Tag: Clinical-Nursing

After emptying a Jackson-Pratt drainage bulb, how does the nurse reestablish negative pressure in the system?

A. Fill the bulb with sterile saline solution.

B. Place the bulb lower than the client’s body.

C. Open the valve and fill the bulb with air.

D. Compress the bulb and close the valve.

A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is closed. This causes fluid around the surgical site to flow into the drain.

Body parts medical terminology

Welcome to our discussion forum on body systems!

In this forum, we will delve into the essential body systems that are fundamental to understanding medical terminology. Consider the following questions as you contribute to the discussion:

Choose one body system (e.g.,
cardiovascular
, respiratory, digestive) and discuss its key components and functions.

Include a brief overview of relevant medical terms associated with that body system.

Instructions:

Initial Post:

Answer the provided questions about the origins of medical terminology.

Your initial post should be well-organized, thorough, and reflect your understanding of the topic.

Your response should be clear and at least 150 words.I

 

Body parts medical terminology

Medical and Terminology

The respiratory system is vital to life as it helps in the exchange of gases, to supply the body with oxygen, and to remove carbon dioxide. The key components are the nose, pharynx, larynx, trachea, bronchi, and lungs. Air is inhaled through the nasal cavity, and here it is filtered, warmed, and humidified before traveling through the pharynx and the larynx to the trachea. The trachea further splits into the right and left bronchi, which further subdivide into smaller bronchioles in the lungs (Marchadier, 2025). These bronchioles end in tiny air sacs known as the alveoli, where the actual exchange of oxygen and carbon dioxide occurs through the bloodstream. The diaphragm is a dome-shaped muscle located under the lungs. It is an essential part of the respiratory system as it contracts and relaxes to enable the lungs to breathe in and out.

GET YOUR PAPER HERE

The medical terminology of the respiratory system often contains suffixes, prefixes, and roots to describe structures and conditions. Examples include pulmo/pulmon/o, which means lungs, and pneum/o or pneumon/o, which means air or lung tissue. Some typical terms are dyspnea (difficulty breathing), apnea (absence of breathing), and bronchitis (inflammation of the bronchi) (Ernstmeyer & Christman, 2024). The suffix -itis denotes inflammation, and the suffix -ectomy denotes extraction, for example, lobectomy, the removal of a lobe of the lung. Knowledge of these terms assists healthcare providers in communicating and explaining respiratory diseases, diagnosis, and interventions effectively and accurately. The respiratory system plays a crucial role in keeping oxygen levels stable and contributing to the functioning of the body cells.

References

Ernstmeyer, K., & Christman, E. (2024).
Respiratory system terminology
. Nih.gov; Chippewa Valley Technical College.
https://www.ncbi.nlm.nih.gov/books/NBK607438/

Marchadier, D. (2025).
The respiratory system
. 21–33.
https://doi.org/10.1007/978-3-662-71489-8_3
  Body parts medical terminology

NURS 6041: Health Care Technology, Teaching & Evaluation in Health Care.

Final Project Guidelines

Introduction: This assignment will be an application of what is learned in the final modules, with application from the earlier modules (Theory and Electronic Health Record).  This work is intended to be a summation of information from this course with application of content.  The student should not cite sources directly (using quotes), but should assimilate and reference where material came from.  Except where noted, personal views and uncited information should not be used.  APA format is expected in all areas, start to finish.  Headers are required to guide the reader.  Appropriate grammar and sentence structure is expected.  Graduate level writing is expected.

You have been given the assignment of reviewing your clinic’s performance in addressing a major health disease/disorder.  In your clinic, the manager has reviewed some records and has asked that you devise a plan to improve how your clinic manages your selected disease process.  For this assignment, you may use a disease process identified as being ‘not being managed well’ or a disease process that could be managed better in the clinic you are currently involved in or from your current clinical practice if you are not in a clinical rotation this summer.

 

Title page (5 points)

Title should be a one sentence summation of the entire report

Review and Utilize APA format throughout title page and paper

 

Introduction (2 paragraphs) (10 points)

Introduction section should start with a broad introduction of the disease process

Next, a discussion on why it is important to address it at the clinic level

Must include a population that can be targeted (population can have a variable application). The population should be targeted based upon who is being seen in the clinic.  Examples below (One is pinpointed to a specific target and one is too broad. Please be specific)

GREAT EXAMPLE: Native American patients over the age of 65 with A1C levels greater than 8.0%.

