Category: Nursing

Transcript

Started:
Mar 25, 2020 |
Total Time:
59 min

Hi Dr. Douglas, My name is Danielle. I will be your provider today

Greet

03/25/20 12:48 AM CDT

Hello.

What is the reason for you visit today?

Question

03/25/20 12:48 AM CDT

I’m here because I’ve got an awful cough, a fever, and my chest feels like I’ve been kicked by a horse. I’m sure this is some kind of upper respiratory infection. I was hoping it would go away on its own, but it hasn’t, so my husband Jeffrey convinced me to come in. As amusing as it is for Jeffrey to serve me my meals, this has gone on long enough. I need to feel better.

I’m sorry to hear that you are so uncomfortable from your symptoms. Your frequent cough sounds like it’s aggravating your already uncomfortable chest pain. You have done a great job toughing it out so far, and we’ll find a treatment plan to help you feel better.

Empathize

03/25/20 12:52 AM CDT

Thank you.

When did your symptoms start?

Question

03/25/20 12:53 AM CDT

Most of my symptoms started three days ago. I developed this nasty cough, and my nose has been all stuffed up. That’s also when the chest pain started, and when I began to feel exhausted. The fever set in last night. That was the last straw, so Jeffrey brought me in.

How often do the symptoms occur?

Question

03/25/20 12:54 AM CDT

Most of my symptoms — the hacking cough, chest pain, fatigue, achiness, stuffy nose — started three days ago. The fever started yesterday. None of it has let up since.

Where is your pain?

Question

03/25/20 12:54 AM CDT

Most of the chest pain is located in the lower right part of my chest. Aside from that, I have some general aches and muscle soreness; this is mostly a deep, dull sort of ache, but it feels more severe when I cough.

I’m sorry to hear that you’re in constant pain, and that your cough makes your pain worse. I will work on finding a therapy that will give you some relief.

Empathize

03/25/20 12:56 AM CDT

I appreciate your saying that.

Are you coughing up any mucous?

Question

03/25/20 12:58 AM CDT

I’m coughing up rust-colored sputum.

Are there any factors that make your symptoms worse? (Clarified to Does anything make your symptoms worse?.)

Question

03/25/20 12:59 AM CDT

Coughing makes this chest pain much worse. Deep breathing also seems to aggravate it, or talking too much. I also can’t move around too much . . . I’ve been staying in bed because any kind of activity makes my pain worse and leaves me exhausted. (Clarified to if anything makes my symptoms worse.)

What helps relieve your symptoms

Question

03/25/20 1:00 AM CDT

Rest has helped me feel a little better. Exerting myself in any way just makes me feel worse. Jeffrey has also been bringing me hot tea and soup. We’ve also kept my humidifier going. Other than that, I tried taking aspirin to help with my fever and chest pain, but that didn’t give me much relief.

how bad is the pain?

Question

03/25/20 1:00 AM CDT

I think that this cough is pretty severe. It brings my chest pain up from a 2 out of 10 to a 5 out of 10.

sorry to hear that

Empathize

03/25/20 1:01 AM CDT

Well, that’s very nice.

Lets talk about your past medical history (Clarified to What is your past medical history?.)

Question

03/25/20 1:01 AM CDT

I have hypertension and chronic kidney disease. stage 2. (Clarified to what health problems I have had.)

how long have you had the conditions? (Clarified to How long have you had your preexisting health problems?.)

Question

03/25/20 1:02 AM CDT

I was diagnosed with stage 2 chronic kidney disease 9 years ago, when I had some blood work done for my hypertension. I don’t know how long I had it before that, but I was diagnosed with hypertension 14 years ago, so it could have been a long time. (Clarified to how long I have had my preexisting health problems.)

any recent hospitalizations?

Question

03/25/20 1:03 AM CDT

I have not been hospitalized recently.

do you have any allergies

Question

03/25/20 1:03 AM CDT

No, I don’t have allergies.

Are you up to date on vaccines?

Question

03/25/20 1:04 AM CDT

Let me think . . . I had a flu shot about three months ago. Other than that, it’s been quite a while since I’ve needed any vaccines. I had a pneumococcal vaccine 12 years ago.

You are due for a pneumococcal vaccine, which you should receive again in your adulthood five to ten years after your first shot. These vaccines protect against the bacteria that most commonly cause pneumonia.

Educate

03/25/20 1:07 AM CDT

Alright.

What medications do you take?

Question

03/25/20 1:09 AM CDT

I take two prescription medications; a trandolapril/verapamil combo and chlorothiazide. I also take two supplements, vitamin D and calcium. And for the last three days I’ve been taking aspirin.

tell me about the trandolapril/verapamil

Question

03/25/20 1:10 AM CDT

I take my trandolapril/verapamil once a day for my stage 2 chronic kidney disease and hypertension.

how long have you taken the chlorothiazide?

Question

03/25/20 1:11 AM CDT

I have taken chlorothiazide for 14 years.

whats is the dosage of your medications?

Question

03/25/20 1:11 AM CDT

The trandolapril/verapamil combination is 2 milligrams of trandolapril and 180 milligrams of verapamil. The chlorothiazide pill is 500 milligrams. The aspirin is 325 milligrams each pill. As for the supplements: the calcium is 1200 milligrams and the vitamin D is 15 micrograms.

are you compliant with all of your medications? (Clarified to Are you compliant with your medications?.)

Question

03/25/20 1:12 AM CDT

I never miss doses of my medication. Jeffrey and I are very diligent, and the pillbox keeps track for us. (Clarified to if I am compliant with medication.)

That is great

Empathize

03/25/20 1:13 AM CDT

Thank you. I appreciate that.

what you taken any antibiotics? (Clarified to Have you taken antibiotics recently?.)

Question

03/25/20 1:13 AM CDT

I haven’t taken any antibiotics in some time . . . I honestly can’t remember when that would’ve been. (Clarified to if I have taken antibiotics recently.)

Do you drink, smoke, or use illicit substances?

Question

03/25/20 1:14 AM CDT

I’ve never used any illicit drugs.

do you exercise?

Question

03/25/20 1:15 AM CDT

I try to stay active by taking a few short walks a week. Jeffrey and I will walk around our neighborhood for about ten minutes. We try to do this two or three times a week. Unfortunately, right now all I can do is rest.

any difficulties with activities of daily living? (Clarified to Do you have trouble performing daily activities?.)

Question

03/25/20 1:16 AM CDT

I’ve been struggling a little with everything of late, but I am quite capable in general, thank you. [AUDIO COMING SOON] (Clarified to if I have trouble performing daily activities.)

tell me about your diet?

Question

03/25/20 1:16 AM CDT

In the morning, Jeffrey and I will have a piece of toast with some eggs, or maybe a fresh croissant that he picks up from the bakery around the corner. We normally eat a very light lunch — a sandwich, or some homemade soup — and for dinner we like to go out to eat a few times a week. Normally we get pasta, or a salad.

For people with hypertension and with chronic kidney disease, some foods are healthier and safer than others. It’s important to consider how your health will be affected when making everyday meal choices.

Empathize

03/25/20 1:18 AM CDT

That’s kind of you to say.

whats your family medical history

Question

03/25/20 1:20 AM CDT

My parents have both passed away. My mother was fairly healthy, but my father had hypertension. [AUDIO COMING SOON]

just want to follow up on the aspirin (No matching questions found.)

Question

03/25/20 1:20 AM CDT

How often do you take the aspirin

Question

03/25/20 1:20 AM CDT

Not normally, but since I got sick three days ago, I have been taking two aspirins three times a day. That’s a 325 milligram pill.

does it help with pain?

Educate

03/25/20 1:21 AM CDT

I’ll keep that in mind.

does it help with pain (No matching questions found.)

Question

03/25/20 1:21 AM CDT

does the aspirin relieve your pain

Question

03/25/20 1:22 AM CDT

It has done a little good, I suppose, both for my chest pain and my fever . . . I suppose it’s hard to tell, though, because I’ve been taking it since my symptoms started, so I haven’t really felt how bad my symptoms are sans aspirin. [AUDIO COMING SOON]

While it’s great that the aspirin has relieved your symptoms, it is not approved for older adults nor for people taking some of your medications. Always ask a healthcare provider before starting a new medication.

Educate

03/25/20 1:24 AM CDT

I’ll remember that.

Hi, i will educate you on the new prescription

Question

03/25/20 1:38 AM CDT

I appreciate it.

Take the medication with a full glass of water

Question

03/25/20 1:38 AM CDT

Shouldn’t be a problem.

Take the full course of medications

Question

03/25/20 1:39 AM CDT

I’ll be sure to take the whole course.

Be sure to avoid the sun

Question

03/25/20 1:39 AM CDT

I won’t be leaving my bed much anyway.

Contact your doctor if you experience rapid weight gain

Question

03/25/20 1:40 AM CDT

Alright then.

call 911 if you show signs of a severe allergic reaction

Question

03/25/20 1:40 AM CDT

I’ll have Jeffrey call 911 if that happens.

take tylenol for pain and fever

Question

03/25/20 1:41 AM CDT

Thanks for that.

guaifenesin will help with your cough

Question

03/25/20 1:41 AM CDT

Good to know.

you should start feeling better in a few days

Question

03/25/20 1:42 AM CDT

Hmm. Okay.

drink plenty of fluids

Question

03/25/20 1:42 AM CDT

I can do that. Does tea work?

yes Mrs Douglas

Question

03/25/20 1:42 AM CDT

That works for me.

