Health Policy Week 15 Reflection Paper

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Health Policy Week 15 Reflection Paper

Please reflect on the topics we have covered over the last 15 weeks.

Discuss healthcare policy and politic and discuss the impact of mentors during the course.

Rationale must be provided

400 words in your initial post

Minimum of two scholarly references in APA format within the last five years published Health Policy Week 15 Reflection Paper

FYI

Topics covered over the last 15 weeks

2- The purpose of learning the ropes of policy, politics and advocacy is to influence health care or broader social agendas that influence human health.  Discuss a time where you influence health care through advocacy.

4-In 2010, the Affordable Care Act opens up the 45-year-old Medicare program to the biggest changes since its inception. Discuss the components of the Affordable Care Act that you think will have a positive effect on improving health care outcomes and decreasing costs.

5-How should healthcare professionals proactively plan to update their knowledge and skills to respond to the major public health issues and challenges facing them and their clients?

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7-Identify some of the social, ethical, and economic reasons for addressing immigration policy reform.

8-On what policy issues might nurses lobby Congress? What strategies might nurse use to have their voices heard?

9- Think about a familiar clinical practice area where interest groups are attempting to bring about a change in clinical care or systems of service delivery.  Assume new, game-changing research finding are published and received wide attention.  Identify groups that might have an interest in these finding.  What are their likely reactions to new research? Health Policy Week 15 Reflection Paper

10-How should nurses assure policy change for advanced practice registered nurses?” What role does the Affordable Care Act (ACA) play in addressing workforce shortages in rural communities?

11-Discuss the advantages and disadvantages of collaborating with physician organizations when pursuing FPA legislation.

12-You will create a grid listing 5 regulatory agencies that regulate health and the health care system within the United States.

13-Discuss the most effective levels of engagement that nurses can provide communities?

14-What are the ways in which a population health focus might be applied in transforming the health care delivery system? Health Policy Week 15 Reflection Paper

Florence Nightingales Environmetal Theory

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Florence Nightingales Environmetal Theory

Identify a theory that uses a concept of interest to you that can be applied in research and nursing practice (clinical, education, or administration). This is a professional paper in which headings, full sentences, paragraphs, correct grammar and punctuation, and correct citation of sources are required. Florence Nightingales Environmetal Theory

The theory you select will be the same theory used for each assignment in the future modules.

Theory Description:
Provide a brief description of the theory using an original source or as close to the original source as possible. Include a brief discussion of the origins of the theory and the scope/level (grand, middle range, practice/situation specific) of the theory. Identify the major concepts of the theory and discuss how they are related (propositions). Pick two of the concepts, including your concept of interest, and state theoretical definitions of these concepts.

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Solution

 

Transcendent Pluralism
Transcendent pluralism is a middle-range theory that explains how human dignity occurs and its connection among diverse groups of people in society through non-violent changes. The theory suggests that curing is required through progressive self-respect (Reischer et al., 2021). The theory shows how the modern social problems that adversely affect health are embedded in the human-environmental and deflation conditions.
Origin of the Theory
Transcendent pluralism originated in logical and inductive ways. Meaning, it uses both processes to conclude a study. For instance, in deductive, the theory begins with a hypothesis testing and examines the possibilities of the research being true or not before making a concrete conclusion. In contrast, it uses an inductive process to try and make general decisions based on observations the researcher has seen. Therefore, the theory is crucial in nursing as it helps nurses make concrete decisions on dignity and acknowledge the appropriate principles to care for the patients. Florence Nightingales Environmetal Theory
Transcendent pluralism is generally developed from middle range theory because of the various frameworks and emphasis on human dignity that comprises an individual’s self-care. Furthermore, the middle-range theory expounds more on the importance of this theory as it tends to focus more on the experimental and observational methods to make a conclusion that can be easily understood and used in interpreting a patient’s health condition. Hence, acts as a guideline in developing a patients’ diagnosis and treatments. Based on the above assumptions it is clear that the theory aims in improving the health and patients’ outcomes.

Major Concepts of the Theory and their Relations
Self-care and self-management are likely the major concepts of the theory. Self-care activities such as behaviour regarding eating, physical activities and substance use can lead to a greater impact on the well-being of an individual, thus affecting healthcare in general (Matarese et al.,2018). Therefore, self-care is important in managing one’s health and ensuring stable health at all times. As long as the negative factors such as alcohol and substance use are not controlled, human dignity will continue diminishing, negatively affecting the population’s health.
Self-management works hand in hand with self-care to contribute to the effectiveness of the transcendent theory. The concept entails more of an individual understanding one’s health and acknowledging the changes, thus taking appropriate action in seeking professional care and treatment before their health is critical. The approach of this concept also helps nurses understand their patients and manage their condition in a caring manner to achieve in the end. Florence Nightingales Environmetal Theory
The mid-range concepts such as self-care and adaptations help interpret the theoretical framework in understanding the effective change created by the social behaviours of different individuals in society. Therefore, to understand the different behaviours and activities of the people, it is important to focus on their self-care and the activities influencing diverse changes in their dignity.
Transcendent pluralism is effective in research and nursing practice. Health practitioners can conduct and analyze the patients’ condition based on physical activities, mental stability, substance use, eating habits, and hygiene to manage their care and assign them for the right treatment. Through the theory, health practitioners can also provide counselling to those patients who show symptoms of the dire need for counselling and therapy (Foli, 2021).
References
Foli, K. J. (2021). A Middle-Range Theory of Nurses’ Psychological Trauma. Advances in Nursing Science. https://journals.lww.com/advancesinnursingscience/Abstract/9000/A_Middle_Range_Theory_of_Nurses__Psychological.99792.aspx
Matarese, M., Lommi, M., De Marinis, M. G., & Riegel, B. (2018). A systematic review and integration of concept analyses of self‐care and related concepts. Journal of Nursing Scholarship, 50(3), 296-305. https://sigmapubs.onlinelibrary.wiley.com/doi/pdf/10.1111/jnu.12385
Reischer, H. N., Roth, L. J., Villarreal, J. A., & McAdams, D. P. (2021). Self‐transcendence and life stories of humanistic growth among late‐midlife adults. Journal of Personality, 89(2), 305-324. Florence Nightingales Environmetal Theory https://onlinelibrary.wiley.com/doi/full/10.1111/jopy.12583

Roles Of Healthcare Professionals Assignment

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Roles Of Healthcare Professionals Assignment

Roles of Healthcare Professionals

This assignment will be at least 1500 words or more. Reflect on the roles of nurses, and other healthcare professionals as the roles of physicians in the healthcare system move from one of working in silos to a more progressive value-based system. Write a paper that discusses in detail why a value-based system may improve health care in the U. S. and address the following questions:

1) How has current policy transformed the current practice of nurses, physicians, and other healthcare professionals?
2) What distinction can you make between physicians/healthcare providers working in a fee-for-service system and a value-based care system?
3) How do you view shared power between physicians and nurses in your healthcare system? How does it impact care?

