Episodic/Focused SOAP Note Template

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Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of 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. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products. Episodic/Focused SOAP Note Template

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 versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

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Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. 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. Pregnancy. LMP: MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). Episodic/Focused SOAP Note Template

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, 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. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. Episodic/Focused SOAP Note Template

Bacterial Vaginosis

Zahavah is a  16 years Gender: Female Race: non-Hispanic White Diagnosis: bacterial vaginosis Subjective Data: HJ is a 16-year-old Hispanic female patient who presented to the office with her  mother with a two week history of severe irritation and soreness of her vulva. The patient reported of having a two-week history of burning sensation on passing urine without increased urinary frequency. In addition, the patient complained of having a thick, creamy-white vaginal discharge. She had normal and regular menstrual periods. She agreed to having multiple sexual partners for the last one year since breaking up with her high school boyfriend. She denied taking medications in the management of the issue of concern. Objective Data: Vital signs; BP 110/76, HR 78, RR 26, temperature 98, and an oxygen saturation of 99 percent on room air. In general, HJ was a healthy lad who was well oriented to place, time, and person, without obvious distress. HEENT without issues of concern. On respiratory assessment, the patient had a clear and normal lung sounds bilaterally without crackles and wheezes. Cardiovascular assessment showing normal heart sound without murmurs and gallops. Normal bowel sounds on all quadrants on gastrointestinal examination. Patient denied to have a physical examination on the perineal area. Assessment: History of presenting illness indicating a possible bacterial vaginosis. Positive Whiff test indicating bacterial vaginosis. Plan of care: Clindamycin 300 mg orally twice daily for 7 days was prescribed to help in the management of the issues. Patient educated on the need to avoid multiple sexual partners to avoid reoccurrence of the issue as well as possible sexually transmitted diseases.

 

Answer below QUESTION

  • Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 3. Episodic/Focused SOAP Note Template

 

Workplace Violence Prevention For Health Care And Social Service Workers Act

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Workplace Violence Prevention For Health Care And Social Service Workers Act

Legislation Grid Based on the health-related bill (proposed, not enacted) you selected, complete the Legislation Grid Template. Be sure to address the following:

· Determine the legislative intent of the bill you have reviewed.

· Identify the proponents/opponents of the bill.

· Identify the target populations addressed by the bill.

· Where in the process is the bill currently? Is it in hearings or committees?

Legislation Testimony/Advocacy Statement Based on the health-related bill you selected, develop a 1-page Legislation Testimony/Advocacy Statement that addresses the following:

· Advocate a position for the bill you selected and write testimony in support of your position.

· Explain how the social determinants of income, age, education, or gender affect this legislation.

· Describe how you would address the opponent to your position. Be specific and provide examples.

· At least 2 outside peer-review resources and 2-3 course specific resources are used. Workplace Violence Prevention For Health Care And Social Service Workers Act

LEGISLATION GRID AND TESTIMONY/ADVOCACY STATEMENT

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To Prepare:

  • Select a bill that has been proposed (not one that has been enacted) using the congressional websites provided in the Learning Resources. (Bill selected H.R. 1195 Workplace Violence Prevention for healthcare and Social Service Workers).

The Assignment: (1- to 2-page Legislation Grid; 1-page Legislation Testimony/Advocacy Statement)

Be sure to add a title page, an introduction, purpose statement, and a conclusion. This is an APA paper.

Part 1: Legislation Grid

Based on the health-related bill (proposed, not enacted) you selected, complete the Legislation Grid Template. Be sure to address the following:

  • Determine the legislative intent of the bill you have reviewed.
  • Identify the proponents/opponents of the bill.
  • Identify the target populations addressed by the bill.
  • Where in the process is the bill currently? Is it in hearings or committees?