THank you

Question

03/25/20 1:42 AM CDT

Alright. Thank you for all of your help today.

Education & Empathy
: 5 of 6 (83.3%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A
Model Statement
is provided as an example of an appropriate response to each opportunity.

Opportunities marked as
Not Encountered
are opportunities that were not elicited in the interview

Opportunities marked as
Not Followed Up
are missed opportunities that were present in the interview, but where no statements were made

Opportunities marked as
Followed Up
were followed up by students, and include the dialogue between student and patient

1 Urinary Pain and UTI Symptoms

Followed Up

Description:
Ms. Henderson reports discomfort with her associated urinary symptoms such as pain, cramping, burning, and feelings of increased urgency to urinate.

What brings you in today?

Question

09:47 PM CDT

I’ve had to pee a lot lately. It burns when I pee, and it looks weird. I thought it would go away on its own, but it hasn’t. So I was like, fine, I need to see someone. [AUDIO COMING SOON]

I’m sorry that you’re experiencing pain and burning during urination. I’ll try to find a medication that will help alleviate these symptoms.

Empathize

09:49 PM CDT

Thanks.

How long have you had these symptoms?

Question

09:50 PM CDT

Three days ago, I started feeling pretty bad. I kept having to pee, and each time I did, it burned. It was gross, too. The pee looked different. [AUDIO COMING SOON]

any other symptoms?

Question

09:51 PM CDT

Other than the pain and burning, I have a little bit of cramping in my lower abdomen. [AUDIO COMING SOON]

where is the pain?

Question

09:52 PM CDT

It hurts the most when I pee, right where it comes out. It’s this burning, stinging feeling.

do the urine have an odor?

Question

09:52 PM CDT

It smells really strong. It’s basically rank. It’s also, like, dark . . . cloudy.

how bad does it hurt (Clarified to: How painful is urinating?)

Question

09:53 PM CDT

It burns every time I pee and I am really not OK with how much pain I’m in. I’d call it a 7 out of 10. (Clarified to: how painful urinating is)

any factors that make it worse? (Clarified to: What aggravates the pain?)

Question

09:54 PM CDT

Well, it burns every time I pee, so peeing makes the pain worse, I guess. (Clarified to: what makes my pain worse)

what do you do to relieve the pain?

Question

09:54 PM CDT

Since it only burns and stings when I pee, I thought maybe it would hurt less if I didn’t pee so much. I tried drinking less water, but I’m not sure how much good it’s doing.

I know that you tried to alleviate your symptoms by not drinking fluids; you should try to stay hydrated by drinking more water and avoiding drinks that irritate the bladder such as soda coffee or alcohol

Educate

09:59 PM CDT

Yeah, OK.

Model Statement:
“I’m sorry that you’re experiencing pain and burning during urination and an increased sense of urgency. I’ll try to find a medication that will help alleviate these symptoms.”

2 Breast Cancer

Followed Up

Description:
Ms. Henderson discloses that her mother is a breast cancer survivor.

any family history of illness

Question

10:20 PM CDT

My dad’s really healthy. My mom’s a breast cancer survivor. She’s fine now, though. Totally cancer free. My Nana — that’s my Mom’s mom — died of it, though.

I’m sorry that your mother had breast cancer. That must have been a difficult thing for your family to go through. I’m glad that she is OK and that you and your sister are are not at risk

Empathize

10:23 PM CDT

OK.

Model Statement:
“I’m sorry that your mother had breast cancer. That must have been a difficult thing for your family to go through. I’m glad that she is OK and that you and your sister are not at risk.”

3 Hydration

Not Followed Up

Description:
Ms. Henderson reports that she avoided drinking fluids in order to alleviate her pain, burning, and increased urinary urgency.

do you drink

Question

10:15 PM CDT

I usually drink one or two nights a week, depending on if there’s good parties or not. But I never have more than a drink or two. Gotta keep my brain right so I can take over the world.

do you practice safe sex

Question

10:16 PM CDT

Model Statement:
“I know that you tried to alleviate your symptoms by not drinking fluids; you should try to stay hydrated by drinking more water and avoiding drinks that irritate the bladder such as soda, coffee, or alcoholic beverages.”

4 Urinating After Intercourse

Followed Up

Description:
Ms. Henderson reports that she does not have any post-intercourse habits, such as urinating after intercourse.

do you urinate after sex?

Question

10:03 PM CDT

Oh . . . I guess I didn’t know you were supposed to.

Urinating after sex helps lower the risk of UTIs by clearing the urinary tract of any bacteria. Making this a regular habit might decrease your chances of getting a UTI again in the future

Educate

10:05 PM CDT

Hm. Alright.

Model Statement:
“Urinating after intercourse helps lower the risk of UTIs by clearing the urinary tract of any bacteria. Making this a regular habit might decrease your chances of getting a UTI again in the future.”

5 Safe Sex

Followed Up

Description:
Ms. Henderson reports that she is sexually active.

do you practice safe sex

Question

10:16 PM CDT

Uh, I always use protection. I take birth control and I use those spermicidal condoms.

good, practice sex safe with partners of all genders in order to minimize the risk of STIs

Educate

10:17 PM CDT

Thanks for the info.

Model Statement:
“Practice safe sex with partners of all genders in order to minimize the risk of STIs.”

6 Cranberry Pills

Followed Up

Description:
Ms. Henderson reports she took cranberry pills to treat her UTI.

do you take any other medications

Question

10:10 PM CDT

I don’t know if it qualifies as medication, but I took some cranberry supplements cause apparently they help with UTIs, which I figured I had when my pee started burning.

do you cranberry pills help (Clarified to: Are the cranberry pills effective?)

Question

10:10 PM CDT

I don’t know . . . I’ve heard you’re supposed to take them for UTIs, but it’s been three days and nothing’s gotten better. And I even took two at a time. I don’t know the dosage, but regardless, you’d think they’d be doing something. (Clarified to: if the cranberry pills are effective)

Cranberry pills aren’t an effective treatment against UTIs. In the future when you notice these symptoms contact a healthcare provider sooner so that you can receive medication that will be more effective treatment

Educate

10:13 PM CDT

Thank you. That makes sense.

Model Statement:
“Cranberry pills aren’t an effective treatment against UTIs. In the future when you notice these symptoms contact a healthcare provider sooner so that you can receive medication that will be more effective treatment.”

Assignment: The Impact of Nursing Informatics on Patient Outcomes and Patient Care Efficiencies

In the Discussion for this module, you considered the interaction of nurse informaticists with other specialists to ensure successful care. How is that success determined?

Patient outcomes and the fulfillment of care goals is one of the major ways that healthcare success is measured. Measuring patient outcomes results in the generation of data that can be used to improve results. Nursing informatics can have a significant part in this process and can help to improve outcomes by improving processes, identifying at-risk patients, and enhancing efficiency.

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.

The Assignment: (4-5 pages)

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.

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.

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.

By Day 7 of Week 3

Submit your completed Project Proposal.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK3Assgn+last name+first initial.(extension)” as the name.

Click the 
Week 3 Assignment Rubric 
to review the Grading Criteria for the Assignment.

Click the 
Week 3 Assignment 
link. You will also be able to “View Rubric” for grading criteria from this area.

Next, from the Attach File area, click on the 
Browse My Computer
 button. Find the document you saved as “WK3Assgn+last name+first initial.(extension)” and click 
Open
.

If applicable: From the Plagiarism Tools area, click the checkbox for 
I agree to submit my paper(s) to the Global Reference Database
.

Click on the 
Submit
 button to complete your submission.

Due to the nature of this assignment, your instructor may require more than 5 days to provide you with quality feedback.

 

NURS_5051_Module02_Week03_Assignment_Rubric

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List View

Excellent

Good

Fair

Poor

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.

·   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.

·   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.

77 
(77%)
 – 85 
(85%)

The response accurately and thoroughly describes in detail the project proposed.

The response accurately and clearly identifies the stakeholders impacted by the project proposed.

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.

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.

Includes: 3 or more peer-reviewed sources and 2 or more course resources.

68 
(68%)
 – 76 
(76%)

The response describes the project proposed.

The response identifies the stakeholders impacted by the project proposed.

The response explains the patient outcome(s) or patient-care efficiencies that the project proposed is aimed at improving, including an explanation, with some supporting evidence of how this improvement would occur.

The response identifies the technologies required to implement the project proposed with an explanation why.

The response identifies the project team (by roles) and explains how to incorporate the nurse informaticist in the project team.

Includes: 2 peer-reviewed sources and 2 course resources.

60 
(60%)
 – 67 
(67%)

The response describing the project proposed is vague or inaccurate.

The response identifying the stakeholders impacted by the project proposed is vague or inaccurate.

The response explaining the patient outcome(s) or patient-care efficiencies the project proposed is aimed at improving, including an explanation of how this improvement would occur, is vague or inaccurate, or includes little to no supporting evidence.

The response identifying the technologies required to implement the project proposed with an explanation why is vague or inaccurate.

The response identifying the project team (by roles) and an explanation of how to incorporate the nurse informaticist in the project team is vague or inaccurate.

Includes: 1 peer-reviewed sources and 1 course resources.