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Assignment Expectations

Length: 1500-2000 words in length

Structure: Include a title page and reference page in APA format. These do not count towards the minimum word amount for this assignment. Your essay must include an introduction and a conclusion. Roles Of Healthcare Professionals Assignment

References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of two (2) scholarly sources are required for this assignment

Solution

Roles of Healthcare Professionals

Introduction

Patients’ outcome is significantly determined by what is done together rather than what are accomplished for them in silos as the future of healthcare communications and effectiveness in care delivery are connected teams (Salmond & Echevarria, 2017). Different factors have influenced the change from silo-based to value-based care models. These include rising costs, increasing aging population, innovative technologies, high staff burnout, and administrative complexity. As a priority, the global healthcare stakeholders are dedicated to inventing solutions and strategies to balance the sector. Increasingly, the healthcare community is establishing collaboration as a transition from a wasteful and siloed care delivery model to more value-based, patient-centered and productive healthcare.

Adopting value-based healthcare connects clinicians with their primary purpose of healing by supporting their professionalism, hence being a powerful mechanism to counter clinician burnout (Teisberg, Wallace & O’Hara, 2020). Linked with better outcomes, reduced spending by improving patients’ health experience, the value-based approach has redefined the roles of nurses and other care professionals by recognizing collaboration approach over individualism in their daily operations as caregivers. This paper discusses the impact of the change from siloed care model to a value-based system of healthcare professional roles and why the system may improve healthcare in the US.

How the Current Policy Has Transformed the Current Practice of Nurses, Physicians, and other Healthcare Professionals

The adoption of value-based policy in the healthcare industry has seen a much-needed revolution in care delivery and the impact on nurses and other professionals’ practice. According to Teisberg et al. (2020), there has been no doubt that nurses, among other professionals in the healthcare industry, have assumed roles to improve health, increase value, and advance health. The policy has seen an increased shift from a disease focus to care to promote health and the best patient experience across the continuum. The policy has fostered the need for a teamwork approach in healthcare delivery as nurses and other professionals have been required to partner with patients and their close friends and families in understanding their social environment and subsequently engage in devising care strategies that would address patient-defined patient outcomes. Roles Of Healthcare Professionals Assignment

Secondly, the policy has recognized teamwork as a significant face in delivering the best patient experience by gaining greater awareness of the diverse resources across the continuum and community needed so that patients can be aligned or accorded support needed for maximal wellness. Tracking outcomes has become a significant unit if the measure for effectiveness and leading the healthcare players to ensure excellence will demand outstanding teamwork for excellence to be registered across departments, roles, and responsibilities. The different professionals working in the healthcare industry can no longer choose to take a back seat. For example, it has become the time for nurses to take their role at the center of patient care, equally taking lean in implementing the policy to make healthcare more patient-based and quality fueled.

The policy has led to the recognition of teamwork and integrated care delivery. This is whereby different professionals work together to complement each other’s role and devise the best, affordable, and quality care practice for a patient (Salmond & Echevarria, 2017). Additionally, with patients recognized as a significant part of the value-based policy, healthcare professionals have focused their input on receiving the best patient experience. This has, in turn, put the professionals to train on how to deliver the best patient experience. These include learning skills such as effective communication, empathy, stress management, time management, flexibility, and teamwork.

The distinction between Physicians/Healthcare Providers Working in a Fee-For-Service System and a Value-Based Care System

The revolution in the healthcare industry is seeing increasing adoption of value-based care models over the traditional fee-for-service. Equally, the transition is redefining the role of caregivers regarding care delivery. The primary difference between the two care delivery strategies is that, while fee-for-service, the professionals’ remunerations are directly aligned with the number of patients served, the valued-based approach views the quality of care provided and patient outcome as central metric units, hence defining how the physicians should be rewarded.

Secondly, professionals in value-based approaches work as a team, collaborating to provide the best patient outcome and the lasting solution to the problem at hand. However, in the fee-for-service model, the physicians’ and clinicians’ contribution is individualized, meaning each care provider works on his/her line of expertise on the patients’ needs (University of Alabama at Birmingham, 2020). The collaborative approach to care delivery in value-based care has led to the recognition and adoption of different stakeholders, deemed less necessary in the fee-for-service care model. These include the nurse informatics and IT experts as part of the team. In value-based care, physicians have actively depended on informatics input in decision making and formulating the best care model for a patient. Roles Of Healthcare Professionals Assignment

Regarding the fee-for-service approach, the teamwork approach is minimized, which reduces the collaboration approach as physicians give their advice and treatment in accordance with their best-known practice and not the best suited for patient needs. In value-based care, quality comes first, directly tethered to reimbursements, incentivizing care providers to prioritize patients and their needs. Fee-for-service sees monetary gain as the primary motivating incentive for the care providers.

Patient position in the healthcare industry determines the role and relationship of nurses and the patient. In the value-based approach, the patient is an integral part of the team in deciding the best care practice. This, in turn, redefines the role of physicians as healers and informers. They instill the patients with understanding and knowledge, facilitating the best quality and available treatment. The fee-for-service approach sees minimal recognition of patients as part of their team, hence seeing minimized contribution by professional caregivers in comparing diverse care practices to settle for the best. Finally, as quality is recognized as a major defining factor in the value-based care model, nurses and physicians are motivated to gain more skills and knowledge, which would make them better in terms of decision making and deciding the best for their patients. Unlike the case in the value-based model, the fee-for-service approach sees individualism on a high level, as physicians, among other experts, view themselves as the best, hence less motivated to learn from others towards improving their skills in care delivery.

View On Shared Power between Physicians and Nurses in Healthcare System & How Does It Impact Care

Shared power between physicians and nurses means collaboration and working together, sharing responsibilities towards devising lasting solutions to problems and making decisions to formulate the best patient care experience. Despite the complexity and revolution witnessed in the healthcare industry, collaboration among healthcare professionals has provided a path towards improving healthcare services in hospitals and other facilities. The shift towards value-based care has seen recognition and the need for teamwork among professionals. Nurse physician collaboration and cooperation in the sector can positively impact patient outcomes while lowering the care cost, increasing the professionals’ job satisfaction, and improving patient safety (Elsous, Radwan & Mohsen, 2017). On the other, communication between different professionals is considered as an integral part of the value-based care and information flow in the care industry. Through the shared power, mutual respect and recognition of each other’s roles and differences are defined, hence fostering cohesion and motivation in every profession to deliver the best patient experience. For example, in Alberta, Canada the shared power has fostered a reliable care workforce with reference to addressing patient needs.