Part 2: Legislation Testimony/Advocacy Statement

Based on the health-related bill you selected, develop a 1-page Legislation Testimony/Advocacy Statement that addresses the following:

  • Advocate a position for the bill you selected and write testimony in support of your position.
  • Explain how the social determinants of income, age, education, or gender affect this legislation.
  • Describe how you would address the opponent to your position. Be specific and provide examples.
  • At least 2 outside peer-review resources and 2-3 course specific resources are used. Workplace Violence Prevention For Health Care And Social Service Workers Act 

 

Required reading for REFERENCES (Use 3 references from this list)

 

 

 

 Rubrics for grading

  1. Federal and State Legislation Part 1: Legislation Grid Based on the health- related bill you selected, complete the Legislation Grid Template. Be sure to address the following:• Determine the legislative intent of the bill you have reviewed.• Identify the proponents/opponents of the bill.• Identify the target populations addressed by the bill.• Where in the process is the bill currently? Is it in hearings or committees? The response clearly and accurately summarizes in detail the legislative intent of the health- related bill. …The response accurately identifies in detail the proponents and opponents of the health-related bill. …The response accurately identifies in detail the populations targeted by the health-related bill. …The response clearly and thoroughly describes in detail the current status of the health- related bill.

 

 

  1. Part 2: Legislation Testimony/Advocacy Statement• Advocate a position for the bill you selected and write testimony in support of your position.• Explain how the social determinants of income, age, education, or gender affect this legislation.• Describe how you would address the opponent to your position. Be specific and provide examples. -Testimony clearly, accurately, and thoroughly provides statements that fully justifies a position for a health-related bill…. Response provides a detailed, thorough, and logical explanation of the social determinant affecting the topic, and how to address opponents to the position for the health-related bill and includes one or more clear and accurate supporting examples. Workplace Violence Prevention For Health Care And Social Service Workers Act
  1. References-Response includes 3 or more course resources and 2 or more outside sources.

 

  1. This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph Development and OrganizationParagraphs make clear points that support well developed ideas, low logically, and demonstrate continuity of ideas.Sentences are carefully focused– neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.- Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.

 

  1. Written Expression and Formatting: English Writing StandardsCorrect grammar, mechanics, and proper punctuation. – Uses correct grammar, spelling, and punctuation with no errors.

 

  1. This criterion is linked to a Learning OutcomeWritten Expression and Formatting: The paper follows correct APA format for title page, font, spacing, indentations, parenthetical/in-text citations, and reference list. – Uses correct APA format with no errors. Workplace Violence Prevention For Health Care And Social Service Workers Act

 

 

 

Using Technology To Prevent Patient Falls Assignment

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Using Technology To Prevent Patient Falls Assignment

  • Review the concepts of technology application as presented in the Resources.
  • Reflect on how emerging technologies such as artificial intelligence may help fortify nursing informatics as a specialty by leading to increased impact on patient outcomes or patient care efficiencies.

In a 4- to 5-page project proposal written to the leadership of your healthcare organization, propose a nursing informatics project for your organization that you advocate to improve patient outcomes or patient-care efficiency. Your project proposal should include the following:

1.Describe the project you propose. (Using Technology to prevent Patient falls)

2.Identify the stakeholders impacted by this project.

3.Explain the patient outcome(s) or patient-care efficiencies this project is aimed at improving and explain how this improvement would occur. Be specific and provide examples.

4.Identify the technologies required to implement this project and explain why.

5.Identify the project team (by roles) and explain how you would incorporate the nurse informaticist in the project team. Using Technology To Prevent Patient Falls Assignment

6.Use APA format and include an introduction and reference page.

THE IMPACT OF NURSING INFORMATICS ON PATIENT OUTCOMES AND PATIENT CARE EFFICIENCIES

To Prepare:

Review the concepts of technology application as presented in the Resources.

Reflect on how emerging technologies such as artificial intelligence may help fortify nursing informatics as a specialty by leading to increased impact on patient outcomes or patient care efficiencies.