POOR EXAMPLE: People with hypertension.

 

Abbreviated treatment guidelines from a nationally recognized professional organization (3-4 paragraphs) (15 points)

(Example: The American Diabetes Association for type two diabetes management).

 

This disease process must be one that is recognized as being managed by a family nurse practitioner in the clinic (Type 2 diabetes, Hypertension, Hyperlipidemia, Asthma, etc.)

Disease process is complex as to require both medical and nursing management

Medical management is
briefly
outlined (not the entire formulary of tiered medication, but a summary of drug classes is fine and for the first one or two tiers

Screenings and interventions associated with your selected disease discussed (example: annual flu shot, annual liver enzyme panels, etc.)

Nursing management (health behaviors) is briefly discussed to address long-term complications or disease progression (Smoking cessation, diet modification, exercise)

Discussion of selected benchmark goals of how clinics should address

Only need to address major ones and ones being addressed in the paper, or identified as being deficient in Review of Electronic Health Record.

Compare your clinic’s outcomes to those benchmark standards either in your area or local/state health departments, or national levels.
Hint
: you want to show you are not meeting a set standard and this is what you are wanting to improve in your clinic.

Review of Electronic Health Record of the office/clinical/unit (2 paragraphs) (10 points)

Population of focus is clearly identified (supported with statistical data)

Clinical outcomes are identified and discussed.

Area of Disease outcome measures are identified and supported with EHR data findings

Lacking management or health behaviors is identified with supported EHR data findings

Discussion of missing data unable to be retrieved from EHR.

How might the problem be alleviated?

 

Questions leading up to PLAN-DO-STUDY-ACT implementation (2-3 paragraphs) (15 points)

What specifically do you need to accomplish with your project? (consider where you are not meeting the benchmark standards. It may not be the same wording)

What specific change are you going to introduce [to help bring about a change] and why? [This will be a discussion on what changes you are going to make in the clinical structure or processes to make a difference]

How will you know the change is making an improvement? [What will you look at after you have made a difference to know if a positive change has been made?]

Answers to each question are to be supported by observation and plausible project implementation.

If research from another source, cite appropriately and address how it can be modified from the area of research to the clinic area.

 

PLAN (2 paragraphs) (10 points)

The basic plan is laid out

Assigned roles are briefly discussed (Review Roger’s diffusion of innovation)

How it will be implemented? What will be developed?

What specific strategies will you employ from the Roger’s Diffusion of Innovations model will you utilize to ensure success? (Strategies must be specific to the clinic) NURS 6041: Health Care Technology, Teaching & Evaluation in Health Care

 

DO (2 paragraphs) (10 points)

Discuss the education model or Theory you will be implementing in your clinic and using with patients to help them make a change. (There may be several, but choose one to discuss)

Provide a short paragraph to summarize and justify use of this particular model with the change you plan to make in the clinical setting to improve outcomes.

 

STUDY (2 paragraphs) (10 points)

Differentiate between process measures and outcome measures, and what you will look at for your project (may be repeated from above).

What EHR data will you be reviewing and analyzing to know if you made a difference?

What environmental data will you be reviewing?

What questions might you be asking of those working in the environment?

Address one possible unintended consequence that might occur.

 

Closing (1-2 paragraphs) (10 points)

Provide a brief, yet information dense, summary of content presented in paper.

Make a connection of concepts you learned from this course that you can apply in your future practice.

 

References (10 points)

Should be a substantial number of scholarly sources to address the required information.

All sources and in-text citations should be cited using APA format

Reference Page should be formatted using APA format

NURS 6041: Health Care Technology, Teaching & Evaluation in Health Care

Cardiovascular medical terminology essay assignment

Medical and Health Terminology

Understanding medical terminologies and their application enhances clinical practices and patient treatment outcomes. These terminologies are standardized language that significantly contribute to diagnostic accuracy, thereby improving patient safety. Medical terminologies further streamline communication among multidisciplinary teams involved in patient care. However, medical terminologies significantly vary from one clinical practice field/medical condition to another. Medical condition selected for this paper is hypertension, which is a common cardiovascular disorder (CVD). This chronic CVD is commonly referred to as high blood pressure. Hypertension is a chronic CVD in which an individual’s arterial pressure is persistently elevated (≥130/80 mmHg) (Saiz et al., 2022). The prevalence of hypertension has increased significantly globally over the last decade (Boateng & Ampofo, 2023). Approximately 50% of U.S. adults have been diagnosed with high blood pressure and this condition is uncontrolled in approximately 75% of this patient population (Muntner et al., 2022). This trend has significantly contributed to serious health complications, including heart disease, stroke, and kidney failure (Anyaogu et al., 2025). Hypertension is critically crucial are in the medical field since this chronic condition significantly contribute high morbidity and mortality rates globally yet it is often asymptomatic. This paper examines various medical terminologies related to hypertension and how they enhance communication among interdisciplinary teams, thereby optimizing patient’s clinical outcomes.