The paradigm of shared power and inter-professional experience has fostered safety and quality in the healthcare industry, hence building an environment best for patient care and outcome. Adopting a collaborative approach in care delivery has improved patient outcomes in reducing preventable negative drug reactions and decreased mortality and morbidity among patients. To the professionals, shared power has been aligned with a unique way to address the shortage of workers and reduce burnout and extra work while increasing job satisfaction (Aghamohammadi et al., 2019). Healthcare leaders and managers have found it easy to implement their role to teams over individual workers. In turn, shared power among healthcare professionals has provided a basic unit for integrated care delivery, making the process more effective and successful for a value-based care system linked with the desired patient outcome. Roles Of Healthcare Professionals Assignment

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Why a Value-Based System May Improve Health Care in the U. S

The lack of a uniform healthcare system and the need to regulate the ever-rising cost of healthcare in the United States has led to government and stakeholders devising strategies to deliver affordable quality care. This quest for better and quality services has led to the adoption of a value-based system linked to a patient-based care model. In order to add value, the shift from fee-for-service to a value-based care model has revolutionized the health industry. In addition to providing an affordable path to healthcare services, the value-based approach has improved healthcare in the US by providing the best care practices and maximizing available resources. The system has promised quality care, increased research, and recognition of professionals’ input in the care delivery process (Teisberg et al., 2020). Other reasons include; reducing the cost of care services, increased patient satisfaction, reduced medical errors, improved care coordination, and promoting healthy habits.

Conclusion

In a recap, the change in healthcare and the widespread adoption of value-based care requires strong collaboration, openness, trust, and strong partnerships between all stakeholder groups. This change has redefined the roles of nurses and other professionals working in the health industry towards being more team players providing patient-based care, resulting in more influence on care quality and patient experience. The care delivery process has become a teamwork approach, demanding each of the professionals to perform their duties as part of the team. Adopting value-based care has shifted the industry to more effective control measures regarding cost and workers’ management. In the US, the value-based model has provided a care improvement model benefiting patients, care providers, more robust cost control, and overall positive and better patient outcome and experience. The policy may be a significant breakthrough regarding redefining the US healthcare system, which has been viewed as the most expensive and lacks a well-recognized healthcare system.

References

Aghamohammadi, D., Dadkhah, B., & Aghamohammadi, M. (2019). Nurse-Physician Collaboration and the Professional Autonomy of Intensive Care Units Nurses. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 23(4), 178–181. https://doi.org/10.5005/jp-journals-10071-23149

Elsous, A., Radwan, M., & Mohsen, S. (2017). Nurses and Physicians Attitudes toward Nurse-Physician Collaboration: A Survey from Gaza Strip, Palestine. Nursing research and practice, 2017, 7406278. https://doi.org/10.1155/2017/7406278

Salmond, S. W., & Echevarria, M. (2017). Healthcare Transformation and Changing Roles for Nursing. Orthopedic nursing, 36(1), 12–25. https://doi.org/10.1097/NOR.0000000000000308

Teisberg, E., Wallace, S., & O’Hara, S. (2020). Defining and Implementing Value-Based Health Care: A Strategic Framework. Academic medicine: journal of the Association of American Medical Colleges, 95(5), 682–685. https://doi.org/10.1097/ACM.0000000000003122

University of Alabama at Birmingham. (2020, July 27). Fee-for-service vs. value-based healthcare. UAB Online Degrees. Retrieved November 27, 2021, from https://businessdegrees.uab.edu/blog/fee-for-service-vs-value-based-healthcare

NURS_6050_Healthcare Program-Policy Evaluation Analysis Essay

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NURS_6050_Healthcare Program-Policy Evaluation Analysis Essay

  • Review the Healthcare Program/Policy Evaluation Analysis Template provided in the Resources.
  • Select an existing healthcare program or policy evaluation or choose one of interest to you.
  • Review community, state, or federal policy evaluation and reflect on the criteria used to measure the effectiveness of the program or policy described.

The Assignment: (2–3 pages)

Based on the program or policy evaluation you selected, complete the Healthcare Program/Policy Evaluation Analysis Template. Be sure to address the following:

  • Describe the healthcare program or policy outcomes.
  • How was the success of the program or policy measured?
  • How many people were reached by the program or policy selected?
  • How much of an impact was realized with the program or policy selected?
  • At what point in program implementation was the program or policy evaluation conducted?
  • What data was used to conduct the program or policy evaluation? NURS_6050_Healthcare Program-Policy Evaluation Analysis Essay

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  • What specific information on unintended consequences was identified?

  • What stakeholders were identified in the evaluation of the program or policy? Who would benefit most from the results and reporting of the program or policy evaluation? Be specific and provide examples.
  • Did the program or policy meet the original intent and objectives? Why or why not?
  • Would you recommend implementing this program or policy in your place of work? Why or why not?
  • Identify at least two ways that you, as a nurse advocate, could become involved in evaluating a program or policy after 1 year of implementation NURS_6050_Healthcare Program-Policy Evaluation Analysis Essay.

Apa format and at least 3 references

https://eds.p.ebscohost.com/eds/detail/detail?vid=0&sid=e50c5c56-ce56-4b12-a3fb-6e0465f063bf%40redis&bdata=JkF1dGhUeXBlPXNoaWImc2l0ZT1lZHMtbGl2ZSZzY29wZT1zaXRl#AN=10595993&db=bth

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5409875/

 

https://www.sciencedirect.com/user/identity/landing?code=ZbD2GEmRUeQFTt6g10-Fxsfqn1l89AnAJSAgqtdb&state=retryCounter%3D0%26csrfToken%3Da9b16931-e111-4612-8486-c87eca9e486b%26idpPolicy%3Durn%253Acom%253Aelsevier%253Aidp%253Apolicy%253Aproduct%253Ainst_assoc%26returnUrl%3Dhttps%253A%252F%252Fwww.sciencedirect.com%252Fscience%252Farticle%252Fpii%252FS0029655418300617%26prompt%3Dlogin%26cid%3Datp-9629f1e6-7729-41ca-a3f2-8f0d33dcb329

Healthcare Program/Policy Evaluation Analysis  

Template

Healthcare Program/Policy Evaluation Analysis Template

 

Use this document to complete the Module 5 Assessment Assessing a Healthcare Program/Policy Evaluation

 

Healthcare Program/Policy Evaluation  

 
Description  

 

 
How was the success of the program or policy measured?