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The Assignment: (4-5 pages not including the title and reference page)

 

In a 4- to 5-page project proposal written to the leadership of your healthcare organization, propose a nursing informatics project for your organization that you advocate to improve patient outcomes or patient-care efficiency. Your project proposal should include the following:

 

1.Describe the project you propose. (Using technology to prevent patient falls)

2.Identify the stakeholders impacted by this project.

3.Explain the patient outcome(s) or patient-care efficiencies this project is aimed at improving and explain how this improvement would occur. Be specific and provide examples.

4.Identify the technologies required to implement this project and explain why.

5.Identify the project team (by roles) and explain how you would incorporate the nurse informaticist in the project team.

6.Use APA format and include a title page and reference page. Using Technology To Prevent Patient Falls Assignment

 

RUBRIC FOR GRADING

  1. In a 4- to 5-page project proposal written to the leadership of your healthcare organization, propose a nursing informatics project for your organization that you advocate to improve patient outcomes or patient care efficiency. Your project proposal should include the following: Describe the project you propose.· Identify the stakeholders impacted by this project. – The response accurately and thoroughly describes in detail the project proposed….The response accurately and clearly identifies the stakeholders impacted by the project proposed.

 

  • This criterion is linked to a Learning Outcome Explain the patient outcome(s) or patient-care efficiencies this project is aimed at improving.· Explain how this improvement would occur. Be specific and provide examples. Use sufficient supporting evidence in your response. – The response accurately and thoroughly explains in detail the patient outcome(s) or patient-care efficiencies that the project proposed is aimed at improving, including an accurate and detailed explanation, with sufficient supporting evidence of how this improvement would occur.

 

  • This criterion is linked to a Learning Outcome Identify the technologies required to implement this project and explain why.· Identify the project team (by roles) and explain how you would incorporate the nurse informaticist in the project team. – The response accurately and clearly identifies the technologies required to implement the project proposed with a detailed explanation why….The response accurately and clearly identifies the project team (by roles) and thoroughly explains in detail how to incorporate the nurse informaticist in the project team.

 

  1. Resources – Assignment includes: 3 or more peer-reviewed research articles and 2 or more course resources.

 

  1. Written Expression and Formatting – Paragraph Development and Organization:Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. – Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

 

  1. This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards:Correct grammar, mechanics, and proper punctuation. – Uses correct grammar, spelling, and punctuation with no errors.

 

  1. Written Expression and Formatting – APA:The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. – Uses correct APA format with no errors.

 

   REQUIRE READINGS ( Use 2-3 from list for REFRENCES) and outside references should be peer-review

 

LEGISLATION GRID AND TESTIMONY/ADVOCACY STATEMENT

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LEGISLATION GRID AND TESTIMONY/ADVOCACY STATEMENT

To Prepare:

  • Select a bill that has been proposed (not one that has been enacted) using the congressional websites provided in the Learning Resources. LEGISLATION GRID AND TESTIMONY/ADVOCACY STATEMENT

The Assignment: (1- to 2-page Legislation Grid; 1-page Legislation Testimony/Advocacy Statement)

Be sure to add a title page, an introduction, purpose statement, and a conclusion. This is an APA paper.

Part 1: Legislation Grid

Based on the health-related bill (proposed, not enacted) you selected, complete the Legislation Grid Template. Be sure to address the following:

  • Determine the legislative intent of the bill you have reviewed.
  • Identify the proponents/opponents of the bill.
  • Identify the target populations addressed by the bill.
  • Where in the process is the bill currently? Is it in hearings or committees?

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Part 2: Legislation Testimony/Advocacy Statement

Based on the health-related bill you selected, develop a 1-page Legislation Testimony/Advocacy Statement that addresses the following:

  • Advocate a position for the bill you selected and write testimony in support of your position.
  • Explain how the social determinants of income, age, education, or gender affect this legislation.
  • Describe how you would address the opponent to your position. Be specific and provide examples. LEGISLATION GRID AND TESTIMONY/ADVOCACY STATEMENT

 

Substance-Related and Addictive Disorders group Assignment

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Substance-Related and Addictive Disorders group Assignment

Choose one diagnosis from the Substance-Related and Addictive Disorders group

  • Alcohol Intoxication

Overview

As you will learn throughout the program, the diagnosis of a variety of psychiatric illnesses is not always an easy or straightforward process. Multiple observations and assessment methods are often employed to reach a diagnosis. This approach can include the use of standardized assessment instruments.  This then aids you in defining a treatment plan and choosing specific treatment plans to use in the care of your clients.

