Assignment Week 1 For EBP – Evidence-Based Practice And The Quadruple Aim Healthcare Organizations
Assignment: Evidence-Based Practice and the Quadruple Aim Healthcare organizations continually seek to optimize healthcare performance. For years, this approach was a three-pronged one known as the Triple Aim, with efforts focused on improved population health, enhanced patient experience, and lower healthcare costs. More recently, this approach has evolved to a Quadruple Aim by including a focus on improving the work life of healthcare providers. Each of these measures are impacted by decisions made at the organizational level, and organizations have increasingly turned to EBP to inform and justify these decisions.
To Prepare: Read the articles by Sikka, Morath, & Leape (2015); Crabtree, Brennan, Davis, & Coyle (2016); and Kim et al. (2016) provided in the Resources. Reflect on how EBP might impact (or not impact) the Quadruple Aim in healthcare. Consider the impact that EBP may have on factors impacting these quadruple aim elements, such as preventable medical errors or healthcare delivery.
To Complete: Write a brief analysis (no longer than 2 pages) of the connection between EBP and the Quadruple Aim. Your analysis should address how EBP might (or might not) help reach the Quadruple Aim, including each of the four measures of: Patient experience Population health Costs Work life of healthcare providers. Assignment Week 1 For EBP – Evidence-Based Practice And The Quadruple Aim Healthcare Organizations
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NRS-440 – Examine Changes Introduced To Reform Or Restructure The U.S. Health Care Delivery System
Examine changes introduced to reform or restructure the U.S. health care delivery system. In a 1,000-1,250 word paper, discuss action taken for reform and restructuring and the role of the nurse within this changing environment. Include the following: Outline a current or emerging health care law or federal regulation introduced to reform or restructure some aspect of the health care delivery system. Describe the effect of this on nursing practice and the nurse’s role and responsibility.
Discuss how quality measures and pay for performance affect patient outcomes. Explain how these affect nursing practice and describe the expectations and responsibilities of the nursing role in these situations. Discuss professional nursing leadership and management roles that have arisen and how they are important in responding to emerging trends and in the promotion of patient safety and quality care in diverse health care settings. Research emerging trends.
Predict two ways in which the practice of nursing and nursing roles will grow or transform within the next five years to respond to upcoming trends or predicted issues in health care. You are required to cite to a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. This assignment uses a rubric.
Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are required to submit this assignment to LopesWrite.
Refer to the LopesWrite Technical Support articles for assistance. NRS-440 – Examine Changes Introduced To Reform Or Restructure The U.S. Health Care Delivery System
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Assignment 1: Lab Assignment: Differential Diagnosis For Skin Conditions
CASE STUDY 1: Focused Nose Exam Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case. Assignment 1: Lab Assignment: Differential Diagnosis For Skin Conditions
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.
Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
Consider which of the conditions is most likely to be the correct diagnosis, and why.
Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment. Assignment 1: Lab Assignment: Differential Diagnosis For Skin Conditions
WEEK 10 Assignment – The Role Of The Nurse Informaticist In Systems Development And Implementation
The Role of the Nurse Informaticist in Systems Development and Implementation 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.
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: 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. WEEK 10 Assignment – The Role Of The Nurse Informaticist In Systems Development And Implementation
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-Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
-Week 4: Mood Disorders in Adults
I am finally doing everything right. I stayed up all night studying for my final exams and even managed to clean out my closet and order a whole new bedroom from the internet. I know I will ace all my exams. Nothing can go wrong like they did a few months ago. I was so low and was sleeping all the time. I did not think I would ever be happy again, but now I know I can do anything. NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
—Jessica, age 22
Patients presenting with mood disorders may find that their moods impact their ability to function or that their moods are not consistent with their circumstances. Bipolar and related disorders are one category of mood disorders. They affect nearly 3% of the U.S. population each year (Depression and Bipolar Support Alliance, n.d.). Although being relatively rare in terms of lifetime prevalence, bipolar disorder is burdensome to the individual and health care system because of its early onset, severity, and chronic nature. The average age of onset is around 25 and it affects men and women equally.
The importance of evidence-based intervention for treatment in persons with mood disorders cannot be underestimated. Unstable moods can result in repeat chronic hospitalizations and profound life disruption. Mood disorders are a leading cause of disability worldwide and can contribute to suicide (World Health Organization, 2020). Practitioners should understand that developing a good rapport and relationship with the patient can make a significant difference in the course, symptom management, and stability of the patient.
This week, you will assess, diagnose, and develop appropriate treatment plans for adults presenting with mood disorders. NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders
Photo Credit: Monkey Business / Adobe Stock
It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms. NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.
TO PREPARE
Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
THE ASSIGNMENT
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the du ration and severity of their symptoms? How are their symptoms impacting their functioning in life? NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this client if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
Read rating descriptions to see the grading standards!
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Assessment:
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently? NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
Chief complaint
History of present illness (HPI)
Past psychiatric history
Medication trials and current medications
Psychotherapy or previous psychiatric diagnosis
Pertinent substance use, family psychiatric/substance use, social, and medical history
Allergies
ROS
Read rating descriptions to see the grading standards!