 

  

 

 

 

 

 

 

 

 
How many people were reached by the program or policy selected?NURS_6050_Healthcare Program-Policy Evaluation Analysis Essay How much of an impact was realized with the program or policy selected?

 

  

 

 

 

 

 

 

 

 

 
At what point in program implementation was the program or policy evaluation conducted?

 

  
What data was used to conduct the program or policy evaluation?

 

  

 

 

 

 

 

 

 

 

 

 
What specific information on unintended consequences were identified?

 

  
What stakeholders were identified in the evaluation of the program or policy? Who would benefit most from the results and reporting of the program or policy evaluation? Be specific and provide examples.

 

  

 

 

 

 

 

 

 

 

 

 
Did the program or policy meet the original intent and objectives? Why or why not?

 

  

 

 

 

 

 

 

 

 

 
Would you recommend implementing this program or policy in your place of work? Why or why not?

 

  

 

 

 

 

 

 

 

 

 
Identify at least two ways that you, as a nurse advocate, could become involved in evaluating a program or policy after one year of implementation.

 

  

 

 

 

 

 

 

 

 

 

 

 
General Notes/Comments  

 

 

 

 

 

 

 

 

 

 

 

NURS_6050_Healthcare Program-Policy Evaluation Analysis Essay

NURS 6051 Week 10 Assignment

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NURS 6051 Week 10 Assignment

Assume you are a nurse manager on a unit where a new nursing documentation system is to be implemented. You want to ensure that the system will be usable and acceptable for the nurses impacted. You realize a nurse leader must be on the implementation team.

To Prepare:

  • Review the steps of the Systems Development Life Cycle (SDLC) and reflect on the scenario presented.
  • Consider the benefits and challenges associated with involving a nurse leader on an implementation team for health information technology NURS 6051 Week 10 Assignment .

The Assignment: (2-3 pages not including the title and reference page)

In preparation of filling this role, develop a 2- to 3-page role description for a graduate-level nurse to guide his/her participation on the implementation team. The role description should be based on the SDLC stages and tasks and should clearly define how this individual will participate in and impact each of the following steps:

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  • Planning and requirements definition
  • Analysis
  • Design of the new system
  • Implementation
  • Post-implementation support
  • Use APA format and include a title page and reference page.

Some resources:

https://digital.ahrq.gov/health-it-evaluation-toolkit

 

https://digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit

 

https://www.youtube.com/watch?v=xtpyjPrpyX8

NURS 6051 Week 10 Assignment

Practicum Activities Reflection Paper

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Practicum Activities Reflection Paper

Leadership Journal: Example

The practicum experience was done at NYC Dept and Health: Office of School Health Division. Over the past 2 weeks, time was spent visiting nurses in the medical room, approved Medication Administration Forms, assisting with training, ensuring nurses have needed supplies, and meeting with principals to discuss issues arising in the medical room and OSH policies. The main focus of my practicum is managing students with asthma in the school setting.

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Journaling provides a valuable tool for recording, reflecting on, and reviewing your learning. This approach provides an opportunity for you to “connect the dots” and observe the relationships between and among activities, interactions, and outcomes.
Unlike a personal journal of thoughts and feelings, this leadership journal is a record of your activities, assessments, and learning related to this academic experience. Practicum Activities Reflection Paper
Journal entries should include a record of the number of hours spent with your nurse leader each week.

Write a journal entry of 750-1,500 words on the subject of serving, including the following:1. Practicum Activities Reflection: Provide observations and thoughts on the activities in your practicum setting during Topics 9-10.
2. Application of Leadership: Identify three to five personal values or characteristics that you believe are critical components of a good leader, such as honesty, compassion, or fairness. How do you express those values in your professional life?
3. Practicum Project Preparation: How have you prepared those who will be affected by your project for its implementation?
4. Leadership Video Reflection: Reflect on at least two things you learned from the “Servant Leadership – Issue of Example” video. https://www.youtube.com/watch?v=jBra6jSTHSE&list=PLqKj_eriTOI9Js2i_C2mitH1P96Zf6Q__&index=6

Use the “Leadership Journal Template” to complete this assignment.
APA format is not required, but solid academic writing is expected. Practicum Activities Reflection Paper

Solution

Practicum Activities Reflection:

Discuss some of your activities with your preceptor, what projects you are working on, and what observations about leadership you have made during the past two weeks. This does not need to be a step-by-step diary.  Instead, this is a place to reflect on how your observations and activities have compared to what you have learned in your courses thus far.

During my practicum, I had a meeting with my nurse preceptor. We came up with a plan for my practicum. The initial experience was a full day spent with the preceptor since I observed him carry out several leadership activities. By the end of the day, I noted down all my observations about how the preceptor interacted with other healthcare providers at the healthcare facility. Later, we held a debriefing session. In the debriefing session, we discussed what I learned, what I observed, and how I saw the leadership concepts I studied in class be9ng applied in the activities of the preceptor. Later, we came up with data on when I would simulate the managers’ role at the facility.

Application of Leadership:

 Each Leadership Journal assignment will include specific questions for you to answer.

Components of a Good Leader

            A good leader should have intentionality, commitment, vision, honesty, compassion and humility.

Intentionality- as a leader, being intentional in all your leadership activities creates the ripple effect and change required in your organization. Besides, a leader ought to be intentional in goal setting, communication, modeling values, being service-minded, reflecting, building relationships, and modeling values (Malik et al., 2017).

Commitment- a good leader should be committed to the people by believing in them. Besides, a good leader should be committed to the concept of shared leadership. Also, commitment in leadership involves seeking a win-win solution for everyone. Practicum Activities Reflection Paper

Vision- Great leaders have a vision for what they are trying to accomplish and how they will get there. Besides, a leader with a clear vision inspires, builds trust, and get results when executed well.

Honesty- a good leader is transparent about all the activities involved in an organization. They open up to all the stakeholders about how the funds on the healthcare facility are used. A transparent leader keeps their team in the loop, share information freely and invite open communication within their companies (Malik et al., 2017).  They support their team members to combine their insights, efforts, skills, passion, talents, and enthusiasm to work together for the greater good.

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Compassion- a compassionate leader will seek influence, not authority. Besides, they are not demanding but encouraging. Also, they support acknowledge and guide their team members.