You are tasked with identifying a standardized assessment instrument/tool to measure the disorders listed for each week. You will keep these instruments in the form of a “portfolio” that you can use in your clinical practice to assess clients who present with a variety of symptoms.  Substance-Related and Addictive Disorders group Assignment

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Instructions:

Instrument/ Tool criteria:

For each assessment, you are tasked with selecting, you will identify an instrument and:

  1. List what DSM diagnosis the tool/instrument is used for.
  2. Identify an assessment/diagnosis instrument.
  3. Appraise a scholarly, peer-reviewed article that addresses the use of the instrument to support your choice as an evidence-based instrument for practice.
  4. Evaluate the instrument’s appropriateness for diagnosing the condition it is designed to assess or if the developers of the instrument reported that the instrument is only part of a comprehensive assessment for the disorder.
  5. Describe whether or not the instrument can be used to measure patient response to therapy/treatment or if it is strictly for assessment and diagnosis.
  6. Discuss the psychometrics/scoring of the instrument, including reliability and validity.
  7. Discuss any limitations associated with the use of the instrument.
  8. Include a link to view the assessment if possible.

Use the following template in completing your portfolio assignments. Your information can be in bulleted format or just a couple of sentences for each criterion listed above. However, you must use APA citation

Student Example Anxiety and Related Disorders

Week 7

 

Instrument: Social Phobia Inventory (SPIN)

 

Article: Psychometric properties of the Social Phobia Inventory

 

Appropriateness for Dx: This tool is meant for screening of individuals with social phobia and assignment of a severity score (Connor et al., 2000). The tool was created in congruence with DSM-4 but is consistent with the DSM-5 diagnosis of social anxiety disorder, minus some minor changes (Substance Abuse and Mental Health Service Administration [SAMHSA], 2016). Although the study is outdated, Duke University School of Medicine (2020) acknowledges that the tool is still relevant and utilized by their Anxiety and Traumatic Stress Program. Substance-Related and Addictive Disorders group Assignment

 

Response to Therapy/Treatment: The SPIN is appropriate for testing treatment response and through studies has proven sensitive to symptom changes over time. Changes in scores are able to determine treatment efficiency (Connor et al., 2000).

 

Psychometrics: The tool is self-administered and consists of 17 separate statements regarding problems a patient may exhibit if they have social phobia. The statement is then rated on how much it has bothered the individual in the last week, from ‘not at all’ (0) to ‘extremely’ (4). Any score over 21 is considered clinically significant. In the study, the assessment tool was able to effectively separate individuals with and without social phobia. Validity is strong in regard to detecting the severity of illness and is sensitive to symptom reductions during treatment. The scale shows significant correlation with the Liebowitz Social Anxiety Scale Test, The Brief Social Phobia Scale and The Fear Questionnaire social phobia subscale (Connor et al., 2000).

 

Limitations: Limitations exist in the tool’s alignment with DSM-4 instead of the more recent edition, although differences are very minor (SAMHSA, 2016). With a cutoff score of 19, sensitivity and specificity were good, but some individuals consider the cutoff score to be 15, in which these measures are weaker (Connor et al., 2000).

 

References

 

Connor, K., Davidson, J., Churchill, E., Sherwood, A., Foa, E., & Wisler, R. (2000).

