Assignment: Practicum Assessing Client Progress

To prepare:

• Reflect on the client you selected for the Week 3 (See the attached case study for client selected in week 3) Practicum Assignment.
• Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format (See attached resource)Assignment: Practicum Assessing Client Progress.

The Assignment

Part 1: Progress Note

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations): (See sample paper)

Treatment modality used and efficacy of approach

Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)

Modification(s) of the treatment plan that were made based on progress/lack of progress

Clinical impressions regarding diagnosis and/or symptoms

Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.) Assignment: Practicum Assessing Client Progress

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Safety issues

Clinical emergencies/actions taken

Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)

Treatment compliance/lack of compliance

Clinical consultations

Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)

Therapist’s recommendations, including whether the client agreed to the recommendations

Referrals made/reasons for making referrals

Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions) Assignment: Practicum Assessing Client Progress

Issues related to consent and/or informed consent for treatment

Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported

Information reflecting the therapist’s exercise of clinical judgment

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment.

The privileged note should include items that you would not typically include in a note as part of the clinical record.

Explain why the items you included in the privileged note would not be included in the client’s progress note.

Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why. Assignment: Practicum Assessing Client Progress

References

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

• Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242)
• Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Note: You will access this text from the Walden Library databases.

Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048

Note: You will access this resource from the Walden Library databases.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)

Note: You will access this article from the Walden Library databases.

Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4

U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/ Assignment: Practicum Assessing Client Progress

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.

Comprehensive Client Family Assessment

Demographic Information

Date of assessment: 09/14/2018.        DOB: 011/01/1970.                Age: 48.          Race: Black.

SSN: 000000001.     Ethnicity: African American.    Address: On file.    Tel: 972-000-0000.

Residential Status: Homeless.             County: 9K.           Military Status: None.

Language: English.     Interpreter Needed:  No.         Primary Insurance: Uninsured.

Annual Gross Income: $0.      Employment Status: Unemployed.

Number of people in the household:  1.         Highest Grade: 11.

School Attendance for the past 3 Months:  None.

Arrival Time: 1000   Time Disposition Completed: 1100

Location of client: Lake Worth Nursing Home

 Presenting Problem

“My meds are not working.”

 History of Present Illness

The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife.  The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013)Assignment: Practicum Assessing Client Progress.

 Past psychiatric history

• Major Depressive disorder, Recurrent Episode with psychotic features
• Alcohol use disorder; severe
• Bipolar I Disorder most recent episode depressed Severe

 Medical history

None Reported

 Substance use history

Alcohol Abuse: began drinking at age 15 and drinks 8 to 10 bottles of beer daily, yesterday was his last time he drank.

 Developmental history

None Reported

 Family psychiatric history

Positive for family history of mental illness on the paternal side.

 Psychosocial history

The patient is unemployed and enjoys hanging out with fellow drunkards on the street with drinks, a living condition currently unstable as the patient is homeless.

 History of abuse/trauma

The patient suffered abuse paternal uncle at age 12.

Review of systems

General:  significant weight gain recently, positive with fatigue, but no fever or a cough.

HEENT: vision and hearing changes not reported at this time, no history of glaucoma, cataracts, diplopia, floaters, excessive tearing or photophobia, last eye exam four years ago. No ear infections, tinnitus or discharges in the ear, have no problems with smell, and taste. Denies epistaxis or nasal drainage, no any loose teeth, mouth sores or bleeding gum when brushing teeth. No difficulty with chewing or swallowing.

Neck: positive for JVD, no bruits

Respiratory: Denies shortness of breath, labored breathing, cough, but could be exposed to TB.

Cardiovascular: S1 and S2, RRR. No Shortness of breath reported, denies chest pain, palpitations, No difficulty during exercise.

GI: No nausea, vomiting, heartburn, indigestion.  No changes in bowel/bladder pattern, bowel sounds present on all four quadrants.

GU: No change in urinary pattern, hematuria or dysuria.

Musculoskeletal: WNL, No joint pain or swelling.

Psych: Positive for the history of mental health, reports anxiety, depression suicidal ideation but no homicidal thoughts.

Neuro:  Alert, oriented x 3, no fainting, dizziness, or loss of coordination, positive for weakness.

Skin: warm to touch and moist, denies any skin changes, rashes or raised lesions, no itching, no history of skin disorders or cancers, no swelling.

