COPD Team Members: Adewale Okanlawon Fatimoh Olateju Uchenna Orji Tracie Pemberton Marlene Rosales COPD “Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that cause airflow blockage and breathing related problems. It includes emphysema and chronic bronchitis.” (CDC, 2018) As you can see on the left lung presented here, the bronchioles are filled with mucous. This causes the ‘crackles’ that are heard upon auscultation of the lungs. Biographics Name: Ana Jones Gender: Female Ethnicity: Hispanic/Latino Age: 56 years old Ht/Wgt: 5’2, 152 lbs (69.09 Kg) Admitting Doctor: Dr. Snow, MD direct admission Medical Diagnosis: COPD Exacerbation with possible Lung Infection Code: Full Diet: Low Sugar Activity as tolerated Our patient has a history of Diabetes, admits to poor diet and lack of physical activity. Patient states has a history of elevated cholesterol levels and hypertension. Patient experienced an MI 3 years previous. Patient does not smoke or drink alcohol and does not use illegal substances. Chief Complaint Patient presents with: Chief complaint: “I can’t catch my breath and I am burning up” fever shortness of breath uncontrolled chills extreme fatigue low/no appetite cough with greenish mucous chest pain when coughing 6/10 on scale As always, ABC is top priority, so have patient on supplemental oxygen and will now proceed with examination Biographics Continued Past Health History: Diabetes Hypertension COPD MI (3 years previous) Social: Patient brought in by her husband. Married 30 years, 2 adult aged children, housewife. Husband states “he is very worried about his wife as she doesnt seem to be able to breath at all”. Husband informed us their daughter and sick grandbaby had been visiting last week. Biographics Continued Current Medication: Metformin Hydralazine Nebivolol Albuterol Fluticasone Metoprolol Patient is currently on Metformin for blood glucose control, Hydralazine and Nebivolol for control of hypertension, Albuterol and Fluticasone for COPD and Metoprolol for MI Physician Orders Administer oxygen via nose cannula and titrate to 98% O2 saturation, 2L/m Start IV, with 0.9 Saline Respiratory - breathing evaluation and treatment Sputum Test (stat) Ct Scan Labs: Full CBC ABG Cholesterol Panel V/S q 4 hours Administer: Levofloxacin 750 mg IV , Tylenol 650 Mg PO, fever greater than 101., Call with Lab report Nurses Notes: Keep patient elevated at 45% to facilitate breathing, advise client to call for assistance when needs to use use the restroom. Sputum test MUST be done before administering Levofloxacin. CT Scan is to check for any inflammation or fluid in the lobes of the lungs. We will be expecting to see an elevated WBC. Physician is suspecting streptococcus pneumococcus This would be supported by the S/S of dyspnea, cough with sputum and activity intolerance. Vital Signs Temperature: 103.6 F R ...

1. COPD
Team Members:
Adewale Okanlawon
Fatimoh Olateju
Uchenna Orji
Tracie Pemberton
Marlene Rosales
COPD
“Chronic obstructive pulmonary disease, or COPD, refers to a
group of diseases that cause airflow blockage and breathing
related problems. It includes emphysema and chronic
bronchitis.” (CDC, 2018)
As you can see on the left lung presented here, the bronchioles
are filled with mucous. This causes the ‘crackles’ that are
heard upon auscultation of the lungs.
Biographics

2. Name: Ana Jones
Gender: Female
Ethnicity: Hispanic/Latino
Age: 56 years old
Ht/Wgt: 5’2, 152 lbs (69.09 Kg)
Admitting Doctor: Dr. Snow, MD direct admission
Medical Diagnosis: COPD Exacerbation with possible Lung
Infection
Code: Full
Diet: Low Sugar
Activity as tolerated
Our patient has a history of Diabetes, admits to poor diet and
lack of physical activity. Patient states has a history of elevated
cholesterol levels and hypertension. Patient experienced an MI
3 years previous. Patient does not smoke or drink alcohol and
does not use illegal substances.
Chief Complaint
Patient presents with:
Chief complaint: “I can’t catch my breath and I am burning up”
fever
shortness of breath
uncontrolled chills
extreme fatigue

3. low/no appetite
cough with greenish mucous
chest pain when coughing 6/10 on scale
As always, ABC is top priority, so have patient on supplemental
oxygen and will now proceed with examination
Biographics Continued
Past Health History:
Diabetes
Hypertension
COPD
MI (3 years previous)
Social:
Patient brought in by her husband. Married 30 years, 2 adult
aged children, housewife.
Husband states “he is very worried about his wife as she doesnt

4. seem to be able to breath at all”. Husband informed us their
daughter and sick grandbaby had been visiting last week.
Biographics Continued
Current Medication:
Metformin
Hydralazine
Nebivolol
Albuterol
Fluticasone
Metoprolol
Patient is currently on Metformin for blood glucose control,
Hydralazine and Nebivolol for control of hypertension,
Albuterol and Fluticasone for COPD and Metoprolol for MI
Physician Orders
Administer oxygen via nose cannula and titrate to 98% O2
saturation, 2L/m
Start IV, with 0.9 Saline
Respiratory - breathing evaluation and treatment
Sputum Test (stat)
Ct Scan
Labs:
Full CBC
ABG

5. Cholesterol Panel
V/S q 4 hours
Administer: Levofloxacin 750 mg IV , Tylenol 650 Mg PO,
fever greater than 101.,
Call with Lab report
Nurses Notes: Keep patient elevated at 45% to facilitate
breathing, advise client to call for assistance when needs to use
use the restroom. Sputum test MUST be done before
administering Levofloxacin. CT Scan is to check for any
inflammation or fluid in the lobes of the lungs. We will be
expecting to see an elevated WBC. Physician is suspecting
streptococcus pneumococcus This would be supported by the
S/S of dyspnea, cough with sputum and activity intolerance.
Vital Signs
Temperature: 103.6 F
RR: 29 (high)
BP: 140/89
HR: 102 bpm
SP02: 92%
Skin is flushed and diaphoretic