Humility- a humble leader needs to understand they are an integral part of the success, but not the sole source (Malik et al., 2017). Besides, humble leaders understand that to be a part of something greater than yourself is one of life’s greatest opportunities.

Practicum Project Preparation:

Each Leadership Journal assignment will include specific questions for you to answer.

How I prepared those who will be affected by my project for its implementation

  • I collected all the requirements from all the stakeholders- After creating the project charter and identifying the key stakeholders, I gathered all the essential requirements. Besides, I defined the scope of the project and determined what I needed to deliver to my stakeholders. I ensured there was effective communication amongst the stakeholders to ensure all the important details of the project were not missed.
  • Defined the scope of the project. Together with the stakeholders, we developed a comprehensive description of the project and the deliverables in form of a project scope statement. Also, I ensured there was a clear understanding of the boundaries of the project.
  • Created a work breakdown structure. I broke down all the project’s scope into small and more manageable deliverables and groups of related tasks. Breaking down the project’s scope allowed me to assign the different resources available to different parts of the project based on the required skills. Therefore, the work breakdown facilitated coordination and planning.
  • Defined the activities of my project. I listed the work packages into a list of project activities. As a result, I was able to plan the activities to be performed to create the deliverables of the project.
  • Estimated activity duration, resources, and cost (Susilowati et al., 2021). I did an estimate of the duration, resources, costs, and resources to determine whether the project was viable and the set expectations. Also, estimation made it possible to keep all the costs under control. Practicum Activities Reflection Paper
  • Build-in contingencies. A plan without contingency is a bad plan. Projects do not go as planned, hence the need for building backup plans. After looking at the historical data on similar projects in the past, I was able to identify the possible risks.
  • Created a performance measurement baseline. Lastly, I developed an integrated scope-schedule-cost baseline for the project work. It served as a control tool for the project. The performance measurement baseline of the project helped me to measure performance upon completion of the project.

Leadership Video Reflection:

In the YouTube video Servant Leadership – The Issue of Humility, leaders should lead their teams by example. For instance, when a leader wants their team to meet the target set by the organization, they should be at the forefront formulating the strategies for achieving the desired results (GCU Academics Nursing, 2016). Besides, a good leader should be the first person to execute the set strategies. Furthermore, a leader should inspire his juniors to be conservative through their action. Inspiration calls for transparency, integrity, and dedication to work. Therefore, a leader should always ensure, they mean what they say, and should keep their promises. Also, leaders ought to be influential in the essence of leadership.

References

GCU Academics Nursing (2016, October) Servant Leadership – The Issue Of Humility.    Retrieved December 4, 2021

https://www.youtube.com/watch?v=jBra6jSTHSE&list=PLqKj_eriTOI9Js2i_C2mitH1P96Zf6Q__&index=6

Malik, W. U., Javed, M., & Hassan, S. T. (2017). Influence of transformational leadership components on job satisfaction and organizational commitment. Pakistan Journal of       Commerce and Social Sciences (PJCSS), 11(1), 147-166.

Susilowati, M., Kurniawan, Y., Prasetiya, H. P., Beatrix, R., Dewa, W. A., & Ahsan, M. (2021,    March). How to manage scope, time and cost of project management plan to develop manufacture information system. In IOP Conference Series: Materials Science and     Engineering (Vol. 1098, No. 6, p. 062006). IOP Publishing. Practicum Activities Reflection Paper

NUR 513 -Worldview and Nursing Process Personal Statement

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NUR 513 -Worldview and Nursing Process Personal Statement

Being able to articulate your personal worldview can help you formulate a personal philosophy of practice and enhance your influence on patients and the industry. In this assignment, you will have an opportunity to reflect on your current and future practice and the ways worldview and nursing theory influence that practice.

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Draft a 1,000-1,250 word paper in which you:

Describe your personal worldview, including the religious, spiritual, and cultural elements that you think most influence your personal philosophy of practice and attitude towards patient care.
Choose a specific nursing theory that is most in line with your personal philosophy of practice and approach to patient care and discuss the similarities. Explain how the nursing theory reinforces your approach to care.
Include in your explanation a specific example of a past or current practice and how your worldview and the nursing theory could assist you in resolving this issue. NUR 513 -Worldview and Nursing Process Personal Statement
Finally, explain how your worldview and the nursing theory will assist you in further developing your future practice.
You are required to cite five to 10 sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.

Complete the \”APA Writing Checklist\” to ensure that your paper adheres to APA style and formatting criteria and general guidelines for academic writing. Include the completed checklist as an appendix at the end of your paper.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.

Solution

NUR 513 -Worldview and nursing process personal statement

NUR 513 -Worldview and nursing process personal statement

The effect of the Christian worldview on my personal philosophy of practice and attitude towards patient care

My personal philosophy of practice as a nurse executive and attitude towards patient care is mostly influenced by the Christian worldview. I chose to major in the nursing executive as my profession since I believe in helping those who are in need. As a Christian, I feel I should be dedicated to helping those who are in need of my services anytime. Consequently, I do not consider nursing executive as a career like any other where am supposed to work for a specified number of hours to qualify for payment. Instead, I consider it a calling to help those in need. I focus on offering nonjudgmental care to individuals in need without any form of discrimination based on religion, ethnicity, and financial status NUR 513 -Worldview and nursing process personal statement.

 

As a Christian, I believe that nurse executives have a God-given duty to provide the public with holistic, safe, quality, patient-centered healthcare services. I consider my patients as human beings who are in need of my medical attention. For this reason, I urge my colleagues to use clinical judgment to address the needs of every patient in the healthcare facility. As Christians, we are urged to love one another. Consequently, I always encourage them to treat patients and their families with love when they are providing care services to them. NUR 513 -Worldview and nursing process personal statement. Treating patients with love give them psychological support, which plays a significant role in their healing process. According to Wade et al (2018), psychological support improves patient outcomes of patients with PPTD and depression. Additionally, delivering psychological support to patients through non-expert staff improves the level of the patient’s outcome (Wade et al, 2018).

Being a Christian I treat others how I would like them to treat me. Thus, I treat patients’ personal details as private and confidential. According to Epstein and Turner (2015), nursing practitioners should treat the details of their patients as confidential. Besides, I keep all relevant information provided by the patients in the hospital’s database for easy retrieval and future reference. Thus, patients get the best treatment since their records serve as a point of reference throughout the treatment process NUR 513 -Worldview and nursing process personal statement. According to Mathioudakis (2016), the proper keeping of clinical records enhances the delivery of quality healthcare services and forms an integral part of good professional practice. More so, both electronic and paper clinical record keeping support continuity of healthcare delivery either by same or different healthcare professionals, thus enhancing the quality of care and overall patient outcomes (Mathioudakis, 2016).

