Category: Nursing

Hide Assignment Information Instructions Instructions Throughout this course, you will begin to write sections for your final paper. As you write these one-page essays, keep in mind what perspective you want your final paper to approach the subject might be. For example, if you want to contrast the roles of the LPN and RN based on board of nursing rules or professional organizations, then each paper try to incorporate that same voice. This will make putting together the final paper less time-consuming. Please see the general guidelines below. Prompt For this module, write a one-page paper on the art of performing a patient assessment. Remember, view the paper through a similar lens as the papers before since this one-pager paper will be combined for the final paper. Guidelines Weekly paper assignments are to be no longer than 500-750 words/1 page Paper. Font no smaller than 11, black in color, and either Times New Roman or Arial. Must use five references, one of which can be your textbook. Papers found to be less than 90% original will be given a zero, so make sure to summarize your references and not copy and paste. Use of AI or non-academic resources such as Wikipedia will immediately receive a zero score. Be original. Have fun with this! Rubrics: Integration of Knowledge The paper demonstrates that the author fully understands and has applied concepts learned in the course. Concepts are integrated into the writers own insights. The writer provides concluding remarks that show analysis and synthesis of ideas. Topic Focus The topic is focused narrowly enough for the scope of this assignment. A thesis statement provides direction for the paper, either by statement of a position or hypothesis. Depth of Discussion In-depth discussion & elaboration in all sections of the paper. Cohesiveness Ties together information from all sources. Paper flows from one issue to the next without the need for headings. Author’s writing demonstrates an understanding of the relationship among material obtained from all sources. Sources More than 5 current sources, of which at least 3 are peer- review journal articles or scholarly books. Sources include both general background sources and specialized sources. Special- interest sources and popular literature are acknowledged as such if they are cited. All web sites utilized are authoritative. Citations Cites all data obtained from other sources. APA citation style is used in both text and bibliography.

Each journal should be a minimum of 250 words.

The purpose of this reflective journal is self-reflection regarding the role in the process of self-reflection as a PMHNP provider. Through reflective practice, the student will evaluate their own emotional health and recognize ones own feelings as well as ones ability to monitor and manage those feelings. The point of the exercise is to learn yourself, your triggers, the types of cases you end up getting overly involved with, and those youd rather refer to someone else. The idea is to be able to personally reflect on your behaviors/thoughts/decisions and how those impact you in the role of PMHNP.

Address the following items:

Teamwork in nursing has these characteristics: good communication, respect for one another, shared planning, common goals, cooperation, coordination, sharing of expertise, and shared decision-making.

• Discuss a clinical experience where you were part of the interdisciplinary team. List the members of the interdisciplinary team of which you were a participant.
• What was the patient case about and why was the collaboration necessary?
• Why is team collaboration important in care of a patient?
• What did you learn from this encounter?

All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.