Overview of the Condition

Hypertension can be primary (essential) or secondary. A significantly high percentage of hypertension cases approximately 85 to 90% are primary cases (WHO, 2023). Gradual development of hypertension does not have a specific identifiable cause. However, essential hypertension is associated with multiple contributing risk factors, including genetic predisposition, sedentary lifestyle, or chronic stress. Environmental factors, including obesity and high sodium intake further predispose individuals to hypertension (Rossios et al., 2023). On the other hand, secondary hypertension is usually caused by underlying medical condition, including chronic kidney disease, endocrine disorders, or renovascular disease (Sudano et al., 2023). Most hypertension cases are usually asymptomatic. Contrarily, symptoms, including headaches, dizziness, visual disturbances, and epistaxis are usually present in severe cases. Hypertension is usually diagnosed following multiple, elevated readings via sphygmomanometry. Hypertension is also evaluated through blood/urine tests. These tests assess end-organ damage associated with hypertension. Lastly, hypertension is treated through a combined approach, including pharmacological management and lifestyle modifications, which is preferred due to its efficacy in lowering blood pressure (Charchar et al., 2024). Non-pharmacological treatment for hypertension includes adopting the DASH diet, reducing sodium intake, increasing potassium in the diet, and limiting alcohol. On the other hand, antihypertensive agents include ACE inhibitors, diuretics, and calcium channel blockers (Faucon et al., 2023).

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Terminology Analysis

Hypertension: Persistently elevated blood pressure (≥130/80 mmHg) in which force of blood against artery walls is adequately high to damage blood vessels (Saiz et al., 2022).

Diastolic: The lowest blood pressure level recorded between heart contractions (Saiz et al., 2022).

Systolic: The highest blood pressure level during heart contraction (Saiz et al., 2022).

Sphygmomanometer: A gadget that is commonly used to measure blood pressure (Saiz et al., 2022).

Essential Hypertension: High blood pressure without a particular cause (WHO, 2023).

Secondary Hypertension: High blood pressure associated with an identifiable cause, such as renal disorder (Sudano et al., 2023).

Antihypertensive: Pharmacological agents used to lower blood pressure (Charchar et al., 2024).

Vasodilators: Pharmacological modalities that relax blood vessels and widen them to enhance the flow of blood, thereby managing high blood pressure (Charchar et al., 2024).

Vasoconstriction: A phenomenon in which blood vessels are narrowed and blood flow limited, contributing to high blood pressure (Zwoliński et al., 2023).

Tachycardia: It’s a condition characterized by rapid heart rate, leading to high blood pressure (Zwoliński et al., 2023).

Myocardial Infarction: A heart attack that kills tissues due to high blood pressure (Saiz et al., 2022).

Renal Failure: Compromised kidney functioning, which makes it hard for the kidneys to filter waste, thereby leading to hypertension (Swiner, 2025).

Cardiovascular: A condition related to blood vessels and the cardiac muscle’s ability to pump blood, leading to high blood pressure (Saiz et al., 2022).

Retinopathy: A condition in which the retina is damaged due to high blood pressure (Dziedziak et al., 2022).

Atherosclerosis: A CVD characterized by hardening of blood arteries due to consistently high blood pressure (Saiz et al., 2022).

Diuretics: Medication agents for controlling blood pressure by elevating urine output to lower volume (Charchar et al., 2024).

Normotensive: Normal blood pressure, ranging 90–119 mmHg (Systolic) and 60–79 mmHg (Diastolic) (Saiz et al., 2022).

Hyperaldosteronism: Elevated aldosterone level, leading to secondary hypertension (Sudano et al., 2023).

Arrhythmia: Irregular heartbeat due to high blood pressure (Zwoliński et al., 2023).

Ischemic: Limited flow of blood to body tissues (Saiz et al., 2022).