Hematologic: No bleeding disorders or clotting issues, no history of anemia or blood transfusions.

Allergic/Immunologic: Penicillin- rash and seasonal allergies, Sulfa drugs – rash.

Physical assessment

Vital signs: B/P 130/78; P 70 regular; T 98.4 orally; RR 20 non-labored; RBS 100mgdl; Wt: 140 lbs.; Ht: 5’6; BMI 22.6.

 Mental status exam

The level of consciousness: cerebral perfusion, coherent thought, concise responses.

Mood: Depressed and sad.

Behavior: Appropriate/Normal and cooperative.

Cognition: displays signs of hallucination and compulsion.

Personal hygiene and grooming: deteriorated grooming and personal hygiene.

Memory and attention: AO x 3 Assignment: Practicum Assessing Client Progress.

 

Differential diagnosis

• Major Depressive disorder, Recurrent Episode with psychotic features
• Alcohol use disorder; severe
• Bipolar I Disorder most recent episode depressed Severe
• Recurrent Episode with psychotic features (DSM-5, 2018).

Columbia Suicide Severity Rating Scale:

• Wish to be dead: Yes
• Suicidal thoughts: yes
• Suicidal thoughts with method (with a specific plan and intend to act): Yes
• Suicidal Intend (with particular plan): Yes
• Suicidal Intend with a specific plan; Yes
• Suicidal behavior question: Yes

If yes to 6, how long ago did you do any of these: Over a year ago (American Psychiatric Association, 2013).

 Case formulation

The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife.  The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013).

 Treatment plan

The client will begin an antidepressant Sertraline (Zoloft) 25 mg PO daily for the next four week and monitor progress. Start patient on an alcohol detox program to help with dependency and encourage to client join the alcohol anonymous (AA) group for support (Wheeler, K., 2014)Assignment: Practicum Assessing Client Progress.

Identify key points on what you would like to educate mom on prior to discharge by answering the questions below: warning signs, breastfeeding, breast infections, signs of infection at suture site, blood clots, proper hydration/nutrition, resumption of intercourse, resumption of normal exercise routine

Please make sure to list your references used for this in APA format at the end of this assignment.

1. What are warning signs that she should call on? Think back to assessment pieces
2. Identify the stages/transitions of breastmilk. When is colostrum produced? When does milk come in? What should the breasts feel like/look like at each stage?
3. How many extra calories should a breastfeeding woman be taking in daily?
4. What is lactation amenorrhea method? Is this effective? For how long? What are the requirements? When can a woman resume hormonal birth control? Is there a difference when she could start combined hormonal versus just progesterone-based methods? Why? Postpartum Education Assignment:
5. What are plugged ducts? Mastitis? During these conditions can mom still breastfeed? Which requires medication management? What does a shiny, red nipple indicate and thrush in baby’s mouth? How is this treated?
6. When can she resume intercourse after birth?
7. When can she resume a normal exercise routine?
8. Women are in a hypercoagulable state in the postpartum period to help prevent hemorrhage. What are signs/symptoms she should look out for that may indicate she needs to be seen?
9. What is the difference between postpartum blues and postpartum depression and postpartum psychosis? When should the woman be evaluated? Which ones are normal versus abnormal?
10. Women are still at increased risk for preeclampsia in the postpartum period. What are some symptoms that you may educate for the woman to look for if she is at risk for this?

Grab a partner and practice Postpartum Assessments. When doing an assessment, I want you to practice providing education to mothers prior to postpartum discharge. In the hospital setting, doing your last postpartum assessment is the opportune time to also provide that pertinent education and answer any questions the woman may have.

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When completing your practice assessments in postpartum think about your main assessments:

Heart & Lungs; Vitals; Pain; Review of Labs (hgb/hct/Rh status)

Then think of Pneumonic BUBBLE

B: Breasts à assessing firmness; are they soft, full, engorged, painful? Redness? Open areas or scabs? Discuss milk stages with mom, when to expect engorgement, what it may look/feel like, what signs to watch out for and call on (think mastitis). Breastfeeding and increased after pains/contractions and why this occurs. Lactation consultants available if needed. Assessing effective latch.