6. Client is in obvious distress with SOB, client has visible chills
and says “I am worried about my condition and my husband’s
anxiety over this situation isn’t helping. This is overwhelming!”
Focused Physical Examination
Respiratory: Crackles bilaterally. Diminished sounds lower lobe
anteriorly and posteriorly. Diffuse inspiratory and expiratory
wheezing bilaterally anterior and posterior. Accessory muscles
used for breathing
Cardiovascular: Heart sounds present and normal anteriorly and
posteriorly, capillary refill less than 3 seconds bilaterally
Neurological: Patient present and aware x4
HEENT: Head normal cephalic, pupils round reactive to light,
mild cyanosis noted to lips with dry mucous membranes
GI/GU: Normal bowel sounds
Dietary History: regular diet with poor control of blood glucose
Integumentary: Skin warm, flushed and diaphoretic
Musculoskeletal: normal tonicity and strength x5 bilaterally
Psychological/Family - Support: Pt lives at home with husband
Laboratory Test Ordered w/rationale

7. Sputum Culture, Gram Positive Stain - tests for streptococcus
pneumococcus or other gram positive (bacterial infections)
Full CBC - Checking for increased WBC to indicate infection
and determine type of infection and link condition to possible
pathogens
ESR - determine inflammation rate in body
CRP - determine inflammation rate in body
Blood Culture - detect bacteria in blood
Cholesterol Panel - pt has history of hypertension and currently
has elevated blood pressure. Need to determine current cause.
Sputum Culture ordered before administration of antibiotics
Full CBC to check counts of RBC, White Blood Cells,
ESR 0 erythrocyte sedimentation rate and C-Reactive Protein to
measure for inflammation
Blood Culture to detect for bacteria in the blood
Results of Test Ordered
Significant Findings
CT Scan: Lower lobes inflamed bilaterally, fluid filled sacs
bilaterally representing alveolar edema
Sputum, GRAM positive came back with a positive result for
streptococcus pneumococcus
ABG reflects Respiratory Acidosis
WBC is elevated
LDL is elevated

8. Dr Snow called with report of findings
Dr Snow was given the full report and ordered we proceed with
his orders as prescribed. He will return in 4 hours to check on
his patient.
Health Care Team Members & Role
Primary care physician - a primary care physician role is to
prescribe medications that can help make breathing easier, such
as prednisolone, albuterol, and antibiotics. They also the first
healthcare provider that is first seen. They come up with a
diagnosis based on signs and symptoms the patients presents.
Pulmonologist - a pulmonologist is a one who specializes in
overall anatomy and physiology of the lungs. The role a
pulmonologist plays in the case of a COPD patient is to create
an individualized plan of treatment of the diagnosis. They also
perform a procedure known as a bronchoscopy, the goal of this
procedure is to have an internal look into the lungs to see the

9. COPD damage and to make breathing easier.
Respiratory therapist- a respiratory therapist role is to help
exercise and train the lungs to expand and recoil during
inspiration and expirations.
Dietician- a dieticians role is to help suggest diets that will help
the patient lose weight , such diets would be low carb diets, or
low fats diets.
Thoracic surgeon - thoracic surgeons role is to perform lung
surgery. Such surgeries are lung volume reduction or lung
transplant.
Psychiatrist- COPD is a severe medical condition and it can
cause the patient to fall into depression and face anxiety.
Image: Getty Images/Image Source
Each care provider plays a major role in the care for a patient
who has COPD, they work together to make sure that the
ultimate treatment for COPD is achieved.
List of Medications
Treatments & Procedures
List of Medications
Albuterol
Prednisolone
Revefenacin
Tiotropium
Olodaterol
Roflumilast

10. Treatment & Procedures
COPD can be treated with either or all of the following:
Oxygen therapy - O2 therapy is needed if oxygen levels begin to
deplete, oxygen can be administered through a simple mask or a
nasal cannula.
Surgery - surgery is typically the last option and often reserved
unless the COPD is severely advanced. Such procedures include
bullectomy, lung transplant and lung volume reduction.
Medication - oral steroids, bronchodilators can be administered
by the physician to help relax and widen the muscles of the
airways, so that breathing can be less stressful. ,
Image Source: Nurse.org
The common medications administered for COPD are albuterol,
prednisolon, revefenacin, tiotropium, olodaterol and roflumilast.
These medications are oral steroids, long and short-lasting
bronchodilators and their indication is to help alleviate the
discomfort while breathing and makes breathing much easier
and bearable. COPD can be treated by placing the patient on
oxygen therapy through a simple mask or cannula to help
administer oxygen when oxygen levels are depleting. Surgical
procedure such as lung transplant, bullectomy and lung volume
reduction are surgical procedures that will help make breathing
comfortable.