The most complex terms can be broken down as indicated below.

Hypertension: The prefix (hyper) means excessive + Root (tens (root) means pressure/strain/tension + suffix (-ion) represents a condition.

Cardiovascular: The first root (Cardi/o) means heart+ Second root (vascul) which means blood vessel + suffix (-ar) means pertaining to.

Antihypertensive: Prefix (Anti-) means against + prefix (hyper) means high + root (tens) is pressure + suffix (-ive) meaning acting upon.

Arteriosclerosis: Root (Arterio) means artery + Root (scler) hard + Suffix (-osis) meaning a condition.

Retinopathy: Root (retin/o) means retina + suffix (-pathy) meaning a disease.

These terminologies provide a standardized way of describing hypertension, its treatment, and related medical complications. Consequently, multidisciplinary teams understand the specific nature of an individual patient’s blood pressure. For instance, team members can develop an appropriate treatment plan by differentiating Essential hypertension from Secondary hypertension. Additionally, the treatment plan is informed by severity of the patient’s hypertension. The treatment is determined by classifying the patient’s hypertension as “Stage 1” or “Stage 2” hypertension, thereby adhering to recommended treatment procedures, which optimizes treatment outcomes (Saiz et al., 2022) Cardiovascular medical terminology essay assignment.

Application in Clinical Settings

The above terminologies are used in different contexts in clinical practice. First, these terms are used in patient records. For instance, a healthcare provider can document a patient as Stage 2 hypertension accompanied by hypertensive nephropathy. These terminologies are further applied in diagnostic reports. For example, a provider can document “Left ventricular hypertrophy” present. Lastly, these terms are applied in treatment plans. For instance, a primary care provider can instruct the nurse to initiate ACE inhibitor therapy.

Using terminologies in documentation enhances understanding of the patient’s condition among healthcare professionals, thereby ensuring efficient hand over. For instance, patient record indicating “Essential hypertension with mild left ventricular hypertrophy” clears informs other care providers about the patient’s primary diagnosis, potential structural damage, and comorbidities. Terminologies further enhance patient safety. Providers avoid potential critical errors when standardized terminologies are used correctly. For example, “Stage 2 hypertension with acute organ damage” indicates need for hypertensive emergency, thereby preventing potential health complications. Lastly, using medical terminologies enhances interdisciplinary communication. For instance, a pharmacist would understand which medication agent to dispense if the nurse indicates “Refractory Hypertension” despite using three different antihypertensive regimens.

Conclusion

Hypertension is a complex and highly prevalent CVD, contributing to high morbidity and mortality rates globally. This trend necessitates accurate diagnosis and effective management of high blood pressure since most hypertension cases are uncontrolled. Understanding of medical terminologies is recommendable since is the backbone of accurate diagnoses, management, and treatment of hypertension and related medical complication. By understanding medical terminologies related to hypertension, clinicians and medical students can accurately document patient diagnosis reports. Multidisciplinary team members can leverage this accurate information to make the best treatment plan and monitor the patient’s progress, thereby optimizing clinical outcomes.

References

Anyaogu, C. N., Momodu, P. A., Okobi, O. E., Amadi, A. T., Okechukwu, J. K., Polna, O., … & Gabriel, H. (2025). Impact of Blood Pressure Control on Stroke and Myocardial Infarction Risk in Hypertensive Patients with and without Diabetes: A Narrative Review. 
Cureus
, 
17
(7).
https://pmc.ncbi.nlm.nih.gov/articles/PMC12393132/

Boateng, E. B., & Ampofo, A. G. (2023). A glimpse into the future: modelling global prevalence of hypertension. 
BMC Public Health
, 
23
(1), 1906.
https://link.springer.com/article/10.1186/s12889-023-16662-z

Charchar, F. J., Prestes, P. R., Mills, C., Ching, S. M., Neupane, D., Marques, F. Z., … & Tomaszewski, M. (2024). Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension. 
Journal of Hypertension
, 
42
(1), 23-49.
https://journals.lww.com/jhypertension/fulltext/2024/01000/lifestyle_management_of_hypertension_.3.aspx?utm_source=chatgpt.com