Also, I believe it is my duty as a nurse executive to educate patients and their families about a particular disease and its management plan. Educating patients to improve their outcomes significantly. According to Wade et al (2018), engaging patients and therapeutic communication improve their outcomes. Finally, I strive to observe positive healthy behaviors as a committed nurse executive and a Christian. This practice enables me to provide better healthcare services to my clients, thus improving overall quality and patients’ outcomes. NUR 513 -Worldview and Nursing Process Personal Statement

Connection and similarities between my personal philosophy of practice and approach to patient care and the Selfless Caring of Theory Commitment

My philosophy of practice and approach to patient care are in line with the Selfless Caring of Theory Commitment. This theory holds that the integral character of nurse professionals play a significant role in determining the quality of health care services, which are offered to individual, family, or groups of people in the community (Gogola, 2018). In other words, it emphasizes on the adherence to the required features. Furthermore, this theory views commitment as the key to the fulfillment of one’s duties in the nursing profession (Alligood, 2017) NUR 513 -Worldview and nursing process personal statement. Nurses are emotionally bound to offer efficient, safe ethical, and selfless care to their patients if they are committed to their duties (Jiang, 2016). Nurses are dedicated to helping those in need irrespective of their social, political, and cultural status (Drahošová & Jarošová, 2016). Their commitment enables them to act in the best interest of their patients.

Similarities exist between the Selfless Caring of Theory Commitment and my philosophy of practice and approach to patient care. First, both of them consider committed nurses as those professionals who are willing to offer care services to people in need regardless of time. Time should not limit a committed nurse from helping a person who is in need (Jafaraghaee et al, 2017). Additionally, both of them perceive a committed nurse as an expert who should be willing to work during special holidays or during their off days if need be. Secondly, both of them view nursing as a calling, which requires commitment or dedication to one’s duties. Unlike other careers where individuals just focus on remaining on the payroll, nurses are interested in helping those in need. Nurse executives should perform their duties beyond expectations despite the challenges that they might face. Thirdly, my philosophy and this theory consider a committed nurse as a person who considers the patients as a valuable human being who are in need of selfless nursing care. Finally, both of them view nursing as a career, which is outcome-based. In other words, nurses focus on providing the best quality to the patients, thus improving their outcomes NUR 513 -Worldview and nursing process personal statement. NUR 513 -Worldview and Nursing Process Personal Statement

This nursing theory reinforces my approach to care. It triggers me to dedicate all my energy to delivering quality care to the patients without discriminating them. In other words, I have become selfless and dedicated towards giving the best services to the patients, thus improving overall patient outcomes.

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An example and how Christian worldview and the Selfless Caring of Theory Commitment could assist me in resolving this issue

After working for the required hours in the healthcare facility, a 25 years old patient was brought in. She was having heavy vaginal bleeding and tissues were coming from her vagina. Additionally, she was complaining of severe abdominal pain or cramping and severe back pain. My time was up in the clinic and I was supposed to go home and have some rest, which I did after directing the nurse on duty to attend to her immediately. Christian worldview and the Selfless Caring of Theory Commitment could assist me in resolving this issue. I was supposed to view the patient as a human being who was in need of my services. As a Christian, I was supposed to be compassionate and attend to her despite my time is over NUR 513 -Worldview and nursing process personal statement. On the other hand, the Selfless Caring of Theory Commitment urges for dedication to a nursing career and the engagement of the practitioners to their duties (Dempsey & Reilly, 2016). Therefore, I could have considered my career as a calling and remained in the healthcare facility until the patient was attended to.
The role of the Christian worldview and the Selfless Caring of Theory Commitment to further developing my future practice

Both the Christian worldview and the Selfless Caring of Theory Commitment play a significant role in assisting me to develop my future practice further. They will guide me towards becoming more dedicated to my duties in the healthcare facility. Consequently, I will be able to attend to all patients who are in need of my services irrespective of time. Additionally, I will be committed to learn new techniques and acquire more knowledge and skills in my profession, to enhance the delivery of care services to the patients. NUR 513 -Worldview and nursing process personal statement According to Brasaitė et al (2016), knowledge of nurses about patients’ safety determines the quality of healthcare services offered.

References

Alligood, M. R. (2017). Nursing Theorists and Their Work-E-Book. Elsevier Health Sciences.

Brasaitė, I., Kaunonen, M., Martinkėnas, A., Mockienė, V., & Suominen, T. (2016). Health care professionals’ skills regarding patient safety. Medicina, 52(4), 250-256.

Dempsey, C., & Reilly, B. (2016). Nurse engagement: What are the contributing factors for success? OJIN: The Online Journal of Issues in Nursing, 21(1) NUR 513 -Worldview and nursing process personal statement.

Drahošová, L., & Jarošová, D. (2016). Concept caring in nursing. Central European Journal of Nursing and Midwifery, 7(2), 453-460.

Epstein, B., & Turner, M. (2015). The nursing code of ethics: Its value, its history. OJIN: The Online Journal of Issues in Nursing, 20(2). NUR 513 -Worldview and Nursing Process Personal Statement

Gogola, D, B. (2018). Selfless Caring of Theory Commitment. International Journal of Nursing Science, 8(3): 45-50

Jafaraghaee, F., Ebadi, A., Negarandeh, R., & Mehrdad, N. (2017). A professional commitment scale for clinical nurses: A study protoco. Medical journal of the Islamic Republic of Iran, 31, 123.

Jiang, Z. (2016). Emotional Intelligence and Career Decision‐Making Self‐ Efficacy: Mediating Roles of Goal Commitment and Professional Commitment. J Employ Couns; 53(1):30-47.

Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe, 12(4), 369-373. NUR 513 -Worldview and nursing process personal statement

Wade, D., Als, N., Bell, V., Brewin, C., D’Antoni, D., Harrison, D. A., … & Mythen, M. (2018). Providing psychological support to people in intensive care: development and feasibility study of a nurse-led intervention to prevent acute stress and long-term morbidity. BMJ open, 8(7), e021083. NUR 513 -Worldview and Nursing Process Personal Statement

NURS 6630 Walden Week 7 Treatment for Patient with Common Condition Discussion

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NURS 6630 Walden Week 7 Treatment for Patient with Common Condition Discussion

Description

Discussion: Treatment for a Patient With a Common Condition

Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychop harmacologic treatments for optimal health and well-being. NURS 6630 Walden Week 7 Treatment for Patient with Common Condition Discussion

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Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-l…

For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.