11. Dietary Prescriptions
People who suffer from COPD usually have low body mass,
decrease in lean body mass and overall weight loss. Therefore it
is imperative that their diet should include foods that are high
in fiber, such as seeds, nuts, vegetable, fruits. Proteins are
necessary to help maintain a strong and healthy respiratory
muscles. Avoid foods that cause bloating and high in sodium, as
it can make breathing uncomfortable and sodium retain water in
the body.
Fluid intake should be taken before meals as it can help reduce
pressure and feeling of being full before meals are consumed..
A good posture should be maintained as it helps reduce the risk
of aspiration and promotes proper breathing and swallowing.
Image: Getty Images/Image Source
COPD patients diet is tailored to their health, they are advised
to incorporate foods that are high in fiber and proteins to help
them gain healthy weight, as COPD patients have low body
mass, decreased lean body mass and overall weight loss. It is
advised that COPD patients do not drink fluids before having
meals as it prevents them from becoming full and they have the
desire to eat. Foods high in sodium should be monitored
because we don’t want them to have edema which makes
breathing difficult. low body mass, decrease in lean body mass
and overall weight loss. have low body mass, decrease in lean
body mass and overall weight loss. have low body mass,

12. decrease in lean body mass and overall weight loss.
Nursing Plans of Care - Physiological Nursing Diagnosis
Priority Nursing Diagnosis - Impaired gas exchange, as
evidenced by SOB, reduced tolerance for activity, abnormal
ABG values, dyspnea and abnormal breath sounds upon
auscultation of lungs
Short term goal - Demonstrate improved ventilation and
adequate oxygenation of tissues by ABGs within patients
normal range and be free of symptoms of respiratory distress
(Vera, 2019)
Long term goal - Participate in treatment regimen within level
of ability
Patient is positive for infection, but airway clearance, breathing
and cardiovascular are always top priority, as such the priority
nursing diagnosis is in regards to dyspnea, shortness of breath
and low O2 saturation.
Nursing Plans of Care - Physiological Nursing Diagnosis
Interventions with rationale
Auscultate breath sounds, noting areas of decreased airflow and
adventitious sounds
Breath sounds may be faint, monitor for airflow and areas of
consolidation. Wheezing can indicate retained secretions and
crackles may indicate interstitial fluid
Monitor V/S, O2 saturation (titrate oxygen to maintain 98%)
and monitor ABGs
We are monitoring for tachycardia, dysrhythmias, changes in

13. BP, changes in O2 saturation so we can maintain proper levels
with supplemental oxygen, and ABGs to monitor PH levels and
PaCo2 levels (respiratory acidosis)
Elevate head of the bed to ease the workload on the lungs and
encourage deep slow breathing with periods of pursed-lip
breathing.
Improvement in oxygen delivery when upright and decreased
airway collapse.
When auscultating, we want to follow this with an assessment
of respiratory rate, use of accessory muscles and ability to
speak and converse. This will help evaluate respiratory
distress.
When monitoring O2 sat, if levels drop, immediately call PCP
and recommend change in oxygen delivery.
Nursing Plans of Care - Physiological Nursing Diagnosis
Interventions with rationale
Auscultate breath sounds, noted improved breath sounds, lungs
clear to auscultation bilaterally
O2 saturation returned to 99% on room air, PH return to 7.38
and supplemental oxygen is no longer needed
After intervention the patient is now able to breath without use
of accessory muscles, take a deep breath without coughing and
sleep prone

14. Statements after Interventions
Nursing Plans of Care - Physiological Nursing Diagnosis
Interventions with rationale
Instruct patient on importance of secretions, expectorate instead
of swallowing.
This will prevent ingestion of bacteria and will facilitate a
visual representation of changes in infection condition as color,
odor and amount of sputum can be tracked
Demonstrate and encourage good hand hygiene, limit visitors
while immune system is compromised and institute isolation
precautions
The goal is to limit the spread of germs, limit reinfection of
patient by others and help client prevent future infections
Preventing reinfection in the future, limiting additional
introduction of pathogens to patient while compromised and
preventing spread of current infection to others is a primary
concern and this is best handled by proper hand washing and
limitation of exposure to others.
Nursing Plans of Care - Physiological Nursing Diagnosis
Interventions with rationale
Quantity of secretions diminished and then were clear. Sputum

15. went from green to clear and now mucous membranes are moist
and clear.
Patient and her husband are able to perform good hand washing
and have repeated back to me the importance of hand hygiene
and avoiding situations with evidence of possible
contamination.
Statements after intervention
Nursing Plans of Care - Psychosocial Nursing Diagnosis
Priority Nursing Diagnosis:
Stress overload r/t coping with chronic illness AEB patient
states “I am worried about my condition and my husband’s
anxiety over this situation isn’t helping. This is
overwhelming!”, patient reports extreme fatigue, patient has HR
102 bpm and 29 breaths/minute.
Short term goal: Patient will identify stressors that can be
controlled and those that cannot
by the end of the shift.
Long term goal: Patient will identify one successful behavior
change to reduce or eliminate that will increase successful
stress management

16. Marlene
Nursing Plans of Care - Psychosocial Nursing Diagnosis
(Cont’d)
Interventions and Rationales
The nurse will assist to recognize patient’s thoughts, feelings,
actions, and physiologic responses
Self-awareness can help the patient reframe and reinterpret their
experiences
The nurse will teach the patient how to decrease heart rate,
respirations, and feelings of stress (engage in a diversional
activity, use of guided imagery, teach to use mini-relaxation
breathing techniques)
Faced with overwhelming multiple stressors, the patient can be
assisted to differentiate which stressors can be modified or
eliminated
The nurse will encourage the patient to discuss stresses with
spouse and children
Discussing stress with loved ones can help them understand her
feelings and emotions and can aid in building a stronger
connection so that she has someone to turn to in times of stress
The nurse will ask the patient to list one or two changes they
would like to make in the next week
In a person who is already overwhelmed, small changes in
lifestyle may have a higher chance for success, will increase
confidence, and reduce chances of future exacerbations
The nurse will assist to set realistic goals to achieve a more
balanced health-promoting lifestyle (What is most important?