Dziedziak, J., Zaleska-Żmijewska, A., Szaflik, J. P., & Cudnoch-Jędrzejewska, A. (2022). Impact of arterial hypertension on the eye: a review of the pathogenesis, diagnostic methods, and treatment of hypertensive retinopathy. 
Medical Science Monitor: International Medical Journal of Experimental and Clinical Research
, 
28
, e935135-1. https://pmc.ncbi.nlm.nih.gov/articles/PMC8790937/

Faucon, A. L., Fu, E. L., Stengel, B., Mazhar, F., Evans, M., & Carrero, J. J. (2023). A nationwide cohort study comparing the effectiveness of diuretics and calcium channel blockers on top of renin-angiotensin system inhibitors on chronic kidney disease progression and mortality. 
Kidney International
, 
104
(3), 542-551. https://www.sciencedirect.com/science/article/pii/S0085253823004180

Muntner, P., Miles, M. A., Jaeger, B. C., Hannon III, L., Hardy, S. T., Ostchega, Y., … & Schwartz, J. E. (2022). Blood pressure control among US adults, 2009 to 2012 through 2017 to 2020. 
Hypertension
, 
79
(9), 1971-1980.
https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.122.19222

Rossios, K., Antza, C., Kachtsidis, V., & Kotsis, V. (2023). The modern environment: the new secondary cause of hypertension? 
Medicina
, 
59
(12), 2095.
https://www.mdpi.com/1648-9144/59/12/2095

Saiz, L. C., Gorricho, J., Garjon, J., Celaya, M. C., Erviti, J., & Leache, L. (2022). Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. 
Cochrane Database of Systematic Reviews
, (11).
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010315.pub5/abstract

Sudano, I., Suter, P., & Beuschlein, F. (2023). Secondary hypertension as a cause of treatment resistance. 
Blood Pressure
, 
32
(1), 2224898.
https://www.tandfonline.com/doi/full/10.1080/08037051.2023.2224898

Swiner, C. N. (2025). 
The Healthy Kidney Handbook: A Comprehensive Guide to Manage Hypertension, Control Stress, and Prevent Renal Failure, Kidney Disease, and More
. UlyssesPress+ ORM.

World Health Organization (WHO). (2023). 
Global report on hypertension: the race against a silent killer
. World Health Organization.

Zwoliński, M., Zemsta, K., Kulesza, B., & Tomasiuk, R. (2023). Bradycardia Concomitant with Hypertension. 
Med Discoveries
, 
2
(11), 1092.
https://meddiscoveries.org/pdf/1092.pdf

 

Cardiovascular medical terminology essay assignment Paper Requirements:

Length: 4–5 pages (double-spaced, 12-pt font, APA 7th edition format)

Sources: Minimum of 4 peer-reviewed articles from LIRN

Terminology: At least 20 medical terms used correctly and defined (in context, not just a glossary)

Citations: Proper APA in-text and reference page citations

? Recommended Topics (Choose One or Propose Your Own):

Alzheimer’s Disease and Neurological Terminology

Asthma and Pulmonary Medical Language

The Terminology of Cancer Diagnosis and Treatment

Medical Language in Cardiovascular Conditions (e.g., Hypertension, MI)

Diabetes Mellitus and Endocrine System Terms

Mental Health Disorders and Psychiatric Terminology

? Paper Structure:

Introduction

Brief description of the condition

Why it’s important in the medical field

Thesis statement: what aspect of terminology the paper will explore

Overview of the Condition

Causes, symptoms, diagnosis, treatment (with proper use of medical terms)

Terminology Analysis

Identify 20+ medical terms throughout the paper

Break down 5–10 of the most complex terms (prefix, root, suffix)

Show how terminology enhances accuracy and clarity in healthcare

Application in Clinical Settings

Discuss how the selected terms appear in real clinical contexts (based on article examples)

Importance of terminology in documentation, patient safety, and interdisciplinary communication

Conclusion

Summarize findings Cardiovascular medical terminology essay assignment

Reflect on the significance of understanding medical language for healthcare professionals and students

NURS 6512 Module 3 Knowledge Check week 5 answers

Question 1                                                          1 pts

A patient presents with scalp tenderness, jaw claudication, and a new-onset headache. What condition should the NP suspect?

Group of answer choices

 

Migraine with aura

 

Cluster headache

 

Temporal arteritis

 

Cervical strain

 

Question 2                                                                   1 pts

A 55-year-old patient presents with painless, unilateral vision loss, flashes of light, and a curtain coming down across the visual field. What is the most likely diagnosis?