In a 57 page written assessment, assess the effect of the patient, family, or population problem youve previously defined on the quality of care, patient safety, and costs to the system and individual. Plan to spend approximately 2 direct practicum hours exploring these aspects of the problem with the patient, family, or group youve chosen to work with and, if desired, consulting with subject matter and industry experts. Document the time spent (your practicum hours) with these individuals or group in the BSN Learner Time Reporting Volunteer Experience Form. Report on your experiences during your first two practicum hours. Organizational data, such as readmission rates, hospital-acquired infections, falls, medication errors, staff satisfaction, serious safety events, and patient experience can be used to prioritize time, resources, and finances. Health care organizations and government agencies use benchmark data to compare the quality of organizational services and report the status of patient safety. Professional nurses are key to comprehensive data collection, reporting, and monitoring of metrics to improve quality and patient safety. In this assessment, you’ll assess the effect of the health problem you’ve defined on the quality of care, patient safety, and costs to the system and individual. Plan to spend at least 2 direct practicum hours working with the same patient, family, or group. During this time, you may also choose to consult with subject matter and industry experts. To prepare for the assessment: Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete and how it will be assessed. Conduct research of the scholarly and professional literature to inform your assessment and meet scholarly expectations for supporting evidence. Review the Practicum Focus Sheet: Assessment 2 [PDF] Download Practicum Focus Sheet: Assessment 2 [PDF], which provides guidance for conducting this portion of your practicum. Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page. Complete this assessment in two parts. Part 1 Assess the effect of the patient, family, or population problem you defined in the previous assessment on the quality of care, patient safety, and costs to the system and individual. Plan to spend at least 2 practicum hours exploring these aspects of the problem with the patient, family, or group. During this time, you may also consult with subject matter and industry experts of your choice. Document the time spent (your practicum hours) with these individuals or group in the BSN Learner Time Reporting Volunteer Experience Form. Use the Practicum Focus Sheet: Assessment 2 [PDF] Download Practicum Focus Sheet: Assessment 2 [PDF] provided for this assessment to guide your work and interpersonal interactions. Part 2 Report on your experiences during your first 2 practicum hours, including how you presented your ideas about the health problem to the patient, family, or group. Whom did you meet with? What did you learn from them? Comment on the evidence-based practice (EBP) documents or websites you reviewed. What did you learn from that review? Share the process and experience of exploring the influence of leadership, collaboration, communication, change management, and policy on the problem. What barriers, if any, did you encounter when presenting the problem to the patient, family, or group? Did the patient, family, or group agree with you about the presence of the problem and its significance and relevance? What leadership, communication, collaboration, or change management skills did you employ during your interactions to overcome these barriers or change the patient’s, family’s, or group’s thinking about the problem (for example, creating a sense of urgency based on data or policy requirements)? What changes, if any, did you make to your definition of the problem, based on your discussions? What might you have done differently? The assessment requirements, outlined below, correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, note the additional requirements for document format and length and for supporting evidence. Explain how the patient, family, or population problem impacts the quality of care, patient safety, and costs to the system and individual. Cite evidence that supports the stated impact. Note whether the supporting evidence is consistent with what you see in your nursing practice. Explain how state board nursing practice standards and/or organizational or governmental policies can affect the problem’s impact on the quality of care, patient safety, and costs to the system and individual. Describe research that has tested the effectiveness of these standards and/or policies in addressing care quality, patient safety, and costs to the system and individual. Explain how these standards and/or policies will guide your actions in addressing care quality, patient safety, and costs to the system and individual. Describe the effects of local, state, and federal policies or legislation on your nursing scope of practice, within the context of care quality, patient safety, and cost to the system and individual. Propose strategies to improve the quality of care, enhance patient safety, and reduce costs to the system and individual. Discuss research on the effectiveness of these strategies in addressing care quality, patient safety, and costs to the system and individual. Identify relevant and available sources of benchmark data on care quality, patient safety, and costs to the system and individual. Document the time spent (your practicum hours) with these individuals or group in the BSN Learner Time Reporting Volunteer Experience Form. Use paraphrasing and summarization to represent ideas from external sources. Apply APA style and formatting to scholarly writing. Format: Format your paper using APA style. APA Style Paper Tutorial [DOCX] is provided to help you in writing and formatting your paper. Be sure to include: A title page and reference page. An abstract is not required. Appropriate section headings. Length: Your paper should be approximately 57 pages in length, not including the reference page. Supporting evidence: Cite at least 5 sources of scholarly or professional evidence that support your central ideas. Resources should be no more than five years old. Provide in-text citations and references in APA format. Proofreading: Proofread your paper, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on its substance. By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria: Competency 3: Transform processes to improve quality, enhance patient safety, and reduce the cost of care. Explain how a patient, family, or population problem impacts the quality of care, patient safety, and costs to the system and individual. Propose strategies to improve the quality of care, enhance patient safety, and reduce costs to the system and individual and document the practicum hours spent with these individuals or group in the BSN Learner Time Reporting Volunteer Experience Form. Competency 5: Analyze the impact of health policy on quality and cost of care. Explain how state board nursing practice standards and/or organizational or governmental policies can affect a patient, family, or population problem’s impact on the quality of care, patient safety, and costs to the system and individual. Competency 8: Integrate professional standards and values into practice. Use paraphrasing and summarization to represent ideas from external sources. Apply APA style and formatting to scholarly writing.

Please re-write this soap note using the ttemplate provided

Not using AI-

The purpose of this discussion is to guide you in thoughtfully selecting a community for your community assessment paper. This step is critical because the choice of community will shape your ability to analyze population health data, identify social determinants of health, and develop evidence-based recommendations. Selecting a community strategically ensures that your assessment is both meaningful and feasible within the scope of the assignment. When choosing a community, consider factors such as size, population demographics, access to healthcare, prevalent health concerns, and available public health data. Once a community is selected, you will apply epidemiological principles, analyze aggregate health data, and integrate insights from nursing and other disciplines to inform practical interventions. The ultimate goal is to demonstrate your ability to translate evidence into actionable strategies that promote equitable health outcomes.