Case: An elderly widow who just lost her spouse.

Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:

  • Metformin 500mg BID
  • Januvia 100mg daily
  • Losartan 100mg daily
  • HCTZ 25mg daily
  • Sertraline 100mg daily

Current weight: 88 kg

Current height: 64 inches

Temp: 98.6 degrees F

BP: 132/86

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By Day 3 of Week 7

Post a response to each of the following:

  • List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. NURS 6630 Walden Week 7 Treatment for Patient with Common Condition Discussion
  • Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
  • Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
  • List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
  • List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
  • For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
  • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. NURS 6630 Walden Week 7 Treatment for Patient with Common Condition Discussion

PRAC 6635 Walden University Advanced Nursing Practice Practicum Experience Plan

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PRAC 6635 Walden University Advanced Nursing Practice Practicum Experience Plan

Question Description

I’m working on a health & medical case study and need an explanation to help me learn.

As you establish your goals and objectives for this course, you are committing to an organized plan that will frame your practicum experience in a clinical setting, including planned activities, assessment, and achievement of defined outcomes. In particular, they must address the categories of clinical reasoning, quality in your clinical specialty, and interpersonal collaborative practice.  PRAC 6635 Walden University Advanced Nursing Practice Practicum Experience Plan

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For this Assignment, you will consider the areas you aim to focus on to gain practical experience as an advanced practice nurse. Then, you will develop a Practicum Experience Plan (PEP) containing the objectives you will fulfill in order to achieve your aims. In this practicum experience, when developing your goals and objectives, be sure to keep psychiatric assessment and diagnostic reasoning in mind.

TO PREPARE

  • Review your Clinical Skills Self-Assessment Form you submitted last week and think about areas for which you would like to gain application-level experience and/or continued growth as an advanced practice nurse. How can your experiences in the Practicum help you achieve these aims??
  • Review the information related to developing objectives provided in this week’s Learning Resources.? Your practicum?learning objectives that you want to achieve during your Practicum experience must be:
    • Specific?
    • Measurable?
    • Attainable?
    • Results-focused?
    • Time-bound
    • Reflective of the higher-order domains of Bloom’s taxonomy (i.e., application level and above)?

Note: Please make sure your objectives are outlined in your Practicum Experience Plan (PEP).?

  • Discuss your professional aims and your proposed practicum objectives with your Preceptor to ascertain if the necessary resources are available at your practicum site.  PRAC 6635 Walden University Advanced Nursing Practice Practicum Experience Plan

NURS 6512: Advanced Health Assessment And Diagnostic Reasoning: Digital Clinical Experience (DCE): Health History Using Shadow Health

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NURS 6512: Advanced Health Assessment And Diagnostic Reasoning: Digital Clinical Experience (DCE): Health History Using Shadow Health

Digital Clinical Experience (DCE): Health History -Using Shadow Health

 

Prepare:

  • Review the DCE (Shadow Health) Documentation Template for Health History and use this template to complete your Documentation Notes for this DCE Assignment.
  • Access and login to Shadow Health.
  • Review the Shadow Health Student Orientation media program and the Useful Tips and Tricks document to guide you through Shadow Health.
  • Review the Week 4 DCE Health History Assessment Rubric, for details on completing the Assignment.

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Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric.

Assignment:

  • Complete your Health Assessment DCE assignments in Shadow Health via login credentials
  • Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload in order to submit to instructor ( I will do this part)
  •  From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database
  • Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment. NURS 6512: Advanced Health Assessment And Diagnostic Reasoning: Digital Clinical Experience (DCE): Health History Using Shadow Health

 

DCE Health History Assessment:

Complete the following in Shadow Health:

Orientation

  • DCE Orientation
  • Conversation Concept Lab ( Required)

Health History

  • Health History of Tina Jones

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 4 Day 7 deadline.

Advanced Heath Assessment Documentation Tutorial

 

In each of the Shadow Health (SH) Assignments, you will be asked to complete a narrative note as part of the grading criteria. Narrative or progress notes are often a new skill. This document is provided to assist students in understanding how to write a narrative note. Shadow Health refers to these notes as Provider Notes.

 

Documentation of patient care is essential to quality and safety of care. Much of the clinical documentation is completed electronically using point and click tools to describe the patient condition (Lindo, et al., 2016). Often computer prompts fall short of fully describing the patient condition. Other situations such as lack of technology, electrical outages, system hacking, failure of equipment, and any number of situations which may interfere with normal electronic documentation may require a narrative nurses/progress note. Nurses must be able to clearly communicate patient information with everyone on the health care team to ensure quality and safety of care (Lindo, et al., 2016). NURS 6512: Advanced Health Assessment And Diagnostic Reasoning: Digital Clinical Experience (DCE): Health History Using Shadow Health

 

Documentation must be clear, paint a picture of the patient, and provide measurable concise information in a timely manner. The information communicated must be able to be understood by others and provide enough information to understand if a change has occurred in the patient condition and to clearly communicate all treatments, interventions, and therapies received by the patient and/or planned for the patient. Documentation also serves as a legal record of care (Lippincott Williams and Wilkins, 2007).

 

Documentation begins with subjective data/information. This is information the patient, family member, or caregiver may provide if the patient is unable to communicate which includes such data as the history of present illness (HPI), the past history- allergies, medications, medical surgical & social and the review of systems (ROS). Objective data/information includes the physical exam, observations and measurements obtained during the examination of the patient. Objective data also includes vital signs, laboratory and diagnostic results (Bates, 2017, pg.7)

 

Subjective vs. Objective Data-As you begin to acquire data from the patient interview and physical exam, it is important to remember the difference between subjective and objective information. Symptoms are the subjective concerns of what the patient tells you of their experience. Signs are the objective findings from your observations. (Bates, 2017, pg.6). Sequence of data is documented in the manner it is collected from the sequence of the examination. Physical examination follows a cephalocaudal sequence with the cardinal techniques of inspection, palpation percussion and auscultation (Bates, 2018)

 

Subjective information assists in understanding the patient condition and provides a basis upon which the nurse decides which body systems need to be assessed and which assessments need to be completed.  Many of the assessments to be performed in the class are focused or problem based and focus on the assessment of a specific body system. The Comprehensive assessment is a complete health history and physical exam of most all body systems (Bates, 2017. Pg.5)

 

