does ot smoke.

ClietAwareess of Abilities, Disease Process, ad Health Care Needs:

Thecliet is aware of the health care eeds ad believes that the healthcare providers will help him gai his health. He is also aware of hisdisease issue ad this has helped him to cope with the disease.

ObjectiveData:

PhysicalAssessmet Fidigs:

VitalSigs: BP right arm sittig 175/70 T: 99 po P: 64 regular R: 18ad o-labored.

Temperature:37.5

Pulse:Rapid heartbeat rate

Respiratio:No trouble i breathig

BMI:

Weight:94

Height:5.6

HEENT:Normal limits.

LymphNodes: It is o-palpated.

Lugs:Clear to auscultatio

&bspICD-9Diagoses/Cliet Problems:

ICD-9is 530.81 ad this is a abbreviated code as per the idicatio othe ceter for Medicaid services (CMS.gov, 2014).The laboratoryreport fidigs idicates that CBC, LFTs, amylase ad lipase are allwithi ormal limits&bspbut H, pylori is positive. However, theradiological studies&bspidicates that gall bladder ad liver areormal&bspbut EKG has ormal sius rhythm(CMS.gov,2014). Therefore, this diagoses idicates that the cliet has aproblem of gastroeterology, which effective health eed pla foreffective patiet care.

AdvacedPractice Nursig Itervetio Pla(icludigiterdiscipliary collaboratio, commuity resources ad follow-upplas):

Plaof Care ad Work-up:

Elimiatioof symptoms ad a effective way of workig out this aspect is bysettig up some goals i mid. Settig up goals ca eable theprimary care provider to achieve the iteded eeds of the patieteffectively. Aother pla of care is by maagig orprevetigcomplicatios. The primary care ca work-up towardsmaagig complicatio through employig iterdiscipliary adpatiet-cetered care approaches. Kitso, Marshall, Bassett ad Zeitz(2013) argue that patiet-cetered approach is a effective model icare plaig whe workig with patiets. Ivolvig the cliet idecisio-makig process about their treatmet is effective imaagemet of chroic coditios. For example, the patiet williitiate chage i the treatmet or medicatio process i the face ofa relapse of his disease, usually i close liaiso with thespecialist health care provider team.Maitaiig remissio ofgastroeterology is also aother effective care. The heath care capla reduce heartburs ad other symptoms by offerig effectivemedicatios.

Collaboratio:

Collaboratioad itegrated are effective strategies i the health care settigbecause they help urses i makig effective care plaig program.Therefore, workig with other healthcare workers ca help i makigeffective health related maagemet decisios. Australia Commissioo Safety ad Quality i Health Care (2010) argue that collaboratiois a effective approach that helps urses to arrive at the effectivedecisios. Maagemet ad care plaig of patiets with chroicdiseases require effective collaboratio (Gill, Duig, McKio,Cook, Bourke, 2014). Collaboratio i care provisios of this clietwill help i decrease of secodary care. By collaboratio, activitiessuch as referral maagemet, treatmet process, cliical assessmetservices ad feedback for advacemet i itegrated care would beachieved effectively.

Followup:

Aprimary health care provider workig with the patiet aftergastroeterological admissio ca see patiet i a sessio, usuallyequivalet to oe PA. The follow-up primary care provider ca takeabout 10-15 miutes to make follow-ups.Gill.et-al (2014) cocludesthat makig follow-ups ca eable the health care provider todetermie the progress of the patiet.

Refereces

AustraliaCommissio o Safety ad Quality i Health Care.(2010).&bspPatiet-ceteredcare:

ImprovigQuality ad Safety by Focusig Care o Patiets ad Cosumers:Discussio Paper, Draft for Public Cosultatio.Caberra: ACSQHC. Retrieved o October 10, 2014 fromhttp://www.safetyadquality.gov.au/wp-cotet/uploads/2012/01/PCCC-DiscussPaper.pdf.

Gill,S. D., Duig, T., McKio, F., Cook, D., &amp Bourke, J. (2014).Uderstadig The

Experieceof Ipatiet Rehabilitatio: Isights Ito Patiet-Cetered Care FromPatiets Ad Family Members.&bspScadiaviaJoural of Carig Scieces,&bsp28,&bsp2,264-272.

CMS.gov.(2014). ICD-9-CM Diagosis ad Procedure Codes: Abbreviated ad FullCode

Titles.Cetersfor Medicare &amp Medicaid Services.Retrieved o October 10, 2014 fromhttp://www.cms.gov/Medicare/Codig/ICD9ProviderDiagosticCodes/codes.html.

CMS.gov.(2014). ICD-9 Code Lookup. Ceters for Medicare &amp MedicaidServices. Retrieved

oOctober 10, 2014fromhttp://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx?KeyWord=GERD&ampbc=AAAAAAAAAAAEAA%3d%3d&amp.

Kitso,A., Marshall, A., Bassett, K., &amp Zeitz, K. (2013). What are theCore Elemets Of

Patiet-CetredCare? A Narrative Review ad Sythesis of the Literature from HealthPolicy, Medicie ad Nursig.&bspJoural of AdvacedNursig,&bsp69,&bsp1, 4-10.