17. What aspects of your life would you like to change the most?)
Setting realistic goals will increase confidence and success
Marlene
Nursing Plans of Care - Psychosocial Nursing Diagnosis
(Cont’d)
Evaluative Statements
Patient was able to recognize her thoughts, feelings, actions,
and physiologic responses.
Patient demonstrated techniques to reduced heart rate,
respirations, and feelings of stress using distraction and
controlled breathing techniques.
Patient discussed stresses with her spouse and children. She
states “I feel better than I can talk to my family about what I’m
feeling and I know I can count on them when I need someone to
talk to.”
The patient identified one lifestyle change that she would like
to make in the next week. She states, “I will walk one to two
blocks each day.”
The patient was able to set realistic goals for herself. She states
“I need to improve my diet, so I will eat at least one vegetable a
day.”

18. Patient/Family Teaching Goals
Physiological Teaching:
Educate patient the importance deep breathing and controlled
coughing.
This reduces fatigue usually associated with forceful coughing
and uncontrolled breathing
Educate the patient on the importance of pursed lip breathing.
Pursed lip breathing helps with slow expiration, helps prevent
collapse of small airways, and control rate of respirations
Educate the patient on the importance daily controlled exercise
regimens.
It is important that the patient participates in controlled
exercises throughout the day. This can help strengthen upper
and lower extremities, increase patient activity tolerance level,
and help manage stress.
Adewale
Patient/Family Teaching Goals
Psychosocial Teaching:
Encourage the patient to take some time to meditate throughout

19. the day.
This will help identify anything current stressors that may be
affecting the patient and also help reduce the patient's stress and
anxiety.
Educate the patients family, especially the husband, on the
importance of making the home environment a stress free area.
This will help with patients anxiety and improve overall patient
outcomes.
Educate the patient on the importance of getting a good night's
rest.
It is important for adults to get 7-9 hours of sleep. This will
also help with the patient’s stress and relieve anxiety.
Adewale
References
CDC - COPD Home Page - Chronic Obstructive Pulmonary
Disease (COPD). (2018, June 06). Retrieved November 25,
2020, from https://www.cdc.gov/copd/index.html
COPD: Who's on Your Medical Care Team? (2019, August 19).
Retrieved November 29, 2020, from
https://www.webmd.com/lung/copd-medical-care-team
Nutrition and COPD - Dietary Considerations for Better
Breathing. (n.d.). Retrieved November 29, 2020, from
https://www.todaysdietitian.com/newarchives/td_020909p54.sht
ml
Vera, M., By, -, Vera, M., & Matt Vera is a registered nurse
with a bachelor of science in nursing since 2009 and is currently

20. working as a full-time writer and editor for Nurseslabs. During
his time as a student. (2019, September 28). 7 Chronic
Obstructive Pulmonary Disease (COPD) Nursing Care Plans.
Retrieved November 25, 2020, from
https://nurseslabs.com/chronic-obstructive-pulmonary-disease-
copd-nursing-care-plans/2/
References (Continued)
Carpenito, L. J. (2017). Nursing diagnosis: application to
clinical practice. 15th edition. Philadelphia, PA: Wolters
Kluwer.

21. Hypertension
Esperanza Jauregui,
Chamberlain University School of Nursing
NR 324 - Adult Health I
Professor Sullivan
August 15, 2021

23. Table of Contents

24. Introduction about the disease
01
About the Disease
Demographics, Medical History, Chief Complaint,
Manifestations
02
Health History
Lab Results and Diagnostic Results
03
Labs & Diagnostics
Procedures, Treatment, and Case Management
04
Collaborative
Management
Plan of Care
06
Psychosocial Nursing Management
05
Physiologic Nursing Management
Plan of Care

25. Esperanza Jauregui
Hypertension, or high blood pressure (BP), is one of the most
important modifiable risk factors that can lead to the
development of cardiovascular disease (CVD).
Hypertension is often called the “silent killer” because it is
often asymptomatic until it becomes severe and target organ
disease occurs
The most common complications of hypertension are target
organ diseases occurring in the heart, brain, peripheral vessels,
kidneys, and eyes.
About the Disease

27. Esperanza Jauregui
Kwong, H. & Reinisch, R. (2020) Lewis’s Medical-Surgical
Nursing (11th ed.) Evolve
Health History
45 y/o Male, African American
Demographics
Heart palpitations, headache, and dizziness
Chief Complaint
Hx. of Type 2 Diabetes Mellitus, Obese and ½ a pack smoker
daily
Medical History
10+ yrs diagnosis of stage 2 hypertension, noncompliant with
medications
History of Present Disease

29. Esperanza Jauregui
J. P is a 45 year old African American male who came to the
emergency room with complaints of heart palpitations since
yesterday evening and a severe headache. The patient states that
“he feels that his head is pounding that it makes him dizzy and
that his heart is going to beat out of his chest.” The patient also
complains of chest pain, SOB, lightheadedness and dizziness.
He states that he has a history of type 2 diabetes mellitus. The
patient is obese and is weighing at 260 lbs (117.9 kg). The
patient is smoker (½ a pack a day), noncompliant with
medications or dietary changes.
When arriving to the emergency department, the patient’s vital
signs were 160/90 for the blood pressure, 86 for the heart rate,
98.6 for the temperature, 90% for the pulse ox, and 15 for the
respirations.
Signs and Symptoms
Despite being red, Mars is actually a cold place
Mars
Mercury is the smallest planet in the Solar System
Mercury

31. Text

32. Despite being red, Mars is actually a cold place
Mars
It’s composed mostly of hydrogen and helium
Saturn
It’s a gas giant and the biggest planet in the Solar System
Jupiter

33. Text

34. Big numbers catch your audience’s attention

36. Text
Big numbers catch your audience’s attention

39. Key Numbers
50,000
Mars is actually a cold place full of iron oxide dust
20,000
Jupiter is a gas giant and also the biggest planet
5,500
Saturn is composed mostly of hydrogen and helium

40. —Someone Famous
“This is a quote, words full of wisdom that someone important
said and can make the reader get inspired.”

