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 How will the degree program you are seeking support your career plans at UHealth Tower as an acute care nurse practitioner in 3-5 years? 

Unit 3 Discussion – ICD-10 Codes. Due 7-25-23. 1000words. 4 references

1. Why is accurate coding using the ICD-10-CM important?

2. Use your lecture materials to determine what ICD-10 Codes to assign for this patient encounter.

3. In paragraph form, construct a discussion that supports the Codes you identified. 

4. In the discussion explore how the ICD-10 Codes that you assigned impact third party payor reimbursement for this visit.

5. Summarize an article that pertains to ICD-10-CM

Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.

Please review the rubric to ensure that your response meets the criteria.

Chief Complaint:

Older sister reports – “Our mother died three weeks ago and we lost our father several months ago. I think that my sister was depressed and just wanted to be with them.”

History of Present Illness:

31-year-old female who was brought to the hospital by ambulance. She was found slumped over in her car in front of the funeral home where memorial services for both her father and mother had recently been held. On the seat beside her were two empty bottles of sleeping pills, a Bible opened to Psalm 23, and a note that read
: “I am going to be with mom and dad. It is just too sad being here anymore without them. I love you all and you will be in my prayers.” When she was found by the funeral home director her hair was oily and unkempt and she smelled as if she had not bathed in a long time. She was wearing a dirty orange T-shirt and jeans.

PMH:

Depression when she was a junior in HS which led to psychiatric admissions at 15 and 19 years of age. For these admissions she was treated with antidepressants and psychotherapy. Length of stay for both admissions was approximately 5 weeks. At age 19, following a suicide attempt, she met her first husband in the psych ward of the hospital. Diagnosed with bipolar disorder 6 years ago.

Information from Sister:

Older sister reports ‘hard life’. Reports both parents were alcoholics. Parents would go to bars almost every night and leave the 8 children in the care. The children were eventually removed from the home. Some of the children went to the Catholic girls’ home others were placed in “horrible” foster homes where they were subjected to physical and sexual abuse.

Reports numerous siblings, including the patient, have been through several detoxification centers for alcohol abuse.

Patient is in her second marriage with 3 daughters – 2 from the first marriage and 1 from the current marriage.

Reports that after having her third baby the patient went into a ‘terrible depression’. The patient was under the care of a psychiatrist for this depression and was placed on an anti-depressant after about 3 months of being under the psychiatrist’s care. After 3 weeks of being on this anti-depressant the patient is reported as having gotten ‘really weird’; patient was staying up all night pacing around her house and talking to people on the phone, she would go on shopping sprees for 2-3 days at a time and max out all her credit cards. The patient finally crashed and was taken to the hospital by her family and it was during this admission, 6 years ago, that the patient was diagnosed with bipolar disorder. Sister reports the patient has been on Lithium since being diagnosed with bipolar disorder.

Reports their father had been sick for a while so his death was not unexpected. However, their mother went downhill fast and the patient is reported to not cope well with the mother’s illness/death.

Reports the patient hadn’t been eating lately with noted weight loss. Additionally, the sister reports the patient had been smoking and drinking ‘more than usual’ lately.

Family Hx:

Paternal grandmother – depression

Two maternal aunts – bipolar disorder

Mother and father – alcohol abuse

Father died from pancreatic cancer

Mother died from heart failure

3 living brothers, 3 living sisters, one deceased brother who had an AMI at age 34

Social Hx:

Divorced and remarried

Worked as a nurse’s aid and health insurance claims adjuster

Attends church regularly

Smoked 1ppd for 15 years

History of alcohol abuse with several DWI violations

History of IV drug use, not in the last 10 years

ROS:

Information from sister:

Neuro – history of migraine headaches since late teens, takes Imitrex prn

SIGECAPS:

Sister reports: at times the patient is up all night – particularly when bipolar symptoms not well controlled, the patient seemed to be more depressed since the loss of their mother, does not believe the patient felt guilty surviving parents, patient has been not been attentive to her personal hygiene, the patient appeared to be obsessing on parental loss, patient appeared to be losing weight and therefore suspect she was not eating well, patient seemed to not be engaging in typical daily activities; patient had not expressed having suicidal ideations, had not expressed homicidal ideations

Medications:

Lithium 600mg po Q AM and 600mg po Q HS

Sumatriptan 50-200mg po PRN

Allergies:

ASA – swelling of face

Physical Examination:

General – lethargic and slow to respond to questions; BP 110/72, P 66, RR 12, T 97.0, SpO2 on RA 95%, Ht 66 in, Wt 135 lbs, BMI 21.8

Integument – skin pale, warm, dry; good turgor; several cystic lesions on chin; no rashes, ecchymoses or petechiae noted

HEENT – Head is normocephalic and atraumatic, pupils dilated with sluggish reaction to light, TMs gray and shiny bilateral, nares patent without discharge noted, no tonsillar enlargement, moist mucous membranes

Neck – supple without adenopathy, no thyromegaly

Lungs – CTA

Breasts – deferred

Cardiovascular – heart with RRR without murmur/gallop, multiple varicosities noted bilateral lower extremities

Abdomen – soft, non-distended, active bowel sounds, non-tender, no organomegaly

Genitalia/Rectum – deferred

Musculoskeletal – no major limitations of ROM or gross abnormalities noted

Neurologic – oriented to person, DTRs 2+ and equal bilateral, no localizing signs, CN II- XII grossly intact

Diagnostics – Na 139 meq/L, K 3.7 meq/L, Cl 108 meq/L, HCO3 23 meq/L, Bun 10 mg/dL, Cr 0.7 mg/dL, fasting Glu 102 mg/dL, Ca 8.7 mg/dL, PO4 3.2 mg/dL, Protein 4.8 g/dL, Mg 2.0 mg/dL, AST 33 IU/L, ALT 20 IU/L, GGT 82 IU/L, Alb 2.9 g/dL, TSH 4.1, Vit B12 203 pg/mL, Hgb 12.2 g/dL, HCT 36.8 %;

Lithium 0.08meq/L

Urine dipstick – 6.3 pH, SG 1.021, all other parameters negative

Assessment:

You will be evaluating the subjective and objective data sets to determine the diagnoses for this patient encounter.