In the Objective section, provide:
Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
Results of the mental status examination, presented in paragraph form.
At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General:Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. NRNP 6665 WU Wk 4 Mood Disorders in Adults Soap Psychiatric Notes Discussion
Biopsychosocial Population Health Policy Proposal Assignment
Develop a 2-4 page proposal for a policy that should help to improve health care and outcomes for your target population. Introduction Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented. Cost and access to care continue to be main concerns for patients and providers. As technology improves our ability to care for and improve outcomes in patients with chronic and complex illnesses, questions of cost and access become increasingly important. As a master’s-prepared nurse, you must be able to develop policies that will ensure the delivery of care that is effective and can be provided in an ethical and equitable manner. As a master’s-prepared nurse, you have a valuable viewpoint and voice with which to advocate for policy developments. As a nurse leader and health care practitioner, often on the front lines of helping individuals and populations, you are able to articulate and advocate for the patient more than any other professional group in health care. Biopsychosocial Population Health Policy Proposal Assignment
This is especially true of populations that may be underserved, underrepresented, or are otherwise lacking a voice. By advocating for and developing policies, you are able to help drive improvements in outcomes for specific populations. The policies you advocate for could be internal ones (just within a specific department or health care setting) that ensure quality care and compliance. Or they could be external policies (local, state, or federal) that may have more wide-ranging effects on best practices and regulations. Preparation As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
What are the relevant best practices from a population health standpoint (cultural competence, disease prevention, and interventions) for your chosen health issue and vulnerable population? How are these best practices relevant to your chosen health issue and vulnerable population? Do the best practices make any reference to standards of care or benchmarks that should be achieved? How could these best practices be leveraged to help inform or develop a policy and guidelines to improve care and outcomes for the vulnerable population you are working with? How could technology be used to identify health concerns or collect data that could help health care practitioners determine which health care issues to focus on in a population? What are the relevant laws, regulations, or policies for employing any of the technology you might find useful? What type of policy and guidelines would be most likely to ensure improvements in care and outcomes related to your chosen health issue and vulnerable population? Are there any policies in existence that could help inform your own policy development? How might your proposed policy and guidelines influence the way in which care is accessed? How might your proposed policy and guidelines influence the amount of access that is available? Biopsychosocial Population Health Policy Proposal Assignment
Assessment 2 will build on the health issue, vulnerable population, and position that you started to develop in the first assessment. For Assessment 2, you will develop a proposal for a policy and a set of guidelines that could be implemented to ensure improvements in care and outcomes. Refer to the resource listed below: Guiding Questions: Biopsychosocial Population Health Policy Proposal [DOC]. Scenario The analysis of position papers that your interprofessional team presented to the committee has convinced them that it would be worth the time and effort to develop a new policy to address your specific issue in the target population. To that end, your interprofessional team has been asked to submit a policy proposal that outlines a specific approach to improving the outcomes for your target population. This proposal should be supported by evidence and best practices that illustrate why the specific approaches are likely to be successful.
Additionally, you have been asked to address the ways in which applying your policy to interprofessional teams could lead to efficiency or effectiveness gains. Instructions For this assessment you will develop a policy proposal that seeks to improve the outcomes for the health care issue and target population you addressed in Assessment 1. If for some reason you wish to change your specific issue and/or target population, contact your FlexPath faculty. The bullet points below correspond to the grading criteria in the scoring guide. Be sure that your submission addresses all of them. You may also want to read the Biopsychosocial Population Health Policy Proposal Scoring Guide and Guiding Questions: Biopsychosocial Population Health Policy Proposal [DOC] to better understand how each grading criterion will be assessed. Propose a policy and guidelines that will lead to improved outcomes and quality of care for a specific issue in a target population. Advocate the need for a proposed policy in the context of current outcomes and quality of care for a specific issue in a target population. Analyze the potential for an interprofessional approach to implementing a proposed policy to increase the efficiency or effectiveness of the care setting to achieve high-quality outcomes. Communicate proposal in a professional and persuasive manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. Integrate relevant sources to support assertions, correctly formatting citations and references using APA style.
Example Assessment: You may use the assessment example, linked in the Assessment Example section of the Resources, to give you an idea of what a Proficient or higher rating on the scoring guide would look like. Additional Requirements Length of proposal: 2-4 double-spaced, typed pages, not including title page or reference list. Your proposal should be succinct yet substantive. Number of references: Cite a minimum of 3-5 sources of scholarly or professional evidence that supports the relevance of or need for your policy, as well as interprofessional considerations. Resources should be no more than five years old. APA formatting: The APA Style Paper Tutorial [DOCX] will help you in writing and formatting your analysis. Competencies Measured By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 1: Design evidence-based advanced nursing care for achieving high-quality population outcomes. Propose a policy and guidelines that will lead to improved outcomes and quality of care for a specific issue in a target population. Competency 2: Evaluate the efficiency and effectiveness of interprofessional interventions in achieving desired population health outcomes. Analyze the potential for an interprofessional approach to implementing a proposed policy to increase the efficiency or effectiveness of the care setting to achieve high quality outcomes.