U: Uterus à check fundus, is it firm/boggy? Bleeding? Clots? Pain? Location? Explaining where fundus should be located upon discharge and identify if abnormal. Postpartum Education Assignment:

B: Bowels à Has she been passing gas, has she had a bowel movement? Hydration importance, using stool softener, pain, and hemorrhoids normal after vaginal delivery. Using products to help relieve this symptom and avoiding straining to cause more pain/irritation to suture site.

B: Bladder à peri-care. Using a peri-bottle when using the restroom. Pat dry. Voiding at least every 3-4 hours. Full bladders can cause non-effective contractions and increase bleeding.

L: Lochia à how bleeding should reduce, change in color, and what signs to watch out for (increased bleeding, excessively large clots, suturing a pad in less than hour, odor)

E: Episiotomy/laceration à Reeda (redness, edema, ecchymosis/bruising, discharge, approximation) and educating on identifying any signs or symptoms of infection. Witch hazels pads, dermoplast sprays, ice pack use intermittently.

H: Hormones (postpartum blues) à How is her mood. Educate on hormonal changes, whats normal versus abnormal (blues versus depression) when to notify doctor and time period. Educate on psychosis. If thoughts of harming self or baby to seek immediate attention.

E: Extremities à assess or edema, redness, possible blood clot in legs. Redness, swelling, tenderness, pain in a leg could all be signs of clot and needs further assessment. Ambulating, elevating legs, and ways to reduce this.

A: Adjustment Questions (support) (siblings) (sleep) à Does she have support? Educating on importance of having help when returning home. Are there other children in the home? The other kids feelings with the addition of newborn. How has she been sleeping overall? Educating on sleeping when baby sleeps.

D: Demonstrates understanding – asking patient to repeat back when to call on warning signs – sleep when baby sleeps – when her next appointment is. Etc. Postpartum Education Assignment:

 

Diagnosis assignment

Directions

Sarah is a 69-year-old female that presented to the emergency department with shortness of breath. Her past medical history includes heart failure and COPD. Her pulse oximetry on room air is 82%. You notify the provider, and he orders oxygen at 2 L via nasal cannula NC. Sarah’s chest x-ray reveals bilateral pneumonia. Her arterial blood gas result are below:

pH: 7.30

PaCO2: 58 mm Hg

PaO2: 78 mm Hg

HCO3: 26 mEq/L

Sarah is admitted to a general medical floor. You are the nurse assigned to Sarah.

1. What potential problems can occur based on the above findings?
2. How would you provide multidimensional care for Sarah?
3. Describe the roles of other departments in Sarah’s treatment plan.

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This paper has to be done in an APA FORMAT

Please give four References.

Directions

Sarah is a 69-year-old female that presented to the emergency department with shortness of breath. Her past medical history includes heart failure and COPD. Her pulse oximetry on room air is 82%. You notify the provider, and he orders oxygen at 2 L via nasal cannula NC. Sarah’s chest x-ray reveals bilateral pneumonia. Her arterial blood gas result are below: Diagnosis assignment

pH: 7.30

PaCO2: 58 mm Hg

PaO2: 78 mm Hg

HCO3: 26 mEq/L

Sarah is admitted to a general medical floor. You are the nurse assigned to Sarah.

1. What potential problems can occur based on the above findings?
2. How would you provide multidimensional care for Sarah?
3. Describe the roles of other departments in Sarah’s treatment plan.

 

This paper has to be done in an APA FORMAT

Please give four References.

Directions

Sarah is a 69-year-old female that presented to the emergency department with shortness of breath. Her past medical history includes heart failure and COPD. Her pulse oximetry on room air is 82%. You notify the provider, and he orders oxygen at 2 L via nasal cannula NC. Sarah’s chest x-ray reveals bilateral pneumonia. Her arterial blood gas result are below:

pH: 7.30

PaCO2: 58 mm Hg

PaO2: 78 mm Hg Diagnosis assignment

HCO3: 26 mEq/L

Sarah is admitted to a general medical floor. You are the nurse assigned to Sarah.

1. What potential problems can occur based on the above findings?
2. How would you provide multidimensional care for Sarah?
3. Describe the roles of other departments in Sarah’s treatment plan.

 

This paper has to be done in an APA FORMAT

Please give four References.

Diagnosis assignment

Atrial Fibrillation Assignment

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Remote Collaboration And Evidence-Based Care

Create a 4-6 page paper with you , as a presenter, in which you will propose an evidence-based plan to improve the outcomes for a patient and examine how remote collaboration provided benefits or challenges to designing and delivering the care.