0 
(0%)
 – 59 
(59%)

The response describing the project proposed is vague and inaccurate, or is missing.

The response identifying the stakeholders impacted by the project proposed is vague and inaccurate, or is missing.

The response explaining the patient outcome(s) or patient-care efficiencies the project proposed is aimed at improving, including an explanation of how this improvement would occur, is vague and inaccurate, includes no supporting evidence, or is missing.

The response identifying the technologies required to implement the project proposed with an explanation why is vague and inaccurate, or is missing.

The response identifying the project team (by roles) and an explanation of how to incorporate the nurse informaticist in the project team is vague and inaccurate, or is missing.

Includes: 1 or fewer resources.

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.

5 
(5%)
 – 5 
(5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

4 
(4%)
 – 4 
(4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

3.5 
(3.5%)
 – 3.5 
(3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%- 79% of the time.

0 
(0%)
 – 3 
(3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5  (5%)  – 5  (5%) Uses correct grammar, spelling, and punctuation with no errors. 4  (4%)  – 4  (4%) Contains a few (1-2) grammar, spelling, and punctuation errors. 3.5  (3.5%)  – 3.5  (3.5%) Contains several (3-4) grammar, spelling, and punctuation errors. 0  (0%)  – 3  (3%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. 5  (5%)  – 5  (5%) Uses correct APA format with no errors. 4  (4%)  – 4  (4%) Contains a few (1-2) APA format errors. 3.5  (3.5%)  – 3.5  (3.5%) Contains several (3-4) APA format errors. 0  (0%)  – 3  (3%) Contains many (≥ 5) APA format errors. Total Points: 100

NURS_5051_Module01_Week02_Assignment_Rubric

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List View

Excellent

Good

Fair

Poor

Develop a 5- to 6-slide PowerPoint presentation that addresses the following:

·   Explain the concept of a knowledge worker.

·   Define and explain nursing informatics and highlight the role of a nurse leader as a knowledge worker.

32 
(32%)
 – 35 
(35%)

The presentation clearly and accurately explains the concept of a knowledge worker.

The presentation clearly and accurately defines and explains nursing informatics with a detailed explanation of the role of the nurse leader as a knowledge worker.

Includes: 3 or more peer-reviewed sources and 2 or more course resources.

28 
(28%)
 – 31 
(31%)

The presentation explains the concept of a knowledge worker.

The presentation defines and explains nursing informatics with an explanation of the role of the nurse leader as a knowledge worker.

Includes: 2 peer-reviewed sources and 2 course resources.

25 
(25%)
 – 27 
(27%)

The presentation inaccurately or vaguely explains the concept of a knowledge worker.

The presentation inaccurately or vaguely defines and explains nursing informatics with an inaccurate or vague explanation of the role of the nurse leader as a knowledge worker.

Includes: 1 peer-reviewed sources and 1 course resources.

0 
(0%)
 – 24 
(24%)

The presentation inaccurately and vaguely explains the concept of a knowledge worker or is missing.

The presentation inaccurately and vaguely defines and explains nursing informatics with an inaccurate and vague explanation of the role of the nurse leader as a knowledge worker or is missing.

Includes: 1 or fewer resources.

·   Develop a simple infographic to help explain these concepts.

14 
(14%)
 – 15 
(15%)

The presentation provides an accurate and detailed infographic that helps explain the concepts related to the presentation.

12 
(12%)
 – 13 
(13%)

The presentation provides an infographic that helps explain the concepts related to the presentation.

11 
(11%)
 – 11 
(11%)

The presentation provides an infographic related to the concepts of the presentation that is inaccurate or vague.

0 
(0%)
 – 10 
(10%)

The infographic provided in the presentation related to the concepts of the presentation is inaccurate and vague, or is missing.

·   Present the hypothetical scenario you originally shared in the Discussion Forum. Include your examination of the data you could use, how the data might be accessed/collected, and what knowledge might be derived from the data. Be sure to incorporate feedback received from your colleagues’ replies.

32 
(32%)
 – 35 
(35%)

The presentation clearly and thoroughly includes the hypothetical scenario originally shared in the Discussion Forum, including a detailed and accurate examination of the data used, how the data might be accessed/collected, and the knowledge that could be derived from the data.

28 
(28%)
 – 31 
(31%)

The presentation includes the hypothetical scenario originally shared in the Discussion Forum, including an accurate examination of the data used, how the data might be accessed/collected, and the knowledge that could be derived from the data.

25 
(25%)
 – 27 
(27%)

The presentation includes the hypothetical scenario originally shared in the Discussion Forum, including an examination of the data used, how the data might be accessed/collected, and the knowledge that could be derived from the data that is vague or inaccurate.

0 
(0%)
 – 24 
(24%)

The presentation includes the hypothetical scenario originally shared in the Discussion Forum, including an examination of the data used, how the data might be accessed/collected, and the knowledge that could be derived from the data that is vague and inaccurate, or is missing.

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.

5 
(5%)
 – 5 
(5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

4 
(4%)
 – 4 
(4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

3.5 
(3.5%)
 – 3.5 
(3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%- 79% of the time.

0 
(0%)
 – 3 
(3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5  (5%)  – 5  (5%) Uses correct grammar, spelling, and punctuation with no errors. 4  (4%)  – 4  (4%) Contains a few (1-2) grammar, spelling, and punctuation errors. 3.5  (3.5%)  – 3.5  (3.5%) Contains several (3-4) grammar, spelling, and punctuation errors. 0  (0%)  – 3  (3%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. 5  (5%)  – 5  (5%) Uses correct APA format with no errors. 4  (4%)  – 4  (4%) Contains a few (1-2) APA format errors. 3.5  (3.5%)  – 3.5  (3.5%) Contains several (3-4) APA format errors. 0  (0%)  – 3  (3%) Contains many (≥ 5) APA format errors. Total Points: 100

Stefankiuk, Bosacka, Wanke-Rytt & Hryniewicz (2017) reports viral pharyngitis is the most common cause of acute pharyngitis, yet over 50% of patients are being treated with antibiotics.  When a patient presents to a clinic seeking treatment for acute pharyngitis a culture can be obtained to help the provider determine the best plan of action (Mastrian & McGonigle, 2017).  In other words, getting a throat swab and performing a rapid strep test can help the provider determine if prescribing antibiotics would be adequate.  If the rapid strep test is positive than prescribing antibiotics is appropriate.  Rapid strep tests are not 100% accurate, but are able to detect the Group A streptococci (GAS) in about 90% of the time (Stefankiuk, Bosacka, Wanke-Rytt & Hryniewicz, 2017).  Chang, Chursri, Sangthong, McNeil, Hu, Du, Li, Fan, Zhou, Chongsuvivatwong & Twang (2019) states that antibiotic resistance is a health problem that continues to increase.  Within the last decade the consumption of antibiotics  has doubled which means that antibiotics once used to treat simple infections will not work(Chang et al., 2019).

References

Chang, Y., Chusri, S., Sangthong, R., McNeil, E., Hu, J., Du, W., Li, D., Fan, X., Zhou, H., Chongsuvivatwog, V., & Tang, L. (2019). Clinical pattern of antibiotic overuse and misuse in primary healthcare hospitals in southwest China. 
PLoS ONE, 14 (6)
, 1-12. Doi: 10.1371/journal.pone.0214779

Mastrian, K., & McGonigle, D. (2017). Introduction to information, information science, and information systems. In D. McGonigle & K. Mastrian (Eds.), 
Nursing Informatics and the foundation of knowledge 
(4
th
 ed.). Burlington, MA: Jones & Bartlett Learning.

Stefaniuk, E., Bosacka, K., Wanke-Rytt, M., & Hryniewicz, W. (2017). The use of rapid test QuikRead go  Strep A in bacterial pharyngotonsillitis diagnosing and therapeutic decisions
. European Journal of Clinical Microbiology & Infectious Diseases, 36(10),
 1733–1738. Doi: 10.1007/s10096-017-2986-8

 

Discussion: The Application of Data to Problem-Solving

In the modern era, there are few professions that do not to some extent rely on data. Stockbrokers rely on market data to advise clients on financial matters. Meteorologists rely on weather data to forecast weather conditions, while realtors rely on data to advise on the purchase and sale of property. In these and other cases, data not only helps solve problems, but adds to the practitioner’s and the discipline’s body of knowledge.

Of course, the nursing profession also relies heavily on data. The field of nursing informatics aims to make sure nurses have access to the appropriate date to solve healthcare problems, make decisions in the interest of patients, and add to knowledge.

In this Discussion, you will consider a scenario that would benefit from access to data and how such access could facilitate both problem-solving and knowledge formation.

To Prepare:

Reflect on the concepts of informatics and knowledge work as presented in the Resources.

Consider a hypothetical scenario based on your own healthcare practice or organization that would require or benefit from the access/collection and application of data. Your scenario may involve a patient, staff, or management problem or gap.

By Day 3 of Week 1

Post
 a description of the focus of your scenario. Describe the data that could be used and how the data might be collected and accessed. What knowledge might be derived from that data? How would a nurse leader use clinical reasoning and judgment in the formation of knowledge from this experience?

By Day 6 of Week 1

Respond
 to at least 
two
 of your colleagues
* on two different days
, asking questions to help clarify the scenario and application of data, or offering additional/alternative ideas for the application of nursing informatics principles.