43. Laboratory Studies
Laboratory Studies that are used to diagnosis hypertension
along with patient history and physical assessment include:
Serum lipid panel (Total lipids, triglycerides, HDL, and LDL)
Complete blood count (cbc)
Basic metabolic panel, Routine urinalysis, BUN and serum
creatinine levels
Serum electrolytes and Uric acid
.
Fasting blood glucose
Brain natriuretic peptide

45. Abigail Morales
Serum lipid panel (Total lipids, triglycerides, HDL, and LDL)
Increased levels of cholesterol and triglycerides are primary
risk factors for atherosclerosis
Hyperlipidemia is more common in people with hypertension
Complete blood count (cbc)
CBC is used to to indicate anemia due to chronic renal disease
and anemia is a risk factor of ischemic heart disease.
Basic metabolic panel, Routine urinalysis, BUN and serum
creatinine levels
Routine urinalysis, BUN, and serum creatinine levels are used
to screen for renal involvement and provide baseline
information about kidney function. Creatinine clearance reflects
the glomerular filtration rate. GFR rate is measure in
hypertension because they are likely to develop chronic kidney
disease.
Serum electrolytes and Uric acid
Measurement of serum electrolytes, especially potassium, is
essential to detect hyperaldosteronism, a cause of secondary
hypertension. Uric acid levels establish a baseline since the
levels often rise with diuretic therapy.
Fasting blood glucose
High glucose levels increased the risk of hypertension
BNP
Measures the pressure within the ventricles of the heart.
Increased BNP may increase the severity of hypertension.

46. References: Kwong, H. & Reinisch, R. (2020) Lewis’s Medical -
Surgical Nursing (11th ed.) Evolve
Normal Laboratory Values
Serum lipid panel (Total lipids, triglycerides, HDL, and LDL)
LDL < 100 mg/dL
HDL > 40 mg/dL
Triglycerides < 150 mg/dL
Total Cholesterol < 200 mg/dL
Complete blood count (cbc)
Hemoglobin (Hgb)
Female: 12–16 g/dL // Male: 14–18 g/dL
Hematocrit (Hct)
Female: 37%–47% // Male: 42%–52%
WBC count
5000–10,000/μL
Platelet count
150,000–400,000

47. Abigail Morales
References: Kwong, H. & Reinisch, R. (2020) Lewis’s Medical -
Surgical Nursing (11th ed.) Evolve

48. Laboratory Studies
Basic metabolic panel, BUN, serum creatinine levels, serum
electrolytes
BUN: 6 to 20 mg/dL
CO2 (carbon dioxide): 23 to 29 mmol/L
Creatinine: 0.8 to 1.2 mg/dL
Serum chloride: 96 to 106 mmol/L
Serum potassium: 3.7 to 5.2 mEq/L
Serum sodium: 136 to 144 mEq/L
Serum calcium: 8.5 to 10.2 mg/dL
Uric acid
Men 3.4-7.0 Mg/dL // Women 2.4-6.0 Mg/dL
Fasting blood glucose
Glucose: 64 to 100 mg/dL
Brain natriuretic peptide
Less than 125 pg/mL for aged 0-74 years
Less than 450 pg/mL for aged 75-99 years

49. Abigail Morales
References: Kwong, H. & Reinisch, R. (2020) Lewis’s Medical -

50. Surgical Nursing (11th ed.) Evolve
Prevention
01
02
03
04
Mercury is the closest planet to the Sun
Mercury
Despite being red, Mars is a cold place
Mars
It’s the biggest planet in the Solar System
Jupiter
Saturn is composed of hydrogen and helium
Saturn

52. Venus has a beautiful name and is the second planet from the
Sun
Treatment
Venus
Mercury is the closest planet to the Sun and the smallest one
Mercury

54. You can describe here what the patient shouldn’t do
You can describe here what the patient shouldn’t do
You can describe here what the patient shouldn’t do
Recommendations
What not to do
You can describe here what the patient should do
You can describe here what the patient should do
You can describe here what the patient should do
What to do
X
V

56. Prevalence
Despite being red, Mars is a cold place
Mars
It’s the biggest planet of them all
Jupiter
02
01

57. Mercury is the closest planet to the Sun and the smallest one in
the Solar System—it’s only a bit larger than the Moon
Healthy Habits

58. Jupiter is a gas giant, the biggest planet in the Solar System and
the fourth-brightest object in the night sky
Text

60. References
Kwong, M.H.D.R.C.R.D.H. J. Lewis's Medical-Surgical
Nursing. [VitalSource Bookshelf]. Retrieved from
https://online.vitalsource.com/#/books/9780323551496/

61. References
● AUTHOR (YEAR). Title of the publication. Publisher

62. ● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher

66. Educational Icons
Medical Icons

70. 1
NR324/329 Adult Health I
Required Uniform Assignment: Case Study Presentation
NR324/329 RUA: Case Presentation Guidelines V2
Revised: 5/2019
11
Purpose
The purpose of this assignment is to help students build
communication skills, utilize evidence‐ based research
relevant to nursing practice, and apply concepts of safety and
quality in nursing care of adults. The goals of this
assignment are to:
• foster teamwork and collaboration through effective
communication
• Utilize research evidence to promote safe and quality nursing
care for adults in acute care settings.