Plan:

The plan cannot be developed until the diagnoses are assigned.

1st 

 

The Theory of Goal Attainment and Transactional process is a theory that guides nurses to practice nursing based on a personal approach. It is a Grand Theory based on Interactive Process.  The purpose of this theory is to be able to achieve patients’ goals by forming a relationship with the client or patient. To be able to form a relationship with a patient/client there are several factors that have to be consider.  One of the main factors that has to be consider is the fact that the patient is a unique individual and as such nurses must think how to approach this patient to form a therapeutic relationship that will involve the patient in his/her own healthcare goals.

The goal of attainment has impacted research, education, and the nursing. However, it has impacted nursing education in particular. “For example, it served as a frame work for the baccalaureate program at the Ohio State University School of Nursing where it determined the content and process taught at each level of the program” (McEwen & Wills,2023, p. 177).

The development of this theory was created by Imogene King in the 1960’s.  “During this time nursing practice was not so much based on theory.  Nursing practice was generally prescribed by others and highlighted by traditional, ritualistic tasks with little regard to rational” (McEwen & Wills, 2023, p.25).

It is interesting to know that this theory has been used not only for the purpose of education, research and nursing practice but it has also help to develop other theories.   “In addition to application in practice and research described previously, King’s work has been the basis for development of several middle-range nursing theories.  For example, was used by Rooda (1992)  to develop a model for multicultural nursing practice” (McEwen & Wills, 2023, p. 117)> 

2nd 

Virginia Henderson was born in Missouri and raised in Virginia. She grew up to receive her diploma in nursing from the Amy School of Nursing located at Walter Reed Hospital. Within two years of working as a bedside nurse her passion for the profession grew immensely.  She applied to and was offered a nurse educator position at a hospital in Virginia. From that day Henderson embarked on a lifelong mission to educate nurses on her concept of the nursing profession. Over a decade she had  went on to obtain her Bachelors of Nursing degree in 1932 and her Master’s degree in 1934. Her concept and theories evolved and was imitative of her passion, practice and education. 

The philosophical and structural components of her theory was focused on educating nurses and providing patient care in an encouraging environment. Henderson was introduced to physiologic principles during her graduate education. The study of these principles was the fundamental basis of her framework for patient care (Henderson, 1965, 1991). The physiologic principle implies that the patient’s biology, psychology and sociology (biopsychosocial) all had to be taken into consideration when providing care. As her studies and work experience progressed, she was also introduced to “Thorndike’s fundamental needs of a man” (McEwen, Grand Nursing Theories Based on Human Needs 2022), in which she gave credit to as having a direct influence on her beliefs. Another major concept of her theory is that nurses should assist patients with otherwise daily activities of life in times of illness until the patient is back to their optimistic level of health. Overall, helping the patient to regain independence by providing a supportive environment. Her concept of nursing included the nurse assisting the patient with 14 activities.

Henderson’s theory of nursing has immensely affected nursing education, nursing research and nursing practice.  Lucier (2018), for example, described how Henderson’s model could be used to enhance the nurse−patient relationship to provide holistic care at the end of life. Similarly, Waller-Wise (2013) found that Henderson’s theory assisted nurses in attaining excellence in childbirth education, and Miranda et al. (2018) used Henderson’s assumptions and model in their analysis of the concept of “nursing care of overweight children.” (McEwen, Grand Nursing Theories Based on Human Needs 2022). Her contribution to nursing textbooks extended from 1930-1990’s. Her contributions to nursing had a global impact by strengthening the focus on nursing practice and confirming the value of tested interventions in assisting individuals to regain health (McEwen, Grand Nursing Theories Based on Human Needs 2022). Researchers internationally continue to be influenced by Henderson’s model as a framework.

Rubric

 

 

Criteria for Grading Discussion Participation
Interactions should be thorough, thoughtful and facilitate the learning community’s growth.
Behaviors will be reviewed on a weekly basis. Contribution toward the course grade total
will be based on the pattern of demonstrating these characteristics.
Please remember, initial posts should be submitted by midnight by deadline. Your
responses to two of your peers’ initial posts should be made by deadlines, and then
responses to questions or comments made to you on your posts or discussion responses
should be made by deadlines also, per syllabus above.
Rubric for evaluating Discussion Participation
Characteristic of the Response Point Value
 No response 0
 Responses are noncontributory (e.g., “I agree with the comment;”
“I was thinking the same thing:” “I had a similar experience.”
2
 On-time response to all points
 Response is not relevant to other statements or the discussion
thesis
 Response shows minimal understanding of the topic
4
 On-time response to all discussion points
 Response reflects the point being discussed; builds on ideas of
other participants
 Facts and examples are appropriate to each thesis and are
accurate
 Rules of communication, language, etc. are utilized so as not to
distract the flow of discussion
6
 All elements in the 6-point division (above) and
 Responses reflect complete understanding of topic and assigned
readings
 Uses greater detail, examples and other sources to support
discussion
 Initiates another question (which may/may not be discussed by
group0
8
 All elements in the 8-point division (above) and
 Analyses, discussions and conclusions explicitly linked to the
10