Psychometric properties of the Social Phobia Inventory. British Journal of Psychiatry, 176, 379-386. Substance-Related and Addictive Disorders group Assignment

 

Nursing homework help

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Instructions

Assignment Objectives:

  • Identify and select appropriate interventions including diagnostic tests and nursing interventions.
  • Analyze physiological and psychological responses to illness and treatment modalities

Purpose: Examine case studies related to neurologic disease and answer the assigned questions. This assignment should help refine your clinical/critical thinking skills.

Assignment Description:

  • Describe the pathophysiology of extradural and subdural hematomas.
  • Identify the surgical emergency and provided rationale for the choice.
  • Describe the most likely type of head injury and outline an appropriate treatment plan.
  • Your answer must follow APA 7th edition format.
  • Submit the answer to this assignment area. Nursing homework help

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Patient 1 – Two individuals come to the emergency department with head injuries. One, 25 years old, has just been in a motor vehicle accident (MVA) and has a temporal lobe injury. The other, 65 years old, has increasing confusion after a fall that happened earlier in the week.

a. Differentiate the pathophysiology of extradural hematoma and subdural hematoma.

b. Identify the patient in the above scenario requiring immediate emergency surgical intervention and provide rationale for your choice.

Patient 2 – An 38 year old was driving his 1970 Chevy Corvette to a Milwaukee Brewers baseball game when a deer jumped out in front of him on the highway. He swerved his car and hit a telephone pole instead. His head hit the windshield and he suffered severe head trauma.

a. Describe the most likely specific type of head injury he suffered.

b. Outline the treatment plan for this patient. Nursing homework help

NU560-8D-Unit 6 Discussion 1 REPLY 1

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NU560-8D-Unit 6 Discussion 1 REPLY 1

Nurses strive for evidence-based practice, according to Gray et al (2016).  Evidence-based practice includes appraising studies critically, synthesizing research finding, and the sound evidence into practice.  Studies are also appraised critically in selected areas, according to Gray et al (2016).  They develop summaries of current knowledge and identify areas to study subsequently.  Critically appraised research is needed for all nursing skill (Gray et al, 2016).  Critical appraisal involves careful examination of research to judge the strengths, limitations, meaning, trustworthiness, and practice applicability (Gray et al, 2016). NU560-8D-Unit 6 Discussion 1 REPLY 1

According to Smith-Strom et al (2008), training students in evidence-based practice should include three steps: formulate a question, search the evidence, and appraise the evidence critically (Smith-Strom et al, 2008).

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Nurses need to know how to do this to secure the best care for patients.  Patients and their family demand that nurses have the best, up to date evidence for their care (Smith-Strom, 2008).  Decisions must be based on the best evidence available.  One way to ensure nurses are prepared is to train them while in school on evidence-based practice (Smith-Strom, 2008).

Clinical significance and credibility have an influence in every area nursing.  I work with patients who have a need in post-settings.  I must make decisions for patients in acute settings based on clinical significance.  I must use evidence-based information to help me make the best decision for their post-acute setting and discharge plans.  There are a variety of settings for post- acute care such as nursing homes, rehabilitation facilities, and home health agencies (Bryant et al, 2004).  Measuring outcomes of evidence- based practice helps implement changes that are designed to improve patient outcomes and care process (Bryant et al, 2004). NU560-8D-Unit 6 Discussion 1 REPLY 1

Social Determinants of Health (SDH) Assignment

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Social Determinants of Health (SDH) Assignment

Use your lecture materials to determine three priority Social Determinants of Health (SDH) to assess for in the patient represented in the SOAP note. NOTE: Priority may refer to a strength in an SDH category necessary for the individual to attain/maintain health OR the priority may be a challenge in an SDH category identified as needing support or intervention for the individual to attain/maintain health.

In paragraph form, construct a discussion that identifies those priority SDHs using data from the objective and subjective data sets where appropriate to support your discussion.
Include in your discussion some strategies you might utilize to address challenges with or support strengths identified in those three priority SDH.
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position. Social Determinants of Health (SDH) Assignment
Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format

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Chief Complaint:

“You all are all morons!  I want to go home. There’s nothing wrong with me and I shouldn’t be here. Do you see that there are alien doctors at the hospital, and they are helping to take over if we don’t do something to stop them?”