Once subjective and objective information are obtained and have been thoroughly considered an assessment/nursing diagnosis or medical diagnosis (physicians and advanced practice only) is identified. A plan of care will then be developed based on the nursing diagnoses. In the health assessment competencies, the primary focus is on gathering accurate subjective and objective data (Bates, 2017, pg.24)

 

Subjective data should be recorded using the patient’s own words and describing his/her feelings and experiences related to health. When interviewing the patient about a current issue or illness the seven attributes of a symptom need to be included in the documentation (Bates, 2017, pg.79)). The seven attributes of a symptom would be asked for any positive response during the health history (HH) and review of systems (ROS). Here is a list of the attirbutes and a few sample questions for a patient with complains of abdominal pain (Bates, 2017, pg.79) NURS 6512: Advanced Health Assessment And Diagnostic Reasoning: Digital Clinical Experience (DCE): Health History Using Shadow Health

 

  • Location: “Where does it hurt?” “Please point to the area of pain.”
  • Quality: “How would you describe the pain?” “Is it sharp pain?” “Dull pain?”
  • Quantity or Severity: “On a scale of 0-10, 0 being no pain and 10 being the worst pain ever, what is your level of pain?” “How has the pain impacted your daily routine?”
  • Timing: “When does the pain occur?” “How long does it last?” “Approximately how long after you have eaten does the pain begin?” ”Does the pain radiate?” “If yes, where does it radiate?”
  • Onset or Setting in which it occurs: “What were you doing when the pain began?”
  • Aggravating or Relieving Factors: “Is the pain worse after eating certain foods?” “What makes the pain better?”
  • Associated Factors: “Do you have any nausea or vomiting?” “Any diarrhea?” “Any constipation?”

Another way to remember what to ask the patient is to use the mnemonic OLDCARTS or OPQRST (Bates, 2017. p.79)

O: Onset

L: Location

D: Duration of symptoms

C: Character

A: Aggravating/Alleviating Factors

R: Radiation

T: Timing

S: Severity

 

OR

 

O: Onset

P: Provocative or Palliative

Q: Quality or Quantity

R: Region or Radiation

S: Site

T: Timing

 

When documenting the ROS it is necessary to document each condition or item asked about because others will be reading the notes and relying on the information provided. If information is incomplete or inaccurate patient safety and quality of care may be affected. Documentation of pertinent negatives should be specifically described. Do not overgeneralize by using terms such as “WNL”, or neurologic exam negative” as this does not convey what exactly was assessed subjectively and/or objectively (Bates, 2018, p. 38)

 ROS (Subjective) Documentation Example:

Review the following ROS areas and the associated documentation and note the quality of the information provided for each system.

  • Skin: Denies any rashes or changes to skin
  • Head: No problems with head or headaches.
  • Ears: Positive for fullness feeling in bilateral ears for past 2 days, denies changes in hearing, pain in ears or any drainage.
  • Eyes: No problems, says they are normal. NURS 6512: Advanced Health Assessment And Diagnostic Reasoning: Digital Clinical Experience (DCE): Health History Using Shadow Health

Skin and ears are documented correctly. The skin description relays what items were subjectively asked of the patient.  The ears ROS also includes pertinent positive with further information and pertinent negatives.

Head and eyes are not documented correctly.  There is not a description of the items subjectively asked and is an incomplete picture.

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(Bates, 2017, pg. 32)

Assessment (Objective) Documentation Example:

Skin: Uniform in color, tan, warm, dry, intact. Turgor good, skin returns immediately when released. Scattered flat small macules on face around nose. On back of left shoulder 4mm, symmetrical, smooth borders, dark brown, evenly colored, slightly raised nevus, without tenderness or discharge. Well healed pale scar 3 cm right forearm. Left wrist approximately 1 cm area around the circumference of the wrist pruritic papules and vesicles with an erythematous base.  Silver colored striae around lower outer quadrants of abdomen and hips.

 

  • Head: Shape okay.
  • Eyes: Eye color brown. brows, lids, and lashes symmetric, right brow ridge piercing with intact silver hoop, no redness, tenderness, or discharge; lacrimal ducts pink and open without discharge. Conjunctiva clear, sclera white, moist, and clear, no lesions or redness, no ptosis, lid lag, discharge or crusting. Snellen vision assessment 20/20 in each eye with corrective lenses. EOMs intact, no nystagmus, PERRLA
  • Ears: TM with good cone of light, pearly gray appearance, canal clear of wax bilaterally, no edema or drainage present. Auditory acuity present bilaterally to whispered voice.

 

Skin is documented very complete and concise a picture of the patient is evolving and measurable assessment data is provided. Complete description of the rash on the left wrist provides a measurable concise picture. A mole was noted and documentation included the ABCDE of the mole. It is important to describe both normal and abnormal findings in a measurable manner. The text offers examples of how to provide measurable information for many assessment findings such as tonsils, pulses, reflexes, and strength (Bates, 2017, pg. 33)

 

The documentation for head is less measurable. How is one to know what “shape okay” is for this patient?

The documentation for the eyes is very thorough and concise. Measurable terms are used and a description of the patient’s eyes is provided.

The documentation for the ears is also very concise and thorough.  Measurable terminology is used and a description is provided.

 

Some of the Shadow Health (SH) exams focus on one body system such as Cardiac. In this situation focus on pertinent questions related to the ROS and physical assessment for cardiac and any associated body systems. In the case of cardiac, peripheral vascular and respiratory would be additional systems to assess.

 

When completing the assessments in SH use the textbook as a guide. Open to the appropriate chapter and follow along to ensure all aspects of the assessment are covered for both subjective and objective assessment areas. Document carefully for each assessment area keeping in mind the differences between subjective and objective information and ensuring measurable concise information is recorded.

 

Subjective and objective information is separated and each body system is used as a heading for easier retrieval of information. When information is disorganized it is difficult to know which is the information provided by the patient and which is the objective clinical assessment data. In an emergency retrieval of information must be done quickly. Well organized and written notes allow for timely retrieval (Lindo et al., 2016).

 

References

Bickley, L. S. (2017). Bates Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins: Philadelphia, PA.

Lindo, J., Stennett, R., Stephenson-Wilson, K., Barrett, K.A., Bunnaman, D., Anderson-Johnson, P., Waugh-Brown, V., and Wint, Y. (2016). An audit of nursing documentation at three public hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 508-516.

Lippincott Williams & Wilkins (2007). Charting: An incredibly easy pocket guide. Ambler, PA: Author. NURS 6512: Advanced Health Assessment And Diagnostic Reasoning: Digital Clinical Experience (DCE): Health History Using Shadow Health