*Note:
 Throughout this program, your fellow students are referred to as colleagues.

Submission and Grading Information

 

NURS_5051_Module01_Week01_Discussion_Rubric

Grid View

List View

Excellent

Good

Fair

Poor

Main Posting

45 
(45%)
 – 50 
(50%)

Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.

Supported by at least three current, credible sources.

Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

40 
(40%)
 – 44 
(44%)

Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.

At least 75% of post has exceptional depth and breadth.

Supported by at least three credible sources.

Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

35 
(35%)
 – 39 
(39%)

Responds to some of the discussion question(s).

One or two criteria are not addressed or are superficially addressed.

Is somewhat lacking reflection and critical analysis and synthesis.

Somewhat represents knowledge gained from the course readings for the module.

Post is cited with two credible sources.

Written somewhat concisely; may contain more than two spelling or grammatical errors.

Contains some APA formatting errors.

0 
(0%)
 – 34 
(34%)

Does not respond to the discussion question(s) adequately.

Lacks depth or superficially addresses criteria.

Lacks reflection and critical analysis and synthesis.

Does not represent knowledge gained from the course readings for the module.

Contains only one or no credible sources.

Not written clearly or concisely.

Contains more than two spelling or grammatical errors.

Does not adhere to current APA manual writing rules and style.

Main Post: Timeliness

10 
(10%)
 – 10 
(10%)

Posts main post by day 3.

0 
(0%)
 – 0 
(0%)

0 
(0%)
 – 0 
(0%)

0 
(0%)
 – 0 
(0%)

Does not post by day 3.

First Response

17 
(17%)
 – 18 
(18%)

Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues.

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.

15 
(15%)
 – 16 
(16%)

Response exhibits critical thinking and application to practice settings.

Communication is professional and respectful to colleagues.

Responses to faculty questions are answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

13 
(13%)
 – 14 
(14%)

Response is on topic and may have some depth.

Responses posted in the discussion may lack effective professional communication.

Responses to faculty questions are somewhat answered, if posed.

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

0 
(0%)
 – 12 
(12%)

Response may not be on topic and lacks depth.

Responses posted in the discussion lack effective professional communication.

Responses to faculty questions are missing.

No credible sources are cited.

Second Response

16 
(16%)
 – 17 
(17%)

Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues.

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.

14 
(14%)
 – 15 
(15%)

Response exhibits critical thinking and application to practice settings.

Communication is professional and respectful to colleagues.

Responses to faculty questions are answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

12 
(12%)
 – 13 
(13%)

Response is on topic and may have some depth.

Responses posted in the discussion may lack effective professional communication.

Responses to faculty questions are somewhat answered, if posed.

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

0 
(0%)
 – 11 
(11%)

Response may not be on topic and lacks depth.

Responses posted in the discussion lack effective professional communication.

Responses to faculty questions are missing.

No credible sources are cited.

Participation

5 
(5%)
 – 5 
(5%)

Meets requirements for participation by posting on three different days.

0 
(0%)
 – 0 
(0%)

0 
(0%)
 – 0 
(0%)

0 
(0%)
 – 0 
(0%)

Does not meet requirements for participation by posting on 3 different days.

Total Points: 100

Once upon a time, there was an era of paper charting and this was the norm in many health care facilities. There were using MAR and TAR  , I had an opportunity to be part of that generation where health care professionals where  locked in this system .This paper system was very stressful and it was hard to find the information needed regarding patients .Little did we all know that technology was evolving so fast and later on , Many software with EMR and ETR emerged . Now, most hospitals I work for are using Electronic Medical Records (EMR) and life is so much better. Since the implementation of EMR, access to critical information or data has been faster and more convenient for all health care professionals.

In the ICU where our patients are usually in a state of shock or going to it, various data collection sets are used to predict the severity of shock or if a patient is going to septic.  The use of MEWS or Modified Early Warning Score together with laboratory data has provided many hospital units to prevent delay in interventions of critically ill patients (Gardner-Thorpe et al., 2006). My current hospital integrated MEWS with our EPIC EMR which triggers or flags nurses to pay more attention to warning signs of sepsis or shock. The nurses will then contact the Rapid Response nurses to evaluate the patient and interventions are made to prevent further decline in health.

Without the integration of data as a useful source of information to drive nursing interventions, it would take nurses and other health care providers some time to gather information and formulate a solution. With our EPIC system, which is maintained by the Information Systems department, led by a Nursing Informatics graduate, the digital solution to electronic records and retrieval is modeled on the nursing science. McGonigle and Mastrian enumerated the foundations of nursing informatics being knowledge acquisition, generation, dissemination, processing and feedback (2018). These processes drive the current nursing practice model to that of information systems.

Access to a vast collection of data about any medical issues has also been integrated into our EPIC. Medline and Micromedex for drugs are excellent resources that enable the nurses to administer correct medications and know the side effects of each medication that are not familiar to them (Flynn, 2001). As we can see, technology has come a long way to help as a tool for health care professionals to work effectively and safely. 

 

References

 

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

 

 

Gardner-Thorpe, J., Love, N., Wrightson, J., Walsh, S., & Keeling, N. (2006). The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study. Annals of the Royal College of Surgeons of England, 88(6), 571-5.

 

Flynn, M. B. (2001). Nursing and informatics: Implications for critical care practice. Critical Care Nurse, 21(4), 8-8, 10, 14, 16. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search-proquest-com.ezp.waldenulibrary.org/docview/228169558?accountid=14872

Levels of Measurement and nurses shortage Discussion Essay

From the research question, the dependent variable is “shortage of nurses” while the independent variables are the “factors that contribute to the shortage of nurses”. The dependent variable refers to the variable being measured or tested. In this case, the “shortage of nurses” is what is being tested. On the other hand, the independent variable is the variable that is directly affecting the dependent variable (Flannelly et al., 2014). The “factors that contribute to the shortage of nurses” are the variables that will have a direct effect on the shortage of nurses.

The level of measurement for the dependent variable (shortage of nurses) is a nominal level. This is because this variable does not…

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This week you will be writing an APA paper to include level headings and a reference page.

Discuss and explain King’s Conceptual System Theory.

First explain the 3 systems and provide examples of each system

Explain how the systems influence goal attainment

How could King’s theory help define a clinical quality problem?

Apply this theory to a potential practice quality improvement initiative within your clinical practice.

How could a quality committee align outcomes with King’s Conceptual System Theory? 
Levels of Measurement and nurses shortage Discussion Essay

What additional nursing theory could also align with an improved quality of practice initiative?

 

Discussion 1: Levels of Measurement

Research Question

“What are the factors that contribute to the shortage of nurses in healthcare facilities?”

From the research question, the dependent variable is “shortage of nurses” while the independent variables are the “factors that contribute to the shortage of nurses”. The dependent variable refers to the variable being measured or tested. In this case, the “shortage of nurses” is what is being tested. On the other hand, the independent variable is the variable that is directly affecting the dependent variable (Flannelly et al., 2014). The “factors that contribute to the shortage of nurses” are the variables that will have a direct effect on the shortage of nurses. Levels of Measurement and nurses shortage Discussion Essay.

The level of measurement for the dependent variable (shortage of nurses) is a nominal level. This is because this variable does not require any ordering among the responses (Marateb et al., 2014). This variable will just be categorized. On the other hand, the level of measurement for the independent variables, in this case, would be the
ordinal level of measurement. This measurement level illustrates some methodical
connections among the observations of the variables (Marateb et al., 2014). In this study, the researcher may wish to measure the impact of the factors that cause a shortage of nurses and thus may ask the respondents to indicate their feelings as either “low, medium, high, or very high”. These items are ordered and they range from the lowest to the highest. This level of measurement will enable comparisons on the factors that affect the shortage of nurses, dependent on the factors with the most significant impact.

When analyzing data related to each variable based on its level of measurement, it will be important to consider the technique that will be used in data analysis. Measuring the relationship between various variables requires different types of data analysis techniques (Kaliyadan & Kulkarni, 2019). For example, from the research question, correlation analysis will help in determining the relationship between the variables in the study. For example, a correlational analysis will determine how specific factors affect nursing shortage within healthcare organizations. Regression analysis may also be used to assess the strength of the relationship between the variables (Simpson, 2015). In this case, the regression analysis may be used to identify the factors that have the strongest impact on the nursing shortage in healthcare organizations. Levels of Measurement and nurses shortage Discussion Essay. It will also be important to take into consideration the number of categories in each variable. For example, factors that affect nursing shortage may have too many categories and thus may require the data to be presented in a using presentation that provides meaningful information. It will also be important to consider that each measurement level gives a different degree of detail (Simpson, 2015).  For example, the nominal level of measurement does not provide much detail and therefore this may present the challenge of having inadequate data during data analysis.

 

 

References

Flannelly, L. T., Flannelly, K. J., & Jankowski, K. R. (2014). Independent, dependent, and other variables in healthcare and chaplaincy research.
Journal of health care chaplaincy
,
20
(4), 161-170.

Kaliyadan, F., & Kulkarni, V. (2019). Types of Variables, Descriptive Statistics, and Sample Size.
Indian dermatology online journal
,
10
(1), 82–86.

Marateb, H. R., Mansourian, M., Adibi, P., & Farina, D. (2014). Manipulating measurement scales in medical statistical analysis and data mining: A review of methodologies.
Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences
,
19
(1), 47–56.