71. Course outcomes: This assignment enables the student to meet
the following course outcomes:
CO 1. Provide effective professional nursing care for adult
patients and their families in acute care settings using
the nursing process. (PO#1)
CO 3. Demonstrate effective communication skills necessary for
collaboration with other health care team
members and for providing professional nursing care to adult
patients and their families. (PO #3)
CO 4. Apply critical thinking strategies to make good clinical
decisions in the adult patient clinical setting. (PO#4)
CO 8. Utilize nursing research literature while providing care to
adult patients and their families in acute care
settings. (PO #8)
Due date: Your faculty member will inform you when this
assignment is due. The Late Assignment Policy applies
to this assignment.
Total points possible: 100 points
Preparing the assignment
The student group must develop a case study based on an actual
or potential clinical‐ based situation on the adult
health topics presented during the 8‐ week session. The student
group must present the topic and literature for the
case scenario.
Students must include the following information in the case
study presentation:
A. Health History – age, gender, ethnicity, past and current
medical history, chief complaint, and history of present

72. illness on admission.
B. Laboratory/Diagnostic Testing – describe the diagnostic tests
ordered/completed, pertinent results (including
normal and abnormal ranges), and rationales for the use of each
diagnostic test.
C. Collaborative Management – provide list of medications,
treatments, dietary prescriptions, and procedures that
have been ordered, administered, completed, and/or pending.
Additionally, provide an overview of members of the
healthcare team involved in managing the care of the person and
family and the interdisciplinary goals that have
been set. Briefly list the role of the team member in the
patient’s care and the ways in which the nurse collaborates
to meet the interdisciplinary goals.
D. Nursing management – using the nursing process, develop
two plans of care ‐ 1 related to one priority physiological
nursing diagnosis and 1 related to one priority psychosocial
nursing diagnosis. Please include the following
information in each plan of care:
• Priority nursing diagnosis
• short and 1 long‐ term goal
• to 5 nursing interventions with rationale statements,
• to 5 evaluative statements based on interventions, and
• A minimum of 3 potential patient education needs for
consideration.
2

73. NR324/329 Adult Health I
Required Uniform Assignment: Case Study Presentation
NR324/329 RUA: Case Presentation Guidelines V2
Revised: 5/2019
21
Assignment Submission Requirements:
• Students must receive approval from the faculty on the
selected topic for the case study presentation
assignment. The faculty will facilitate selection of topics during
class.
• Each student in the group must contribute to the development
of the case study information.
• Each student group must submit a 1‐ page typed paper
containing the Health History, Laboratory/Diagnostic
Testing, and Collaborative Management elements of the case
study.
• Each student group must submit a 1‐ page typed paper of the
plan of care addressing the priority
physiological nursing diagnosis and a 1‐ page typed paper of
the plan of care addressing the priority
psychosocial nursing diagnosis. Students may choose to submit
a concept map for each of the priority
nursing diagnoses instead of a plan of care. Each concept map
must incorporate the same information
required for the plans of care.
• Each student group must submit a reference list with each
member’s nursing care plan or concept map,
formatted according to APA 6TH edition. A minimum of at least

74. three (3) references are required for this
assignment. Student must cite at least two (2) research or
evidence‐ based practice (EBP) sources. All
resources must be within 5 years of publication.
• Each student group is required to develop and present a 15
minute presentation on a topic from the case
study, the plan of care or the concept map. Each group
presentation will all an additional 5 minutes for
questions and answers relevant to the content of the
presentation and/or the clinical experience.
* If a student in the group is absent the day of the presentation,
the student group will not be penalized.
NR324/329 Adult Health I
Required Uniform Assignment: Case Study Presentation
NR324/329 RUA: Case Presentation Guidelines V2
Revised: 5/2019
31
Grading Rubric
Criteria are met when the student’s application of knowledge
demonstrates achievement of the outcomes for this assignment.
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of

75. Performance
High Level of
Performance
Satisfactory Level of
Performance
Unsatisfactory
Level of
Performance
Health History
(10 points/10%)
10 points 9 points 8 points 0 points
Required criteria
1. Presents pertinent and relevant information on: the
person’s age, gender, ethnicity, past and current
medical history, chief complaint, and history of
present illness on admission.
• Comprehensively presents
key/relevant Information
accurately and in
sufficient detail: person’s
age, gender, ethnicity, past
and current medical history,
chief complaint, and history
of present illness on
admission.
• Information presented in a

76. clear, organized, and
professional manner
• One of the key/relevant
Information not
presented: person’s age,
gender, ethnicity, past
and current medical
history, chief complaint,
and history of present
illness on admission.
• Key/relevant information
are accurate and
presented in sufficient
detail.
• Information presented in
a clear, organized, and
professional manner
Two of the key/relevant
Information not
presented: person’s age,
gender, ethnicity, past and
current medical history,
chief complaint, and history
of present illness on
admission.
Key/relevant information
may be inaccurate and/or
insufficient in detail.