Group of answer choices

 

Acute angle-closure glaucoma

 

Retinal detachment

 

Cataract

 

Optic neuritis

GET EXAMS HELP HERE

Question 3                                                1 pts

Which of the following exam findings is most concerning for thyroid malignancy?

Group of answer choices

 

A soft, mobile, symmetrical goiter

 

A tender thyroid with diffuse enlargement

 

A firm, fixed thyroid nodule with cervical lymphadenopathy

 

A bruit heard over the thyroid

 

NURS 6512 Module 3 Knowledge Check week 5 answers Question 4                                               1 pts

A patient presents with fever, muffled voice, drooling, and difficulty opening the mouth. What is the likely diagnosis and appropriate action?

Group of answer choices

 

Pharyngitis; prescribe oral antibiotics

 

Epiglottitis; observe in clinic

 

Peritonsillar abscess; urgent ENT referral

 

Acute sinusitis; treat with decongestants

 

Question 5                                                                    1 pts

Which heart sound is most commonly associated with chronic heart failure due to volume overload?

Group of answer choices

 

S1

 

S2

 

S3

 

S4

 

Question 6                                             1 pts

Which combination of symptoms should prompt immediate consideration of pulmonary embolism (PE)?

Group of answer choices

 

Productive cough and nasal congestion

 

Dyspnea, pleuritic chest pain, and hemoptysis

 

Orthopnea and bilateral pedal edema

 

Wheezing and prolonged expiration

 

Question 7                                                                 1 pts

On auscultation, a patient has diffuse expiratory wheezes and prolonged expiration. Which diagnosis is most likely?

Group of answer choices

 

Pneumonia

 

Asthma

 

Pleural effusion

 

Pulmonary embolism

 

Question 8                                                                         1 pts

A patient presents with unilateral leg swelling, warmth, and tenderness. What diagnosis must be ruled out first?

Group of answer choices

 

Chronic venous insufficiency

 

Lymphedema

 

Cellulitis

 

Deep vein thrombosis (DVT)

 

Question 9                                                                            1 pts

Which physical exam finding most strongly suggests aortic dissection?

Group of answer choices

 

Bradycardia and hypotension

 

Unequal peripheral pulses with sudden tearing chest pain

 

Loud S2 at the right upper sternal border

 

Jugular venous distension and hepatomegaly

 

Question 10                                                            1 pts

A patient with acute shortness of breath has decreased breath sounds and dullness to percussion over the right lung base. What condition is most likely?

Group of answer choices

 

Asthma exacerbation

 

Pneumothorax

 

Pleural effusion

 

Pulmonary embolism

 

NURS 6512 Module 3 Knowledge Check week 5 answers

 

Module 3: Knowledge Check

Summer 2026(05/25/2026-08/09/2026)-PT27.202670.27

Home

Announcements

Grades
5

Syllabus

Modules

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Module 3: Knowledge Check

Due
 
Jun 28 at 10:59pm

Points
 
10

Questions
 
10

Time Limit
 
20 Minutes

Instructions

 
Back to Module 3: Cardiovascular, Peripheral Vascular, Pulmonary, and Abdominal Systems

Knowledge Check: Weeks 4–5

This Knowledge Check provides the chance for you to check your knowledge of the content covered in Weeks 4–5 of the course. You will have 20 minutes and one attempt to complete it. You may refer to the Learning Resources to
answer the Knowledge Check questions.

Level 1: No AI Permitted

AI tools may 
not
 be used at any stage

Common for clinical documentation or performance‑based work

Resources

 

Be sure to review the Learning Resources before completing this assessment.

Required Resources

NOTE: Utilize this text as a clinical reference to aid your analysis for the relevant areas noted.
 Also utilize study questions to develop your understanding of the concepts and topics presented throughout this course.

Soriano, R. P. (2026). 
Bates’ guide to physical examination and history taking
 (14th ed.). Wolters Kluwer Health.

Chapter 17, “Thorax and Lungs”

Chapter 18, “Cardiovascular System”

Chapter 19, “Peripheral Vascular System”

To prepare:

Study Learning Resources from Weeks 4–5, focusing on the HEENT, neck, cardiovascular, peripheral vascular, and pulmonary systems.

By Sunday of Week 5

Complete
 the Knowledge Check.

Attempt History

Attempt

Time

Score

LATEST

Attempt 1

Time:
17 minutes

Score:
10 out of 10

Quiz results are protected for this quiz and are not visible to students.