 

History of Present Illness:

37-year-old female brought into the state psychiatric hospital by the police.  The patient attacked a police officer under the bridge where she is apparently living.  The police were investigating a report of theft of food from a nearby grocery store. The report included information about the thief did not appear to be making any sense talking about needing food to store for when aliens invade the planet.  The police report that when they went to investigate the reported theft, the patient talked of the city water supply being poisoned by aliens, seeing aliens under the bridge that look just like her and that alien men had been raping her.

 

PMH:         

Depression 5 years ago secondary to the death of her son; reports being on anti-depressants for a few months; denies history of any other mental health concerns

Complications secondary to arthroscopic knee surgery resulting in long term IV Vancomycin

Lymphoma diagnosed 7 years ago treated with six cycles of chemo with excellent response, in remission

+PPD for six years, treated for 12 months

Family Hx:

Mother diagnosed with schizophrenia at age 36

Maternal grandfather – placed in an ‘insane asylum for hysteria’

Social Hx:

Divorced with a daughter, son is deceased

Heterosexual

Homeless – living under the bridge, stating her family disowned her ‘years ago’

Employment history – primary work experience as a nurse aid, reports she has ‘difficulty keeping a job’

Legal history – no history arrests or legal charges

 

ROS:

General – denies loss of appetite or recent weight loss

Neuro – reports occasional headache due to ‘surgery performed on her by aliens’

Otherwise ROS is negative. Social Determinants of Health (SDH) Assignment

 

SIGECAPS:

Reports sleep interrupted by aliens entering her space under the bridge, interest is focused on thoughts of alien invasion and her need to stop it, expresses no guilt, reports feels ‘hyper’ most of the time as she has to be on the lookout at all times, reports concentrates solely on alien invasion, denies changes in appetite, reports is constantly on the move, denies suicidal/homicidal ideations

Medications:                                                                                                                                                              

OTC Ibuprofen 400mg PRN HA

Allergies:

Mycins – upset stomach

Bactrim – rash

 

Physical Examination:

General – thin Hispanic female who appears older than stated age; disheveled in appearance;

BP 143/84, P 82, RR 16, Ht 64 in, Wt 109 lbs, BMI 19

Integument – warm, dry; good turgor; no rashes, ecchymoses or petechiae noted

HEENT – Head is normocephalic and atraumatic, PERRLA, EOMs intact, TMs gray  and shiny bilateral, nares patent without discharge noted, no tonsillar enlargement

Neck – supple without adenopathy, no thyromegaly

Lungs – CTA

Breasts – deferred

Heart – RRR without murmur/gallop

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

Genitalia/Rectum – deferred

Musculoskeletal – no gross abnormalities noted

Neurologic – lethargic, DTRs 2+ and equal bilateral, negative Babinski

Diagnostics – Na 140 meq/L, K 4.0 meq/L, Cl 102 meq/L, HCO3 22 meq/L, Bun 14 mg/dL, Cr 0.8 mg/dL, non-fasting Glu 134 mg/dL, Ca 9.9 mg/dL, PO4 3.2 mg/dL, Total Protein 7.0 g/dL, Mg 2.7 mg/dL, AST 21 IU/L, ALT 15 IU/L, Alb 4.5 g/dL, TSH 2.33, Hgb 14.6 g/dL, HCT 42 %, RBC 4.2 million/mm3, WBC 6000/mm3, Plt 264,000/mm3

Urine pregnancy test – negative; urine drug screen – negative; urine dipstick – specific gravity 1/017, pH 5.8, other parameters negative

 

Assessment:

Diagnoses are not needed for this assignment.