77. Information presented in a
clear, organized, and
professional manner
3 or more of the
key/relevant Information
not presented: person’s
age, gender, ethnicity, past
and current medical history,
chief complaint, and history
of present illness on
admission.
Key/relevant information
may be inaccurate and/or
insufficient in detail.
• Information is not
clear, organized, or
professional in appearance.
Laboratory and Diagnostic Testing
(10 points/10%)
10 points 9 points 8 points 0 points
Required criteria
1. Presents description of the ordered/completed
diagnostic tests, pertinent results (including normal
and abnormal ranges), and rationales for each
diagnostic test.
• Comprehensively
presents key/relevant

78. Information accurately
and in sufficient detail:
description of the
ordered/completed
diagnostic tests,
pertinent results (normal
and abnormal ranges),
• One of the key/relevant
Information not
presented: description of
the ordered/ completed
diagnostic tests, pertinent
results (normal and
abnormal ranges), and
rationales for each
diagnostic test.
• Two of the key/relevant
Information not
presented: description of
the ordered/ completed
diagnostic tests, pertinent
results (normal and
abnormal ranges), and
rationales for each
diagnostic test.
• 3 or more of the
key/relevant Information
not presented: description
of the ordered/ completed
diagnostic tests, pertinent
results (normal and
abnormal ranges), and
rationales for each

79. diagnostic test.
NR324/329 Adult Health I
Required Uniform Assignment: Case Study Presentation
NR324/329 RUA: Case Presentation Guidelines V2
Revised: 5/2019
41
and rationales for each
diagnostic test.
• Information presented in
a clear, organized, and
professional manner
• Key/relevant information
are accurate and
presented in sufficient
detail.
• Information presented in
a clear, organized, and
professional manner
• Key/relevant information
are accurate and
presented in sufficient
detail.
• Information presented in a

80. clear, organized, and
professional manner
• Key/relevant information
may be inaccurate and/or
insufficient in detail.
• Information is not clear,
organized, or professional
in appearance.
Collaborative Management
(20 points/20%)
20 points 15 points 10 points 0 points
Required criteria
Presents list of medications, treatments, dietary
prescriptions, and procedures that have been ordered,
administered, completed, and/or pending
Additionally, provide an overview of members of the
healthcare team involved in managing the person and
family. Briefly list their role in the care provided and how
nursing collaborates in meeting interdisciplinary goals.
• Comprehensive
discussion of collaborative
management including: list
of medications, treatments,
dietary prescriptions, and
procedures that have been
ordered, administered,
completed, and/or pending.

81. • Complete overview of
members of the healthcare
team involved in managing
the person and family;
Listed ALL key/relevant
roles in the care provided
and how nursing
collaborates in meeting
interdisciplinary goals.
• Information presented
in a clear, organized, and
professional manner.
• Discussed collaborative
management, but does
not include 1of these
items: list of
medications, treatments,
dietary prescriptions, and
procedures that have
been ordered,
administered, completed,
and/or pending
• Complete overview of
members of the
healthcare team involved
in managing the person
and family; Listed most
of the key/relevant roles
in the care provided and
how nursing collaborates
in meeting
interdisciplinary goals

82. • Information presented in
a clear, organized, and
professional manner.
• Discussed collaborative
management, but does
not include 2 of these
items: list of medications,
treatments, dietary
prescriptions, and
procedures that have been
ordered, administered,
completed, and/or
pending.
• General overview of
members of the healthcare
team involved in managing
the person and family;
Listed SOME key/relevant
roles in the care provided
and how nursing
collaborates in meeting
interdisciplinary goals.
• Information is not
presented in a clear,
organized, and/or
professional manner.
• Poor/Minimal discussion
of collaborative
management which does
not include 3 or more of

83. these items: list of
medications, treatments,
dietary prescriptions, and
procedures that have been
ordered, administered,
completed, and/or
pending.
• Poor/Broad overview of
members of the healthcare
team involved in managing
the person and family;
Listed SOME of
key/relevant roles in the
care provided and how
nursing collaborates in
meeting interdisciplinary
goals.
• Information is not
presented in a clear,
organized, and/or
professional manner.
Nursing Management: Physiologic 15 points 12 points 8 points
0 points
NR324/329 Adult Health I
Required Uniform Assignment: Case Study Presentation
NR324/329 RUA: Case Presentation Guidelines V2
Revised: 5/2019

84. 51
(15 points/15%)
Required criteria
Utilized the nursing process to develop two plans of
care: 1 physiological and 1 psychosocial nursing
diagnosis
Included the following information in each* plan of care:
1. Priority nursing diagnosis
2. 1 short‐ term and 1 long‐ term goal
3. 3 ‐ 5 nursing interventions with rationale
statements
4. 3 ‐ 5 evaluative statements based on
interventions
5. A minimum of 3 teaching considerations
Used the nursing process to
develop a plan of care for
physiological nursing
diagnosis
All information in the plan of
care included: o Priority
nursing diagnosis o 1
short‐ term and 1 long‐ term
goal
o 3 ‐ 5 nursing interventions
with rationale statements
o 3 ‐ 5 evaluative

85. statements based on
interventions
o A minimum of 3 teaching
considerations
Used the nursing process to
develop a plan of care for
physiological nursing
diagnosis
Missing 1 item of
information
in the plan of care: o
Priority nursing
diagnosis o 1 short‐
term and 1 long‐ term
goal
o 3 ‐ 5 nursing
interventions with
rationale statements
o 3 ‐ 5 evaluative
statements based on
interventions
o A minimum of 3
teaching
considerations
Used the nursing process to
develop a plan of care for

86. physiological nursing
diagnosis
Missing 2 items of
information
in the plan of care: o
Priority nursing diagnosis
o 1 short‐ term and 1 long‐
term goal
o 3 ‐ 5 nursing
interventions with
rationale statements
o 3 ‐ 5 evaluative
statements based on
interventions
o A minimum of 3 teaching
considerations
Used the nursing process to
develop a plan of care for
physiological nursing
diagnosis
Missing 3 or more items of
information in the care
plan: o Priority nursing
diagnosis o 1 short‐ term
and 1 long‐ term goal
o 3 ‐ 5 nursing