As technologies and the health care industry continue to evolve, remote care, diagnosis, and collaboration are becoming increasingly more regular methods by which nurses are expected to work. Learning the ways in which evidence-based models and care can help remote work produce better outcomes will become critical for success. Additionally, understanding how to leverage EBP principles in collaboration will be important in the success of institutions delivering quality, safe, and cost-effective care. It could also lead to better job satisfaction for those engaging in remote collaboration Remote Collaboration And Evidence-Based Care.

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Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 2: Analyze the relevance and potential effectiveness of evidence when making a decision.
  • Reflect on which evidence was most relevant and useful when making decisions regarding the care plan.
• Competency 3: Apply an evidence-based practice model to address a practice issue.
  • Explain the ways in which an EBP model was used to help develop the care plan.
• Competency 4: Plan care based on the best available evidence.
  • Propose an evidence-based care plan to improve the safety and outcomes for a patient.
• Competency 5: Apply professional, scholarly communication strategies to lead practice changes based on evidence.
  • Identify benefits and strategies to mitigate the challenges of interdisciplinary collaboration to plan care within the context of a remote team.
  • Communicate in a professional manner that is easily audible and uses proper grammar, including a reference list formatted in current APA style Remote Collaboration And Evidence-Based Care.

Professional Context

Remote care and diagnosis is a continuing and increasingly important method for nurses to help deliver care to patients to promote safety and enhance health outcomes. Understanding best EBPs and building competence in delivering nursing care to remote patients is a key competency for all nurses. Additionally, in some scenarios, while you may be delivering care in person you may be collaborating with a physician or other team members who are remote. Understanding the benefits and challenges of interdisciplinary collaboration is vital to developing effective communication strategies when coordinating care. So, being proficient at communicating and working with remote health care team members is also critical to delivering quality, evidence-base care.

Scenario

The Vila Health: Remote Collaboration on Evidence-Based Care simulation provide the context for this assessment.

Instructions

Before beginning this assessment, make sure you have worked through the following media:

• Vila Health: Remote Collaboration on Evidence-Based CarePlease find attached word document with Villa Health Scenario

For this assessment, you are a presenter! You will create a 5–10-minute video using Kaltura or similar software. In the video:

• Propose an evidence-based care plan that you believe will improve the safety and outcomes of the patient in the Vila Health Remote Collaboration on Evidence-Based Care media scenario.
• Discuss the ways in which an EBP model and relevant evidence helped you to develop and make decision about the plan you proposed
• Wrap up your video by identifying the benefits of the remote collaboration in the scenario, as well as discuss strategies you found in the literature or best practices that could help mitigate or overcome one or more of the collaboration challenges you observed in the scenario.

Be sure you mention any articles, authors, and other relevant sources of evidence that helped inform your video. Important: You are required to submit an APA-formatted reference list of the sources you cited specifically in your video or used to inform your presentation.

The following media is an example learner submission in which the speaker successfully addresses all competencies in the assessment Remote Collaboration And Evidence-Based Care.

• Exemplar Kaltura Reflection.
  • Please note that the scenario that the speaker discusses in the exemplar is different from the Vila Health scenario you should be addressing in your video. So, the type of communication expected is being model, but the details related to the scenario in your submission will be different.

Make sure that your video addresses the following grading criteria:

• Propose an evidence-based care plan to improve the safety and outcomes for a patient based on the Vila Health Remote Collaboration on Evidence-Care media scenario.
• Explain the ways in which an EBP model was used to help develop the care plan.
• Reflect on which evidence was most relevant and useful when making decisions regarding the care plan.
• Identify benefits and strategies to mitigate the challenges of interdisciplinary collaboration to plan care within the context of a remote team.
• Communicate in a professional manner that is easily audible and uses proper grammar, including a reference list formatted in current APA style Remote Collaboration And Evidence-Based Care.

Additional Requirements

Your assessment should meet the following requirements:

• Length of video: 5–10 minutes.
• References: Cite at least three professional or scholarly sources of evidence to support the assertions you make in your video. Include additional properly cited references as necessary to support your statements.
• APA reference page: Submit a correctly formatted APA reference page that shows all the sources you used to create and deliver your video. Be sure to format the reference page according to current APA style Remote Collaboration And Evidence-Based Care.