Simpson S. H. (2015). Creating a Data Analysis Plan: What to Consider When Choosing Statistics for a Study.
The Canadian journal of hospital pharmacy
,
68
(4), 311–317. Levels of Measurement and nurses shortage Discussion Essay

 

 

Nursing shortage

The Healthcare sector is one of the delicate sectors in any country all over the world. Nursing is among the critics and the most significant part of the healthcare profession. According to reports and research did it is estimated there are about 29 million nurses and midwives all over the world, while 3.9 of them are from the United States. With the increase in chronic disease and new infections and viruses like the COVID 19 that has affected the healthcare sector, more nurses are in demand. According to experts, it is estimated that by 2020 1 million nurses will be required because of the shortages of nurses in the healthcare facilities. According to the reports from the American nurses association, it has been predicted that there will be more registered nurse vacancies available than any other profession in America in the year 2020. Levels of Measurement and nurses shortage Discussion Essay

Shortages of nurses in the healthcare facilities have negatively impacted on the quality of healthcare patients receive. For example, the development of COVID 19 has affected how patients receive healthcare information because there are fewer nurses to take care of the significant number of patients visiting healthcare facilities. The ratio of nurses to patients is alarming because the country still needs more nurses who will help in providing quality healthcare services to patients.  The shortage of nurses forces the few nurses in healthcare facilities to work more hours to provide care. This can be tiresome to nurses because they work more hours than they are supposed to work, which results in to decrease in service production because of fatigue and tiresomeness. If nurses work more hours without better pay, then this might end up affecting the quality of services to patients and even resulting in turnovers.  The following are some of the significant causes of shortages of nurses in healthcare facilities;

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More salaries for educators and low wages for clinicians

Inability to fill open faculty role

Looming retirement of a large number of employees nurses

Levels of Measurement and nurses shortage Discussion Essay

Late point career development to enter into educative roles.

The age-delayed trajectory of nurses who get higher education levels.

Hospital acuity

Aging workforce

Aging population

Work and workload environment

The research on the shortage of nurses in healthcare facilities is fundamental because it helps to identify the problems nurses are facing. Nurses have to work in a stressful environment just because of the shortage of nurses in the country. This can end up causing fatigue to nurses, job dissatisfaction, and even injury because of fatigue.  The hardship environment the nurses’are subjected to because of a shortage of nurses can result in nurses making a medical error or making mistakes because of fatigue.

The research on nursing shortage on hospitals and health facilities will bring light to the government by showing how the nurses’suffered at the places of work. The process will be a campaign for improving the professional image and making it a profession that many people want. The research will help to enhance the business by ensuring nurses get better education and training so that they can deliver quality services to patients. The introduction of new nurses will cause a reduction of crowding because there will be an excellent nurse to patient ration. This will help to improve social interaction and how patients receive healthcare services. Levels of Measurement and nurses shortage Discussion Essay

 

References

Haddad, L. M., Annamaraju, P., & Toney-Butler, T. J. (2020). Nursing shortage. In 
StatPearls [Internet]
. StatPearls Publishing.

Shukri, R. (2020). Environmental Pressure, Nursing Shortage, Future Size, Shape, and Purpose of Sultanate of Oman’s Nursing Workforce. Levels of Measurement and nurses shortage Discussion Essay

Education & Empathy : 3 of 7 (42.9%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

Opportunities marked as Not Encountered are opportunities that were not elicited in the interview

Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made

Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

1 Treatment Inefficacy

Not Followed Up

Description: Mr. Bailey reports that some of his attempted pain treatments have proven ineffective, causing him suffering and exasperation.

This is your avatar.

Did you go to the hospital

Question

03:41 PM CDT

Tanner Bailey

I went to the hospital when I hurt myself picking up that box thirteen weeks ago. They looked me over but they couldn’t figure out what kind of back injury I had.

This is your avatar.

Did the hospital recommend anything

Question

03:41 PM CDT

Tanner Bailey

All they did was tell me to take ibuprofen and do physical therapy. They couldn’t even tell me what was wrong, even after an MRI. It turned up nothing.

This is your avatar.

What did the hospital diagnose you with

Question

03:42 PM CDT

Tanner Bailey

The ER did an MRI, but they can’t tell me what’s actually wrong with my back. My coworker drove me all the way out to the hospital the day I hurt myself, and there’s not a whole lot to show for it.

This is your avatar.

Have your pain levels changed since your injury

Question

03:44 PM CDT

Model Statement: “I’m sorry that it’s been so difficult to find a proper treatment plan for your pain and that you haven’t always received enough relief. We’re going to figure out how best to treat your pain quickly and effectively.”

2 Chronic Back Pain

Followed Up

Description: Mr. Bailey reports severe back pain that has debilitated and frustrated him for many weeks.

This is your avatar.

What brings you in today

Question

03:35 PM CDT

Tanner Bailey

I picked up this heavy box at work–with like, sound equipment and stuff in it–and ever since then, the pain in my lower back has been killing me. I think I need to be on opioids or something.

This is your avatar.

I am sorry your back has continued to hurt so severely for so long, We’re going to determine the best plan of action to ease your pain

Empathize

03:38 PM CDT

Tanner Bailey

Hey, thanks.

This is your avatar.

Have your pain levels changed since your injury

Question

03:44 PM CDT

Tanner Bailey

My back pain hasn’t gotten better at all. I feel like I’ve been in pain forever. I need it to stop.

This is your avatar.

When does your pain occur

Question

03:45 PM CDT

Tanner Bailey

The pain starts when I wake up in the morning. It does fade away for a little bit during the day, but it’s not a reliable thing and it always comes back.

This is your avatar.

I’m sorry that it’s been so difficult to find a proper treatment plan for your pain and that you haven’t always received enough relief. We’re going to figure out how best to treat your pain quickly and effectively.

Empathize

03:48 PM CDT

Tanner Bailey

I appreciate your saying that.

This is your avatar.

Do you take opioids

Question

03:56 PM CDT

Tanner Bailey

I was taking them, but I’m out. It was my first time trying them, and I had my last one this morning. My friend only had a week’s worth after his surgery, so now I’m here for a prescription. My back hurts too much to wait it out.

This is your avatar.

While the medication your friend gave you was effective for pain relief and even though he no longer needed it you should only take prescriptions that a healthcare provider can safely endorse and oversee

Educate

03:57 PM CDT

Tanner Bailey

Yeah, I guess that makes sense.

Model Statement: “I’m sorry your back has continued to hurt so severely for so long. We’re going to determine the best plan of action to ease your pain.”

3 Prescription Borrowing

Followed Up

Description: Mr. Bailey reports taking leftover pain medication given to him by a friend after his friend’s surgery.

This is your avatar.

Do you take opioids

Question

03:56 PM CDT

Tanner Bailey

I was taking them, but I’m out. It was my first time trying them, and I had my last one this morning. My friend only had a week’s worth after his surgery, so now I’m here for a prescription. My back hurts too much to wait it out.

This is your avatar.

While the medication your friend gave you was effective for pain relief and even though he no longer needed it you should only take prescriptions that a healthcare provider can safely endorse and oversee

Educate

03:57 PM CDT

Tanner Bailey

Yeah, I guess that makes sense.

Model Statement: “While the medication your friend gave you was effective for pain relief, and even though he no longer needed it, you should only take prescriptions that a healthcare provider can safely endorse and oversee.”

4 Prescription vs Over the Counter

Followed Up

Description: Mr. Bailey reports not filling an ibuprofen prescription so as to avoid the hassle of going through the pharmacy, and instead, he purchased and used over-the-counter ibuprofen.

This is your avatar.

Was it over the counter (Clarified to: Did you take ibuprofen that was just over the counter?)

Question

03:58 PM CDT

Tanner Bailey

The hospital prescribed me ibuprofen, but I just bought some over the counter — prescriptions are such a hassle to fill and pick up and all that. Figured it’d be easier. (Clarified to: If the ibuprofen was over the counter)

This is your avatar.

Prescription and over-the-counter medications are not always identical. you should always fill your prescription instead of buying them over the counter and always take your medication as prescribed

Educate

04:00 PM CDT

Tanner Bailey

Thank you. One more thing to think about, huh?

Model Statement: “Prescription and over the counter medications are not always identical. You should always fill your prescription instead of buying them over the counter, and always take your medications as prescribed.”

5 Dangers of Opioids

Not Followed Up

Description: Mr. Bailey reports taking opioids to treat his back pain.

This is your avatar.

Does anything relieve the pain

Question

03:52 PM CDT

Tanner Bailey

Sometimes just shifting around–changing the way I’m sitting or lying–can help a little. Rest helps a little bit, too. Drinking kind of worked, but I did have to go up to three drinks a day. Ibuprofen didn’t work at all, but these opioids I tried–hydrocodone and acetaminophen–they actually stopped the pain.

This is your avatar.

Do you have any type of allergies (Clarified to: What allergies do you have?)

Question

03:54 PM CDT

Tanner Bailey

I don’t have allergies. (Clarified to: what allergies I have)

This is your avatar.

Can you tell me about your family history

Question

03:55 PM CDT

Tanner Bailey

My mom’s has depression. She’s also an alcoholic. My dad’s pretty healthy.