• Describe what influenced your selection.
• What key health indicators or population health metrics do you anticipate analyzing in the community?
• What sources will you use to collect the epidemiological data?
• How might the social determinants of health within this community influence your assessment findings and proposed interventions?
• Describe how these social determinants compare to the state, national and global level health outcomes.

Write a 4-5 page paper describing the use of a specific screening tool. Discuss what diagnosis you are using the tool for, how to score the tool, and support use of the tool with evidence and rationale. Next, develop a treatment plan for the patient based on your findings in the diagnostic test and interpretation.

Sections should include:

• Introduction to the diagnostic tool
• Discussion of Tool: why it is used, how, and for what diagnosis
• Discussion of Interpretation of Scoring for the Tool
• Treatment Plan for patient with positive results from the tool, include non-pharmacological and pharmacological approaches, patient education, additional testing required, and follow-up as needed.

FOCUSED SOAP NOTE GUIDE and RUBRIC (ATTACHED IS THE RUBRIC).

Do NOT reuse SOAP note from previous practicum.

Patient and diagnosis in any of the SOAP notes cannot be the same as Case Study Presentation.

SOAP notes should discuss adult patients, age 16 and older, who present with a chief complaint. Please indicate, next to the selected patient, a case number that correlates with one of your EXXAT patients seen in clinical setting. Pre-op patients or pre-procedure patients, who present for clearance, and who don’t have a chief complaint, do not meet the criteria.

The SOAP note should mimic clinical documentation in the practicum setting. The documentation should be accurate, clear, well organized and utilizes medical terminology.

SUBJECTIVE (20 points)

CC – the reason for the visit as stated in the patient’s own words

Example: I have been coughing frequently for 5 days.

HPI (History of Present Illness)

1-Describe the chief complaint in a chronological manner and include symptom dimensions, and chronological narrative of patients complains.

a.First sentence should include patient’s identifying data, including age, gender, race if clinically relevant, and pertinent past medical history. If the information is obtained from other sources, always identify source

b.Use PQRST or OLDCARTS mnemonic to guide you in obtaining pertinent information.

c.Incorporate elements of the PMHx, FHx and SHx relevant to the patients chief complaint, and elaborate on them to add pertinent information.

d.Include pertinent positives and negatives based on relevant portions of the R.O.S.

e.HPI should also present the context for the differential diagnoses.

2- If the patient has a PMHx, relevant to the the chief complaint, it should be described and elaborated on in a separate small paragraph

For example:

Mr. X is a 54 year old man with PMHx of asthma, who presents with persistent cough X 5 days, worse at night, productive of small amount of whitish phlegm etc. (continue with all pertinent negatives and pertinent positives that help you reach your primary diagnosis and help you rule out your differential diagnoses).

Asthma was diagnosed 5 years ago, triggered by exercise and cold weather, and treated with inhalers as needed. Reports that he last used inhalers one month ago. ( Elaborate on Asthma in a separate paragraph in HPI, since Asthma is part of PMHx tha is relevant to cc)

PMH (Pertinent past medical history)

PSHx (Pertinent surgical history)

Pertinent Family History, Social History and other subjective data if relevant to the patients presenting problem and diagnosis.

Medications – Current medications (list with daily dosages).

Allergies: describe the nature of the adverse reaction

ROS (Pertinent review of systems) a system- based list of questions that help uncover symptoms not otherwise mentioned by the patient. In a focused SOAP note, only include systems pertinent to the presenting problem and/or diagnosis. Follow the proper order of the different systems.

OBJECTIVE (15 points)

Vital signs

PE focused physical exam finding limited to systems pertinent to the problem

Same systems reviewed in ROS should be addressed in PE. Follow the proper order of the different systems in PE.

Laboratory or diagnostic data, if perfomed before this visit, and if applicable, belong in this section and after physical exam, with the appropriate date.

Laboratory or diagnostic data during this visit belong under Plan, not here.

ASSESSMENT (Problem List) with ICD-10 Codes (20 points)

This section documents the synthesis of subjective and objective evidence to arrive at a diagnosis. This is the assessment of the patients status through analysis of the problem, possible interaction of the problems, and changes or progress in the status of the problems.

The assessment could also contain the possible causes of the patients problem, especially if the patient is experiencing an illness.