Competency 3: Analyze population health outcomes in terms of their implications for health policy advocacy. Advocate the need for a proposed policy in the context of current outcomes and quality of care for a specific issue in a target population.
Competency 4: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with organizational, professional, and scholarly standards. Communicate proposal in a professional and persuasive manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. Integrate relevant sources to support assertions, correctly formatting citations and references using APA style. Biopsychosocial Population Health Policy Proposal Assignment
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Portfolio Assignment: The Role Of The Nurse Informaticist In Systems Development And Implementation
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.
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: 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.
Use the Safe Assign Drafts to check your match percentage before submitting your work. Portfolio Assignment: The Role Of The Nurse Informaticist In Systems Development And Implementation
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Social Determinants of Health The discussion assignment provides a forum for discussing relevant topics for this week on the basis of the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned and complete your participation for this assignment by Day 7.
To support your work, use your course and text readings and also use resources from the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format. Support your work, using your course lectures and textbook readings. Helpful APA guides and resources are available in the South University Online Library. Week 2 Discussion Social Determinants of Health
Below are guides that are located in the library and can be accessed and downloaded via the South University Online Citation Resources: APA Style page. The American Psychological Association website also provides detailed guidance on formatting, citations, and references at APA Style.
APA Citation Helper
APA Citations Quick Sheet
APA-Style Formatting Guidelines for a Written Essay
Basic Essay Template Begin reviewing and replying to peer postings/responses early in the week to enhance peer discussion.
See the rubric for participation points. Participate in the discussion by asking a question, providing a statement of clarification, providing viewpoints with a rationale, challenging aspects of the discussion, or indicating relationships between two or more lines of reasoning in the discussion. Always use constructive language, even in criticism, to work toward the goal of positive progress. TASK Post your initial response to one of the two topics below. Social Determinants of Health Topic 1 Increasingly, health policymakers are becoming aware of the social determinants of health and the role they play in prevention disease and promoting health and wellness.
In the “Frameworks for Action in Policy and Politics” chapter, examine Box 1-1 (Political Aspects of the Social Determinants of Health) and Figure 1-6 (The Who, What, Where, When, and Why of Nursing’s Policy Influence). Compare these with the story about Lilian Wald’s work in New York City. Reflect on the “what” of Wald’s strategies. In your opinion, which did she use effectively? Looking further at the “what” in Figure 1-6, answer any one of the following questions:
Discuss at least three competencies/strategies that you have used effectively. Identify three competencies/strategies that you don’t currently use and discuss how you might incorporate them into your advocacy toolbox. Topic 2 Review the four recommendations in the IOM report The Future of Nursing: Leading Change, Advancing Health and find your state’s action coalition. Discuss your state’s action coalition’s work as it aligns with these four recommendations. Is each recommendation being addressed? Based on your analysis of the website, how would you describe your state’s progress toward meeting the IOM recommendations? Week 2 Discussion Social Determinants of Health
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The purpose of this assignment is to apply the concepts you have learned in this course to a situation you have encountered. Choose one quality or patient safety concern with which you are familiar and that you have not yet discussed in this course.
In a 1,250-1,500 word essay, reflect on what you have learned in this course by applying the concepts to the quality or patient safety concern you have selected. Include the following in your essay: Briefly describe the issue and associated challenges.
Explain how EBP, research, and PI would be utilized to address the issue. Explain the PI or QI process you would apply and discuss why you chose it. Describe your data sources, including outcome and process data. Explain how the data will be captured and disseminated. Discuss which organizational culture considerations will be essential to the success of your work.
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Discussion 1: Leadership Theories in Practice 2 peers response
A walk through the Business section of any bookstore or a quick Internet search on the topic will reveal a seemingly endless supply of writings on leadership. Formal research literature is also teeming with volumes on the subject. However, your own observation and experiences may suggest these theories are not always so easily found in practice. Not that the potential isn’t there; current evidence suggests that leadership factors such as emotional intelligence and transformational leadership behaviors, for example, can be highly effective for leading nurses and organizations. Yet, how well are these theories put to practice? In this Discussion, you will examine formal leadership theories. You will compare these theories to behaviors you have observed firsthand and discuss their effectiveness in impacting your organization. NURS – 6053N Module 3: Leadership
Review the Resources and examine the leadership theories and behaviors introduced.
Identify two to three scholarly resources, in addition to this Module’s readings, that evaluate the impact of leadership behaviors in creating healthy work environments.
Reflect on the leadership behaviors presented in the three resources that you selected for review.
By Day 3 of Week 4 Post two key insights you had from the scholarly resources you selected.
Describe a leader whom you have seen use such behaviors and skills, or a situation where you have seen these behaviors and skills used in practice. Be specific and provide examples.
Then, explain to what extent these skills were effective and how their practice impacted the workplace. NURS – 6053N Module 3: Leadership
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