Model Statement: “Though it’s good that opioids have proven effective for you for pain relief, and that they could be again, they are addictive and dangerous. You should only take them if a healthcare provider determines it is a safe and logical option.”

6 Physical Activity

Not Followed Up

Description: Mr. Bailey reports that besides shifting positions while resting, and besides at-home exercises he tried that only exacerbated his pain, he has gone without physical activity due to wanting to rest.

This is your avatar.

Does exertion make your pain worse

Question

03:50 PM CDT

Tanner Bailey

The pain is worst when I’m doing something. Walking, lifting, bending over. It makes it hard enough to move I can’t even go to the physical therapist like the ER doctors wanted. I tried some exercises at home and they just hurt too much.

This is your avatar.

Does exercise make your pain worse

Question

03:50 PM CDT

Tanner Bailey

I can’t exercise. Which just stinks. I used to lift weights and do cardio three times a week. Now, every little thing hurts. I can’t bend or lift stuff, and even walking is just so painful. I tried some PT exercises for my back at home, but it just hurt so much.

This is your avatar.

What is the pain like

Question

03:51 PM CDT

Model Statement: “While it’s great that shifting your position can lessen your back pain, remaining otherwise sedentary can actually increase it. You may feel better by taking slow, short-paced walks, stretching, or trying specific exercises. Despite the pain involved, physical therapy could also be an effective healing tool.”

7 Alcohol Use

Not Followed Up

Description: Mr. Bailey reports drinking alcohol to dull his back pain.

This is your avatar.

Has your alcohol consumption endangered you

Question

04:04 PM CDT

Tanner Bailey

If you mean like, drinking at work or something, no, I’d never. I’ve just been at home.

This is your avatar.

Can I examine your back

Question

04:05 PM CDT

Tanner Bailey

Have at it. [AUDIO COMING SOON]

This is your avatar.

thank you

Question

04:05 PM CDT

Tanner Bailey

You’re welcome.

Tanner Bailey

Alright, let’s do it.

Tanner Bailey

Thanks for the tip.

Tanner Bailey

Got it.

Tanner Bailey

Fine by me.

Tanner Bailey

Aw, man. No more whiskey?

Tanner Bailey

I get it, but just so you know, you’re asking a lot of me.

Tanner Bailey

That sounds awful. Is this stuff really safe to take?

Tanner Bailey

I guess it’s worth the risk. I mean, I’ve got to do something.

Tanner Bailey

But it hurt so bad. That can’t be good for my back, can it?

Tanner Bailey

Alright . . . guess I gotta work through the pain a little bit.

Tanner Bailey

I mean, I know you’re not supposed to . . . but it did work a lot better than the ibuprofen.

Tanner Bailey

Okay, okay. I understand. Really. I knew it wasn’t a good idea . . . I just couldn’t find anything that worked. This time will be better.

Tanner Bailey

Thanks. You have a good one.

Model Statement: “Though alcohol has been effective for you as a back pain reliever, it’s a dangerous substance that could damage your health and behaviors. We will work to find you a treatment plan whose risks can be minimized and overseen.”

Subjective Data Collection: 25 of 25 (100.0%)

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Pro Tips
and
Example Questions
.

Found:

Indicates an item that you found.

Available:

Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

Finding:

Established chief complaint and reason for admittance

Finding:

Reports chronic lower back pain resulting from work injury

(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

What is your chief complaint?

Finding:

Reports wanting a prescription for opioids

(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

What is your chief complaint?

History of Present Illness

Finding:

Asked about onset of injury

Finding:

Reports sustaining injury thirteen weeks ago

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

When did the pain start?

Finding:

Reports injury occurred after lifting a heavy box

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

When did the pain start?

Finding:

Reports pain onset immediately after injury

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

When did the pain start?

Finding:

Reports being driven to hospital immediately after injury

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Did you go to the hospital?

Finding:

Followed up on hospitalization

Finding:

Reports hospital exams could not diagnose the type of back injury

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What did the hospital diagnose you with?

Finding:

Reports hospital prescribed ibuprofen

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Did the hospital prescribe you anything?

Finding:

Reports being told at the hospital to attend physical therapy

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Did the hospital recommend anything?

Finding:

Asked about frequency, duration, and timing of pain

Finding:

Reports back injury and pain have not healed since onset

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Have your pain levels changed since your injury?

Finding:

Reports pain fluctuates in and out throughout the day at irregular intervals

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

When does the pain occur?

Finding:

Asked about additional symptoms of injury

Finding:

Denies additional symptoms

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What other symptoms do you have?

Finding:

Asked about aggravating factors of pain

Finding:

Reports exertion such as walking, bending, or lifting aggravate pain

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does exertion make your pain worse?

Finding:

Reports at-home physical therapy exercises aggravated pain, discouraging attendence of physical therapy

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does exercise make your pain worse?

Finding:

Asked about nonmedicational treatment and relieving factors of pain

Finding:

Reports drinking alcohol relieves pain

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does drinking alcohol relieve your pain?

Finding:

Reports shifting positions when sitting or lying down can slightly relieve pain

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does shifting positions relieve your pain?

Finding:

Reports resting slightly relieves pain

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does resting relieve your pain?

Finding:

Denies trying heat or ice packs

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Have you tried heat packs?

Finding:

Asked about characteristics of pain

Finding:

Descibes pain as usually sharp and burning

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What is the pain like?

Finding:

Describes pain as occasionally tingling

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What is the pain like?

Finding:

Asked about severity of pain

Finding:

Reports sometimes pain is not present or low, or 0-2

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How much pain are you in?

Finding:

Reports sometimes pain is moderate to severe, or 4-7

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How much pain are you in?

Past Medical History

Finding:

Asked about other existing health conditions

Finding:

Denies other health problems

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

What other health problems do you have?

Finding:

Asked about history of mental health

Finding:

Denies mental health disorders

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have a history of psychiatric illness?

Finding:

Asked about allergies

Finding:

Denies allergies

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have any allergies?

Family Medical History

Finding:

Asked about relevant family medical history

Finding:

Reports mother has depression and is an alcoholic

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Can you tell me about your family history?

Home Medications

Finding:

Asked about gender-affirming medications

Finding:

Reports currently taking testosterone enanthate for gender-affirmation therapy

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Are you currently taking testosterone?

Finding:

Asked about home medications for injury

Finding:

Reports previously taking ibuprofen for back pain

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take ibuprofen?

Finding:

Reports previously taking opioid analgesics for back pain

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take opioids?

Finding:

Followed up on testosterone therapy

Finding:

Reports testosterone is in injection form

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What form is your testosterone in?

Finding:

Reports dosage is 100 milligrams per week

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What dosage is your testosterone?

Finding:

Reports having taken testosterone for two years

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How long have you taken testosterone?

Finding:

Reports most recent dose of testosterone was yesterday

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

When was your last dose of testosterone?

Finding:

Followed up on ibuprofen

Finding:

Reports buying over-the-counter ibuprofen to avoid the hassle of filling a prescription

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Did you fill your prescription?

Finding:

Reports having taken two 200 milligram ibuprofen pills at a time

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How much ibuprofen did you take?

Finding:

Reports having taken ibuprofen every four hours

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How often did you take ibuprofen?

Finding:

Reports ibuprofen was ineffective as an analgesic

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Did ibuprofen help the pain?

Finding:

Followed up on opioid analgesic

Finding:

Reports having been given opioids leftover from his friend’s surgery

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Where did you obtain opioids?

Finding:

Reports the opioids were a combination of 325 milligrams acetaminophen and 5 milligrams hydrocodone

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What dose of opioids did you take?

Finding:

Reports having taken the opioids twice daily, morning and night

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How often did you take the opioids?

Finding:

Reports the opioids were effective as an analgesic

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Did opioids help the pain?

Finding:

Denies being dependent on opioids

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Are you dependent on opioids?

Finding:

Asked about medication timeline

Finding:

Reports having started ibuprofen 13 weeks ago just after hospitalization and stopping 11 weeks ago

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What period of time did you take ibuprofen?

Finding:

Reports stopping ibuprofen 11 weeks ago to more safely use alcohol as a stronger analgesic

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

When did you stop taking ibuprofen?

Finding:

Reports stopping alcohol use 1 week ago to more safely use opioids as a stronger analgesic

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

When did you stop drinking alcohol?

Finding:

Reports having taken the opioids for a week until running out this morning

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What period of time did you take the opioids?

Finding:

Asked about medication regimen adherence

Finding:

Denies missing doses

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you miss doses of your medication?

Social History

Finding:

Asked about income level

Finding:

Reports steady but low income as a theatre director

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What level of income do you make?

Finding:

Asked about gender identity

Finding:

Reports transgender (female to male) identity

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What gender do you identify as?

Finding:

Reports wearing a chest binder to masculinize appearance

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What do you do to masculizine your appearance?

Finding:

Asked about substance use

Finding:

Reports using alcohol

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you drink alcohol?

Finding:

Denies using illicit drugs

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Have you ever used illicit substances?

Finding:

Denies using nicotine or tobacco

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Have you ever used nicotine products?

Finding:

Followed up on alcohol use

Finding:

Reports increasing alcohol use for its slight efficacy as an analgesic

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

How often did you drink alcohol before your injury?

Finding:

Reports drinking 1-2 servings of alcohol a month before injury

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

How often did you drink alcohol before your injury?