If the patient had made a visit before, it should also contain the progress which had been made since the last visit as well as the overall progress towards fully treating the symptoms, based on the perspective of the main physician.

List the problem list (diagnosis/es) in order of importance.

1.Primary diagnosis (most likely)

2.Relevant chronic medical condition (s)

Example:

#1 Primary Diagnosis acute viral bronchitis (J20.9) –

Mr. X is a 54 yr old man with HTN presents with frequent cough x 5 days, worse at night with small amount whitish sputum, denies SOB, fever and chills, and with a normal lung exam. Symptoms are most likely consistent with acute viral bronchitis.

#2 Asthma (I10), controlled. No recent use of inhalers and no wheezing on exam (ex. of how you address the patient’s chronic relevant medical condition in Assessment)

PLAN (20 points)

This has to be evidence- based, using the latest clinical guidelines. This should include pharmacologic, non-pharmacologic, education, referrals, and follow-up when applicable. The plan should be personalized and appropriate for the patient. The plan should address all the problems in Assessment, new and relevant chronic.

Example:

#1 acute viral bronchitis (J20.9)

• supportive care, no antibiotic therapy
• OTC Dextromethorphan/guaifenesin 10ml Q4hrs
• Follow up in 1 week if no improvement or if condition worsens, a CXR can be done to r/o pneumonia.

#2 Asthma, controlled (ex. of how you include chronic conditions in your plan)

continue inhalers as needed

DIFFERENTIAL DIAGNOSES (See Rubric) include ICD-10 Codes and Evidence- Based Rationale (20 points)

• Identify 3 considered differential diagnoses. DDx are related to the chief complaint. Include the Most LIKELY diagnosis/diagnoses in your differential. Order your differential to reflect the most likely or more serious first. Provide a brief rationale for each differential diagnosis (3-4 sentences) – rationale should provide data that support your differential diagnoses presentation, PE finding and/or lab/diagnostic test results that make it similar to the diagnosis and explain the difference between the differential and working diagnoses and/or the laboratory/diagnostic tests that would make the diagnosis. Explain what makes it likely and what makes it less likely. Cite.
• Briefly discuss the rationale of the plan. Provide clinical guidelines used to support the plan, cite.

HERE IS THE PATIENT THE NOTE IS BASED ON WITH ID# 260130190453

Pt is here today with c/o urinary symptoms.

This is a 29-year-old woman who presents with a 2-day history of dysuria, urinary frequency, and urgency. She reports a burning sensation with urination and suprapubic discomfort. She denies flank pain, fever, chills, nausea, vomiting, vaginal discharge, or hematuria. No recent history of UTIs. No concern for STI at this time.

Medications: None

PE:

Vitals: Temp 98.6F BP 116/74 HR 82 RR 16 SpO2 99% RA

General: Well appearing female, in no acute distress

Cardiac: Regular rate and rhythm. No murmurs

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-distended. Mild suprapubic tenderness. No CVA tenderness bilaterally

Impression: Acute uncomplicated urinary tract infection N39.0

Plan: Nitrofurantoin (Macrobid) 100 mg, 1 capsule PO BID x 5 days, Urine culture obtained and sent; will adjust antibiotics if indicated based on results, Increase oral fluids, Educated patient on UTI prevention measures, Advised to return to office or call for fever, flank pain, worsening symptoms, or no improvement, F/U 1 week with lab revieww.

Objective Implement research for your project

Deliverables Write a 5-6 page (not including the title and reference pages) APA-formatted paper with an introduction and conclusion APA headings for each section of the paper At least 5 peer-reviewed references

Step 1: Capstone Project Write a thorough literature review paper

Step 2: Consider Subheadings (Themes Discovered In Review) Notice Of Gaps In Knowledge At least 5 references within 5 years and peer-reviewed.

Step 3: Write Write a paper that addresses the current literature for your project. Use the template attached below.

Objective Implement research for your project

Deliverables Write a 5-6 page (not including the title and reference pages) APA-formatted paper with an introduction and conclusion APA headings for each section of the paper At least 5 peer-reviewed references

Step 1: Capstone Project Write a thorough literature review paper

Step 2: Consider Subheadings (Themes Discovered In Review) Notice Of Gaps In Knowledge At least 5 references within 5 years and peer-reviewed.

Step 3: Write Write a paper that addresses the current literature for your project. Use the template attached below.