Plan:

The assignment directs identification of priority social determinants of health and development of a plan that ‘address challenges with or support strengths identified in’ the three priority SDH that you identified in this patient. Social Determinants of Health (SDH) Assignment

 

 

Nursing homework help

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A 60-year-old man is brought to the ER by ambulance because of slurred speech and left side weakness. His wife states they went to bed at 11pm and woke up at 5am when she noticed his symptoms. He is right-handed with a history of coronary artery disease, hypertension, and hypercholesterolemia and a heart attack at age 50.

He currently is unable to move his left arm and leg.
He had an episode of amaurosis fugux (blindness)in his right eye one month ago that lasted for 5 minutes.
Around 3 months ago his wife states he had bilateral pain in his legs while they were on a walk that lasted about 15 minutes.
He is taking a baby aspirin a day an ACE inhibitor, and statin as well.
He does have a history of alcohol use and smoking in the past but stopped after his heart attack.
His blood pressure is 195/118 Pulse 106, Respiratory rate 18, Temperature 99.8, O2 sat is 97% on room air.
Although his pupils are equal and reactive, and the ocular movements are intact, he is unable to turn his eyes voluntarily toward the left side. Nursing homework help
The neck is supple, there is no jugular vein distension, and there are no bruits.
The lungs are clear heart sounds regular without murmurs, and abdomen is normal.
The limbs are not well perfused distally.
The neurologic examination reveals that he is alert and oriented, although he does not recognize he is sick.
He shows loss of awareness and attention with respect to objects or stimuli on his left side.
He has mild dysarthria but, his speech is fluent, and he understands and follows commands very well.
There is mild weakness on the left side of the face and left sided homonymous hemaianopsia, but there is no nystagmus or ptosis, and no tongue or uvula deviation.
He is not able to move his left arm and leg, has hyperreflexia, and the left great toe is upgoing.
What are two questions you would ask this patient?
Identify the subjective data for this patient.
Identify the objective data for this patient.
What Social Determinants of Health would be relevant for this patient? Nursing homework help

NURS 6053 Discussion Reply 2

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NURS 6053 Discussion Reply 2

Leadership can be defined as ‘‘a process whereby an individual influences a group of individuals to achieve a common goal’’ (Northouse, 2004). This means here is relationship in leadership. Examples of relationally focused leadership styles include transformational leadership which motivates others to do more than they originally intended and often more than they thought possible, individualized consideration, which focuses on understanding the needs of each follower and works continuously to get them to develop to their full potential, and resonant leadership that inspires, coaches, develops and includes others even in the face of adversity (Stantou, et al., 2017). Transformational leaders use idealized influence, inspiration and motivation, intellectual stimulation and individualized consideration to achieve superior results and resonant styles are based on the emotional intelligence of the leaders (Stantou, et al., 2017). In task focused or non-relationally focused leadership styles can be categorized as management by exception, laissez-faire, transactional leadership, dissonant leadership styles, and instrumental leadership. In Active Management-by-Exception, the leadership focuses on monitoring task execution for any problems that might arise and correcting those problems to maintain current performance levels.

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In laissez-faire styles, they are passive avoidance of issues, decision making and accountability and only tend to react only after problems had reaches a critical point and often avoids making any decisions at all. Passive– avoidant leadership tends to react only after problems have become serious to take corrective action, and often avoids making any decisions at all (Stantou, et al., 2017). Transactional leadership emphasize the transaction or exchange that takes place among leaders, colleagues and followers to accomplish the work (Bass and Avolio, 1994). Dissonant leadership is characterized by pacesetting and commanding styles that undermine the emotional foundations required to support and promote staff success (Goleman et al., 2002). Instrumental leadership focuses on the strategic and task-oriented developmental functions of leaders (Stantou, et al., 2017). Initiating structure referred to the degree to which leaders articulate clear role expectations, create well defined communication channels and focus on tasks and attaining goals (Judge et al., 2004). NURS 6053 Discussion Reply 2

Where I do PRN job, my director used transformational leadership style. This has made many of us to practice collective responsibility. This hospital has a high nurse-retention level because of this humane leadership.