87. interventions with
rationale statements
o 3 ‐ 5 evaluative
statements based on
interventions
o A minimum of 3 teaching
considerations
Nursing Management: Psychosocial
(15 points/15%)
15 points 12 points 8 points 0 points
Required criteria
Utilized the nursing process to develop two plans of
care: 1 physiological and 1 psychosocial nursing
diagnosis
Included the following information in each* plan of care:
1. Priority nursing diagnosis
2. 1 short‐ term and 1 long‐ term goal
3. 3 ‐ 5 nursing interventions with rationale
statements
Used the nursing process to
develop a plan of care for
psychosocial nursing
diagnosis
All information in the plan

88. of care included:
o Priority nursing
diagnosis
o short‐ term and 1
long‐ term goal
o 3 ‐ 5 nursing interventions
with rationale statements
Used the nursing process to
develop a plan of care for
psychosocial nursing
diagnosis
Missing 1 item of
information in the plan
of care:
o o Priority
nursing diagnosis
o o 1 short‐ term
and 1 long‐ term
goal
Used the nursing process to
develop a plan of care for
psychosocial nursing
diagnosis
Missing 2 items of
information in the plan of
care:

89. o o Priority nursing
diagnosis
o o 1 short‐ term and
1 long‐ term goal
o 3 ‐ 5 nursing
Used the nursing process to
develop a plan of care for
psychosocial nursing
diagnosis
Missing 3 or more items of
information in the care
plan:
o Priority nursing
diagnosis
o 1 short‐ term and 1
long‐ term goal
o 3 ‐ 5 nursing
NR324/329 Adult Health I
Required Uniform Assignment: Case Study Presentation
NR324/329 RUA: Case Presentation Guidelines V2
Revised: 5/2019
61
4. 3 ‐ 5 evaluative statements based on
interventions
5. A minimum of 3 teaching considerations

90. o 3 ‐ 5 evaluative
statements based on
interventions
o A minimum of 3 teaching
considerations
o 3 ‐ 5 nursing
interventions with
rationale
statements
o 3 ‐ 5 evaluative
statements based
on interventions
o A minimum of 3
teaching
considerations
interventions with
rationale statements
o 3 ‐ 5 evaluative
statements based on
interventions
o A minimum of 3
teaching
considerations
interventions with
rationale statements
o 3 ‐ 5 evaluative
statements based on
interventions

91. o A minimum of 3
teaching
considerations
Presentation
(25 points/25%)
25 points 20 points 15 points 0 points
Required criteria
1. All components of the assignment guidelines
included.
2. Information presented in a logical, interesting
sequence which audience can follow.
3. Participation by all group members.
4. All presenters are professional and
demonstrated appropriate presence
throughout presentation.
5. Used presentation materials and methods
effectively.
6. Responded appropriately to audience
questions.
• ALL required
assignment components
are present.
• Information is presented in
a logical sequence; main
ideas easy for the audience

92. to follow.
• Participation is by all group
members.
• Presenters are professional
• Presenters maintained
appropriate eye contact with
audience and projected
voices for all audience to
hear.
• Presenters addressed
audience questions
appropriately.
• Used presentation materials
and methods effectively.
• Presenters stayed
within allotted 20‐ minute
timeframe.
• ONE required
assignment
component is missing.
• Information is presented
in a logical sequence;
main ideas easy for the
audience to follow.
• Participation is by all
group members.
• Presenters are

93. professional.
• Presenters have
limited eye contact OR
the audience has
difficulty hearing the
presenters.
• Presenters addressed
audience questions
appropriately.
• Used presentation
materials and methods
effectively.
• Presenters stayed
within allotted 20‐
minute timeframe.
• 1‐ 2 required assignment
components are
missing.
• Information is not
presented in a logical
sequence, yet main ideas
are still obvious.
• Participation is by all
group members.
• Presenters are
professional.
• Presenters have limited
eye contact OR the

94. audience has difficulty
hearing the presenters.
• Presenters addressed
audience questions
appropriately.
• Used presentation
materials and methods
effectively.
• Presenters stayed
within 5 minutes of the
allotted 20 minute
timeframe.
• 3 or more required
assignment components
are missing.
• There is no logical
sequence to presentation
of material; main ideas
difficult to follow.
• Some members did not
participate.
• Some or ALL presenters
are unprofessional.
• Presenters have limited
eye contact OR the
audience has difficulty
hearing the presenters.
• Presenters did not address

95. audience questions
appropriately.
• Did not effectively use
presentation materials and
methods.
• Presenters stayed
within 5‐ 10 minutes of
the allotted 20 minute time
frame.
NR324/329 Adult Health I
Required Uniform Assignment: Case Study Presentation
NR324/329 RUA: Case Presentation Guidelines V2
Revised: 5/2019
71
APA Style and Organization
(5 points/5%)
5 points 4 points 2 points 0 points
Required criteria
1. References are submitted with assignment.
2. Uses appropriate APA format (6th ed.) and is free
of errors.
3. Grammar and mechanics are free of errors.
4. Used at least three (3) different sources, with at
least two (2) from research literature.

96. • More than 3 references
used, at least 2 are research
articles
• References submitted with
assignment
• Citations and references are
listed using APA format (6th
ed.) and are free of errors.
• Exactly 3 references
used, at least 2 are
research articles
• References submitted
with assignment
• Citations and
references are listed
using APA format (6th
ed.), but have one type
of error.
• Two (2) references used,
at least 1 is a research
article
• References submitted with
assignment
• Citations and references
are listed using APA
format (6th ed.), but have

97. two types of errors.
• One to Two references
used, but are NOT
research articles
• References submitted with
assignment
• Citations and references
are listed using APA
format for citations and,
but have three or more
types of errors.
PurposePreparing the assignmentGrading Rubric