Finding:

Reports now drinking 3 servings of alcohol a day

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

How many servings of alcohol do you have a day?

Finding:

Reports spreading alcohol servings throughout the day

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

When in the day do you drink?

Finding:

Denies adverse effects of alcohol

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you have adverse effects from alcohol use?

Finding:

Denies dependency on alcohol

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Are you dependent on alcohol?

Finding:

Asked about intoxication during risky activities

Finding:

Denies intoxication during risky activities

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Has your alcohol consumption endangered you?

Comments

Case Study

Introduction

The symptoms present in patients experiencing gastrointestinal (GI) conditions are often non-specific, and it is important for care providers to conduct an extensive assessment to identify the underlying cause of the presentations. This process is further complicated by the fact that GI manifestations can occur on the background of diseases involving other systems. For example, patients with serious migraines frequently present with vomiting and nausea (Elliot et al., 2018). Hence, assessment of GI symptoms should be thoroughly performed on all system for both an accurate diagnosis and the appropriate therapeutic intervention. The paper will assess a case study involving GI manifestations, establish a diagnosis and rationale, and a treatment plan for the patient.

The case presents a patient with nausea, vomiting, and diarrhea, which are non-specific gastrointestinal symptoms. The patient has a confirmed history of drug abuse and suspected hepatitis C. However, the latter can only be placed as a diagnosis following a polymerase chain reaction (PCR) that identifies HCV RNA in the serum (Altaf et al., 2019; Ferri et al., 2016). Therefore, based on the medication history, the patient is suspected to be experiencing complications from the use of prednisone.

The side effects of prednisone on the GI tract have been well documented in scholarly literature due to their use in the management of different conditions. For example, patients that have been prescribed this drug have been found to have an elevated production of gastric acid within one month (Resanen, 2016). Furthermore, corticosteroids adversely impact the gastric mucosa, which further increases the risk of gastritis or gastric ulcers. These phenomena can be better understood through the mechanism of action of prednisone. This involves inhibition of phospholipid conversion to arachidonic acid, which stops prostaglandin production and its gastro protective functions (Caplan et al., 2017). This makes the gastric wall susceptible to the physiologically acidic pH of the stomach, leading to the manifestations displayed by the patient.

The general principles applied to minimize the side effects from oral glucocorticoids include a reassessment of their use and necessity for the patient, reducing the duration of use, and providing mucosal protective agents such as bismuth subsalicylate or sulcrafate. These agents help in coating areas of ulcers or erosion and preventing further damage from gastric acid. In the case of this patient bismuth subsalicylate will be selected agent as it also contributes to stimulating the secretion of mucus, prostaglandin, and bicarbonate (O’Malley, 2020). Patient education will also be provided, and include information on diet and different products that should be avoided while taking prednisone. Spicy and fried foods are not recommended, and smoking and alcohol should also be avoided as they irritate the gastric mucosa. The patient has a history of drug abuse, which makes education on abstaining from alcohol important as this can lead to ulcers, and gastric perforation, which is life threatening.

Summary

The paper discusses a patient that reports with non-specific gastrointestinal manifestations, a history of drug abuse, and currently synthroid, nifedipine, and prednisone. The preliminary diagnosis of the patient is gastritis on the background of prednisone use. This is a glucocorticoid, which affects the gastric mucosa through inhibition of prostaglandins. The drug bismuth subsalicylate was prescribed due to its mucosal protective properties. Other recommendations such as patient dietary education were also stated as certain food products can also affect the state of the mucosa and cause the existing manifestations to persist or lead to more life threatening situations.

 

 

 

References

Altaf, S., Tarar, A., & Naeem, N. (2019). Current Status of Therapeutics and Diagnosis of

HCV. 
BioScientific Review (BSR)
, 
1
(2), 01-12.

Caplan, A., Fett, N., Rosenbach, M., Werth, V. P., & Micheletti, R. G. (2017). Prevention and

management of glucocorticoid-induced side effects: a comprehensive review: a review of glucocorticoid pharmacology and bone health. 
Journal of the American Academy of Dermatology
, 
76
(1), 1-9.

Elliot, S. Y., SS, Y. P., & Venkatesan, T. (2018). Migraine, cyclic vomiting syndrome, and

other gastrointestinal disorders. 
Current treatment options in gastroenterology
, 
16
(4), 511-527.

Ferri, C., Ramos-Casals, M., Zignego, A. L., Arcaini, L., Roccatello, D., Antonelli, A., … &

Lamprecht, P. (2016). International diagnostic guidelines for patients with HCV-related extrahepatic manifestations. A multidisciplinary expert statement. 
Autoimmunity reviews
, 
15
(12), 1145-1160.

O’Malley, P. A. (2020). Pink Prescribing: Bismuth Subsalicylate; History, Actions, Risks,

and Future Use. 
Clinical Nurse Specialist
, 
34
(2), 45-47.

Rasanen, T. O. I. M. I. (2016). Some aspects of the humoral mechanism of gastric

secretion. 
Gastric Secretion, Mechanism and Control
, 255.

Assignment: Pharmacotherapy for Gastrointestinal and Hepatobiliary Disorders

Photo Credit: Getty Images/iStockphoto

Gastrointestinal (GI) and hepatobiliary disorders affect the structure and function of the GI tract. Many of these disorders often have similar symptoms, such as abdominal pain, cramping, constipation, nausea, bloating, and fatigue. Since multiple disorders can be tied to the same symptoms, it is important for advanced practice nurses to carefully evaluate patients and prescribe a treatment that targets the cause rather than the symptom.

Once the underlying cause is identified, an appropriate drug therapy plan can be recommended based on medical history and individual patient factors. In this Assignment, you examine a case study of a patient who presents with symptoms of a possible GI/hepatobiliary disorder, and you design an appropriate drug therapy plan.

To Prepare

Review the case study assigned by your Instructor for this Assignment

Reflect on the patient’s symptoms, medical history, and drugs currently prescribed.

Think about a possible diagnosis for the patient. Consider whether the patient has a disorder related to the gastrointestinal and hepatobiliary system or whether the symptoms are the result of a disorder from another system or other factors, such as pregnancy, drugs, or a psychological disorder.

Consider an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.

By Day 7 of Week 4

Write
a 1-page paper that addresses the following:

Explain your diagnosis for the patient, including your rationale for the diagnosis.

Describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.

Justify why you would recommend this drug therapy plan for this patient. Be specific and provide examples.

Reminder:
The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center offers an example of those required elements (available at
http://writingcenter.waldenu.edu/57.htm
). All papers submitted must use this formatting.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK4Assgn+last name+first initial.(extension)” as the name.

Click the 
Week 4 Assignment Rubric 
to review the Grading Criteria for the Assignment.

Click the 
Week 4 Assignment 
link. You will also be able to “View Rubric” for grading criteria from this area.

Next, from the Attach File area, click on the 
Browse My Computer
 button. Find the document you saved as “WK4Assgn+last name+first initial.(extension)” and click 
Open
.

If applicable: From the Plagiarism Tools area, click the checkbox for 
I agree to submit my paper(s) to the Global Reference Database
.

Click on the 
Submit
 button to complete your submission.

NURS_6521_Week4_Assignment_Rubric

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Fair

Poor

Explain your diagnosis for the patient, including your rationale for the diagnosis.

Points Range:
23
(23%)
– 25
(25%)

The response accurately and clearly explains in detail the diagnosis for the patient, including an accurate and thorough rationale for the diagnosis that supports clinical judgment.

Points Range:
20
(20%)
– 22
(22%)

The response provides a basic explanation of 1-2 diagnoses for the patient, including an accurate rationale for the diagnosis that may support clinical judgment.

Points Range:
18
(18%)
– 19
(19%)

The response inaccurately or vaguely explains the diagnosis for the patient, including an inaccurate or vague rationale for the diagnosis that may or may not support clinical judgment.

Points Range:
0
(0%)
– 17
(17%)

The response inaccurately and vaguely explains the diagnosis for the patient, including an inaccurate and vague rationale for the diagnosis that does not support clinical judgment, or is missing.

Describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.

Points Range:
27
(27%)
– 30
(30%)

The response accurately and completely describes in detail an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.

Points Range:
24
(24%)
– 26
(26%)

The response describes a basic explanation of the appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.

Points Range:
21
(21%)
– 23
(23%)

The response inaccurately or vaguely describes an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.

Points Range:
0
(0%)
– 20
(20%)

The response inaccurately and vaguely describes an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.

Justify why you would recommend this drug therapy plan for this patient. Be specific and provide examples.

Points Range:
27
(27%)
– 30
(30%)

The response provides an accurate, clear, and detailed justification for the recommended drug therapy plan for this patient.

The response includes specific, accurate, and detailed examples that fully support the justification provided.

Points Range:
24
(24%)
– 26
(26%)

The response provides a basic justification for the recommended drug therapy plan for this patient.

The response includes only 1-2 examples that fully support the justification provided.

Points Range:
21
(21%)
– 23
(23%)

The response provides an inaccurate or vague justification for the recommended drug therapy plan for this patient.

The response may include examples, which may inaccurately or vaguely support the justification provided.

Points Range:
0
(0%)
– 20
(20%)

The response provides an inaccurate and vague justification for the recommended drug therapy plan for this patient, or is missing.