 Correct answers are hidden.

Score for this quiz: 
10
 out of 10

NURS 6512 Module 3 Knowledge Check week 5 answers

Latin and Greek in medical terminology

Medical and Health Terminology

The Importance of Latin and Greek in Medicine

The Latin and Greek languages are the main sources of many modern medical terms due to the fact that the earliest scientific and medical scholarship relied on these languages. According to Musokhranova and Astafyeva (2024), ancient medical practitioners, such as the Greek physician Hippocrates, and the later Roman scholars, used both Latin and Greek to record and communicate their knowledge of medicine. Also, Latin and Greek were the dominant languages of education and scientific scholarship for nearly a millennium and, as a result, established a standard for the naming of illnesses, anatomical structures, and procedural interventions (Musokhranova & Astafyeva, 2024). Thus, the integration of these classical languages enables medical practitioners to communicate, and therefore, maintain the accuracy and clarity of medical terminology and concepts in all healthcare systems around the world.

Medical Terminology Originating from Latin and Greek

It is possible to identify the ancient origins of most medical terms. An example is the medical specialty of cardiology which comes from Greek kardia meaning ‘heart’ and -logy meaning ‘study’ (Gerontas et al., 2023). In the same way, the specialization dermatology is formed from Greek derma meaning ‘skin’, and -logy. An example of Latin origin is the word muscle, which is derived from Latin musculus which means ‘little mouse’, because of the early anatomists’ belief that there are mice moving under the skin (Dotou-Huetz, 2023). In that case, the knowledge of the origin of medical terms provides the means to interpret the meaning of complex words. For example, if someone knows the meaning of the prefix neuro- as ‘nerve’, and the suffix -itis as ‘inflammation’, then they will understand that the word neuritis means inflammation of a nerve.

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Fascinating Origins of Medical Terminology

Some medical terms have surprisingly interesting origins, for instance, the word influenza comes from Italian influentia meaning ‘influence’ (Pekesen et al., 2022). In the Middle Ages, people believed the illness was caused by the influence of the stars. Malaria also has an interesting origin. Malaria comes from Italian mal aria, which means ‘bad air’, and illustrates the early belief that disease was caused by air from the swamps (Pekesen et al., 2022). These examples show the importance of understanding the origins of medical terms. It also shows the importance of studying the roots of words in order to simplify and aid in the memorization of complicated medical terms.

 

References

Dotou-Huetz, M. (2023). Towards selective bifunctional senolytic compounds: Design, mechanistic studies and proof of concept.
Hal.science
. https://theses.hal.science/tel-05426937

Gerontas, A., Avgerinos, D. V., Charitakis, K., Maragou, H., & Drosatos, K. (2023). 1821–2021: Contributions of physicians and researchers of Greek descent in the advancement of clinical and experimental cardiology and cardiac surgery.
Frontiers in Cardiovascular Medicine
,
10
. https://doi.org/10.3389/fcvm.2023.1231762

Musokhranova, M. B., & Astafyeva, E. N. (2024). Cultural and historical aspect of Greek Latin medical terminology.
Scientific Bulletin of the Omsk State Medical University
,
4
(3), 46–52. https://doi.org/10.61634/2782-3024-2024-15-46-52

Pekesen, M., Ataman, A. D., & Özdinç, A. (2022). Medicine in philately: Pandemics from past to present.
Anadolu Kliniği Tıp Bilimleri Dergisi
. https://doi.org/10.21673/anadoluklin.1213647

 

 

Consider the following questions as you contribute to the Latin and Greek in medical terminology discussion:

Many medical terms have roots in Latin and Greek. Why do you think these ancient languages are the foundation of modern medical terminology?

Can you provide examples of medical terms that originate from Latin or Greek? Explain how knowing the origin of these words can help in understanding their meanings.

Are there any
medical terms
with interesting or surprising origins that you’ve come across? Share your findings and explain how the term’s origin relates to its modern meaning.

Instructions:

Initial Post:

Answer the provided questions about the origins of medical terminology.

Your initial post should be well-organized, thorough, and reflect your understanding of the topic.

