What two code(s) would be required for this scenario?

_____ and _____

Documentation:

Patient presented to the emergency department with two lacerations, one on her right wrist and another on her right forearm, as the result of breaking a glass window by accident. Simple repair of the 2.0-cm laceration on her right wrist and intermediate repair of the 4.0-cm laceration on her right forearm were performed by the emergency department.

During the day, while being admitted to the nursing unit from the emergency department, a patient tells the nurse "I'm having difficulty breathing" and has pain in her chest when she breathes. When she was asked by the nurse about the pain scale, she stated that it was 10. Her respiratory rate is 28 and she is coughing up yellow sputum. Her skin is hot and moist, and her temperature is 39°C. The laboratory results show white blood cell count elevation and the sputum result is pending. The patient says that coughing makes her head hurt and she aches all over. 

Based on the given scenario, what is your priority problem?

Apply the ICD-10-CM Official Guidelines for Coding and Reporting of the Principal Diagnosis for Inpatient Care (Guidelines I A- J) to identify the principal diagnosis in the following scenario.

The patient was admitted to the hospital for a total right knee replacement for osteoarthritis of the knee. During the patient's preoperative preparation, the patient began having chest pain. The patient's knee surgery was canceled, and the patient had extensive testing to determine the source of the chest pain, which was determined to be due to hypertensive heart disease.

1. The nurse working in a long-term care facility incorporates a focused assessment of
the immune system for all newly admitted patients over the age of 65. Older adults

are more likely to develop problems related to immune function than are middle-
aged people. The focused immune assessment includes a systemic approach based

on age-related changes in immunologic function. (Learning Objective 4)
a. What changes in the immune system in the older adult increase the incidence of
infection and cancer in this population?
b. Explain why older adults may have decreased inflammatory responses.
c. Why are older adults at increased risk of gastroenteritis and diarrhea secondary
to proliferation of intestinal organisms?

2. The nurse educator for an oncology unit is preparing an in-service presentation for
new nurses about the care of patients with immunodeficiencies. Patients with cancer
who are receiving chemotherapy, as well as those with bone marrow transplants, are
immunocompromised and require special attention to assess for signs of infection.
The nurse educator focuses on special care needs of this patient population.
a. What is the rationale for assessing the pulse and respiratory rates for 1 full
minute in a patient with immunodeficiency?
b. What special precautions about dietary restrictions and food preparation should
be included in the teaching for a patient with immunodeficiency?
c. What nursing actions should be implemented to decrease the risk of infection in
the patient with immunodeficiency?
3. Molly Baker, a 22-year-old patient, presents to the clinic with the diagnosis of
allergic rhinitis. She states that she develops paroxysmal sneezing, clear nasal
drainage and congestion, watery, red eyes, and nasal itching from the late spring
until the first frost in the fall. She states that she has a dry cough and voice
hoarseness. She complains of feeling extremely tired, unable to sleep at night, and
having difficulty concentrating on her collegiate course work.
a. What further assessment should the nurse provide?

1. Ellie Long, a 55-year-old patient, presents to the pain clinic with the diagnosis of
   fibromyalgia syndrome. The nurse at the clinic obtains a history and physical
   assessment of the patient. (Learning Objective 2)
   a. On what areas should the nurse concentrate when interviewing the patient
   during the history process?
   b. On what areas should the nurse concentrate when assessing the patient?
   c. What diagnostic tests are used with fibromyalgia syndrome?