The response does not include examples that support the justification provided, or is missing.

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.

Points Range:
5
(5%)
– 5
(5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

Points Range:
4
(4%)
– 4
(4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

Points Range:
3.5
(3.5%)
– 3.5
(3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

Points Range:
0
(0%)
– 3
(3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.

Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuation

Points Range:
5
(5%)
– 5
(5%)

Uses correct grammar, spelling, and punctuation with no errors

Points Range:
4
(4%)
– 4
(4%)

Contains a few (1–2) grammar, spelling, and punctuation errors

Points Range:
3.5
(3.5%)
– 3.5
(3.5%)

Contains several (3–4) grammar, spelling, and punctuation errors

Points Range:
0
(0%)
– 3
(3%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.

Points Range:
5
(5%)
– 5
(5%)

Uses correct APA format with no errors

Points Range:
4
(4%)
– 4
(4%)

Contains a few (1–2) APA format errors

Points Range:
3.5
(3.5%)
– 3.5
(3.5%)

Contains several (3–4) APA format errors

Points Range:
0
(0%)
– 3
(3%)

Contains many (≥ 5) APA format errors

Total Points: 100

Transcript

Started:
Mar 17, 2020 |
Total Time:
53 min

Hello Mr. Bailey. My name is Danielle Scott, I will be your provider today.

Greet

03/17/20 3:34 PM CDT

Hey.

What brings you in today

Question

03/17/20 3:35 PM CDT

I picked up this heavy box at work–with like, sound equipment and stuff in it–and ever since then, the pain in my lower back has been killing me. I think I need to be on opioids or something.

I am sorry your back has continued to hurt so severely for so long, We’re going to determine the best plan of action to ease your pain

Empathize

03/17/20 3:38 PM CDT

Hey, thanks.

When did the pain start?

Question

03/17/20 3:39 PM CDT

I lifted a box at work . . . probably thirteen weeks ago now, and it hurt right away. I just knew I really hurt myself.

Did you go to the hospital

Question

03/17/20 3:41 PM CDT

I went to the hospital when I hurt myself picking up that box thirteen weeks ago. They looked me over but they couldn’t figure out what kind of back injury I had.

Did the hospital recommend anything

GET SHADOW HEALTH HELP HERE

Question

03/17/20 3:41 PM CDT

All they did was tell me to take ibuprofen and do physical therapy. They couldn’t even tell me what was wrong, even after an MRI. It turned up nothing.

What did the hospital diagnose you with

Question

03/17/20 3:42 PM CDT

The ER did an MRI, but they can’t tell me what’s actually wrong with my back. My coworker drove me all the way out to the hospital the day I hurt myself, and there’s not a whole lot to show for it.

Have your pain levels changed since your injury

Question

03/17/20 3:44 PM CDT

My back pain hasn’t gotten better at all. I feel like I’ve been in pain forever. I need it to stop.

When does your pain occur

Question

03/17/20 3:45 PM CDT

The pain starts when I wake up in the morning. It does fade away for a little bit during the day, but it’s not a reliable thing and it always comes back.

I’m sorry that it’s been so difficult to find a proper treatment plan for your pain and that you haven’t always received enough relief. We’re going to figure out how best to treat your pain quickly and effectively.

Empathize

03/17/20 3:48 PM CDT

I appreciate your saying that.

What other symptoms do you have

Question

03/17/20 3:49 PM CDT

No other health issues, no disorders, no other symptoms. Just excruciating lower back pain.

Does exertion make your pain worse

Question

03/17/20 3:50 PM CDT

The pain is worst when I’m doing something. Walking, lifting, bending over. It makes it hard enough to move I can’t even go to the physical therapist like the ER doctors wanted. I tried some exercises at home and they just hurt too much.

Does exercise make your pain worse

Question

03/17/20 3:50 PM CDT

I can’t exercise. Which just stinks. I used to lift weights and do cardio three times a week. Now, every little thing hurts. I can’t bend or lift stuff, and even walking is just so painful. I tried some PT exercises for my back at home, but it just hurt so much.

What is the pain like

Question

03/17/20 3:51 PM CDT

The pain is sharp and burning, and it tingles sometimes. It’s always in my lower back. Never really thought about being hurt at work, and now I’ve been laid up forever.

How much pain are you in

Question

03/17/20 3:51 PM CDT

The pain is hard to deal with. Sometimes it’s between a 0 to 2 out of 10 — sometimes it’s at 4-7. I need a prescription for opioids at this point.

Does anything relieve the pain

Question

03/17/20 3:52 PM CDT

Sometimes just shifting around–changing the way I’m sitting or lying–can help a little. Rest helps a little bit, too. Drinking kind of worked, but I did have to go up to three drinks a day. Ibuprofen didn’t work at all, but these opioids I tried–hydrocodone and acetaminophen–they actually stopped the pain.

Do you have any type of allergies (Clarified to What allergies do you have?.)

Question

03/17/20 3:54 PM CDT

I don’t have allergies. (Clarified to what allergies I have.)

Can you tell me about your family history

Question

03/17/20 3:55 PM CDT

My mom’s has depression. She’s also an alcoholic. My dad’s pretty healthy.

Are you currently taking testosterone

Question

03/17/20 3:55 PM CDT

Yeah, I take testosterone. 100 mg of testosterone enanthate, to be exact.

Do you take opioids

Question

03/17/20 3:56 PM CDT

I was taking them, but I’m out. It was my first time trying them, and I had my last one this morning. My friend only had a week’s worth after his surgery, so now I’m here for a prescription. My back hurts too much to wait it out.

While the medication your friend gave you was effective for pain relief and even though he no longer needed it you should only take prescriptions that a healthcare provider can safely endorse and oversee

Educate

03/17/20 3:57 PM CDT

Yeah, I guess that makes sense.

Do you take ibuprofen

Question

03/17/20 3:58 PM CDT

I was taking ibuprofen because the hospital prescribed it. It didn’t work for the whole two weeks I was on it.

Was it over the counter (Clarified to Did you take ibuprofen that was just over the counter?.)

Question

03/17/20 3:58 PM CDT

The hospital prescribed me ibuprofen, but I just bought some over the counter — prescriptions are such a hassle to fill and pick up and all that. Figured it’d be easier. (Clarified to If the ibuprofen was over the counter.)

Prescription and over-the-counter medications are not always identical. you should always fill your prescription instead of buying them over the counter and always take your medication as prescribed

Educate

03/17/20 4:00 PM CDT

Thank you. One more thing to think about, huh?

Do you miss doses of your medication

Question

03/17/20 4:03 PM CDT

I’ve been in way too much pain to miss doses.

What level of income do you make

Question

03/17/20 4:03 PM CDT

I make around 25 grand a year from the theatre — it’s mostly enough, but I need to be super careful with spending.

Has your alcohol consumption endangered you

Question

03/17/20 4:04 PM CDT

If you mean like, drinking at work or something, no, I’d never. I’ve just been at home.

Can I examine your back

Question

03/17/20 4:05 PM CDT

Have at it. [AUDIO COMING SOON]

thank you

Question

03/17/20 4:05 PM CDT

You’re welcome.

hi Tanner I’m going to continue with the ibuprofen

Question

03/17/20 4:11 PM CDT

Alright, let’s do it.

Take the medication with food milk or antacids to decrease the chance of GI issues like constipation nausea or vomiting

Question

03/17/20 4:11 PM CDT

Thanks for the tip.

Taking higher doses than recommended does not increase really but may increase the likelihood of adverse effects do not take more than 2400 milligrams in day

Question

03/17/20 4:12 PM CDT

Got it.

Stomach bleeding is a serious side effects of ibuprofen if you notice any blood in your stools or vomit seek medical attention immediately

Question

03/17/20 4:13 PM CDT

Fine by me.

Avoid drinking alcohol while on this medication this may increase the risk of GI bleeding

Question

03/17/20 4:13 PM CDT

Aw, man. No more whiskey?

though alcohol has been effective for you as a back pain reliever it is dangerous substance that could damage your health and behaviors. we will work to find you a treatment plan whose risk can be minimized and overseen

Question

03/17/20 4:15 PM CDT

I get it, but just so you know, you’re asking a lot of me.

Stomach bleeding is a serious side effect

Question

03/17/20 4:16 PM CDT

That sounds awful. Is this stuff really safe to take?

If you notice any blood please contact your provider immediately

Question

03/17/20 4:17 PM CDT

I guess it’s worth the risk. I mean, I’ve got to do something.

You should start going to physical therapy again it is important part of your recovery from chronic back pain

Question

03/17/20 4:17 PM CDT

But it hurt so bad. That can’t be good for my back, can it?

Taking the proper medication will assist in the pain

Question

03/17/20 4:18 PM CDT

Alright . . . guess I gotta work through the pain a little bit.

Taking prescriptions that has not been prescribed to you is a dangerous and ineffective

Question

03/17/20 4:18 PM CDT

I mean, I know you’re
not supposed
to . . . but it did work a lot better than the ibuprofen.

Taking prescriptions that don’t belong to you is dangerous and ineffective

Question

03/17/20 4:19 PM CDT

Okay, okay. I understand. Really. I knew it wasn’t a good idea . . . I just couldn’t find anything that worked. This time will be better.

Thanks Tanner have a good day

Question

03/17/20 4:20 PM CDT

Thanks. You have a good one.