Your response should be clear and at least 150 words. Latin and Greek in medical terminology

Team Collab Assignment – Interdisciplinary Health Promotion Plan: Hypertension Prevention and Management in the United States

ASSIGNMENT OVERVIEW

Development of health promotion plans with patients, families, communities, and professionals is vital to

the improvement of health disparities and disease prevention. As an advanced practice leader you are

required to develop a plan that promotes health on the clinical unit or in your community that can be shared with clients. Select a health promotion topic and complete an interdisciplinary collaboration plan for the roll

out of this project.

a. Identifies a health promotion need on the clinical unit, facility, or in the community that impacts

health and includes literature support that demonstrates it’s a problem.

b. Addresses why collaboration is important and what techniques will be incorporated including how

interdisciplinary strategies will be utilized. Literature support for how the plan will improve

outcomes needs to be included.

c. Identifies team members for supporting this plan including how the health promotion plan will be

rolled out. Literature support that demonstrates the benefits of an interdisciplinary approach to

health promotion needs to be included.

d. Summary

Sources older than five years may not be used without the permission of the class professor.

3. Title page, pagination, subheadings, body of paper, citation of sources, and reference page must

follow APA guidelines as found in the most current edition of the manual.

4. Rules of grammar, spelling, word usage, punctuation, sentence and paragraph structure are

followed and consistent with formal, scholarly writing as noted in the most current edition of the

APA Manual.

Team Collab Assignment – Interdisciplinary Health Promotion Plan: Hypertension Prevention and Management in the United States

Hypertension is one of the most prevalent chronic diseases in the United States that could be prevented. According to the CDC (2025), almost half of all Americans are diagnosed with hypertension, and only one in four Americans has their hypertension under control. In that case, health promotion activities related to hypertension are, therefore, critically needed in healthcare settings. The paper discusses a health promotion plan that can be implemented in a clinical setting in the United States and the surrounding community. This health promotion plan will improve hypertension outcomes through education and interdisciplinary efforts. Also, following the standards of the Healthy People 2030 initiative, this health promotion plan will aim to reduce health disparities and improve health outcomes for the United States population.

Health Promotion Need Identification

Hypertension impacts a significant number of individuals in the United States. According to Richardson et al. (2024), there are approximately 120 million American adults impacted by hypertension, making it the leading risk factor for heart disease and stroke in the United States. Furthermore, the CDC (2025) reports that hypertension contributes to approximately 664,470 deaths in the United States each year. There are disparities in the number of individuals affected by hypertension based on race, socioeconomic, and geographic populations. For instance, African American communities and populations with limited access to healthcare services tend to have higher rates of hypertension compared to other racial and geographic demographics. In addition to the disparities in hypertension rates across the United States, hypertension is correlated with various lifestyle factors. For instance, high levels of sodium intake, obesity, physical inactivity, and tobacco use are all prevalent among the United States’ population (Richardson et al., 2024).

Furthermore, individuals with hypertension have increased medical costs for the individual and the healthcare system, as well as have higher rates of hospitalization visits due to cardiovascular-related issues (Abdalla et al., 2023). Thus, intervention in the form of a health promotion program is critical in outpatient and primary care clinics. Addressing hypertension will help individuals adhere to the health-related recommendations published by health institutions and researchers nationwide (Richardson et al., 2024). Additionally, addressing this medical issue has the potential to reduce the health disparities existing in the United States and improve the health outcomes of the American people over the long term.

Importance of Collaboration and Interdisciplinary Strategies

Collaboration among several healthcare professionals is essential for effectively managing hypertension. Branigan et al. (2024) have studied team-based healthcare approaches to hypertension management and found that there were significant improvements in blood pressure and health outcomes of patients under such care. Otto et al. (2025) also discovered that the American Heart Association advocates for team-based approaches to managing hypertension, as they can lead to improved outcomes for patients with the condition. In that case, the health promotion plan that will be utilized will incorporate several different techniques for collaboration. Team-based care will be one of the strategies used to manage the hypertension of patients in the care program. Furthermore, shared decision-making strategies will be employed to give patients a voice in their treatment plan and encourage them to adhere to the treatments prescribed to them (Abdalla et al., 2023). Finally, health information technology will be used to effectively coordinate the care that will be delivered by the healthcare professionals in the care team.

On the other hand, interdisciplinary strategies that will be used to manage the hypertension will involve nurses who will help these patients to manage hypertension. Also, there will be pharmacists that will work with these patients to create medication plans that minimize hypertension levels, and dietitians that will work with these patients to develop dietary plans like the DASH (Dietary Approaches to Stop Hypertension) diet (Otto et al., 2025). Additionally, various community organizations will also be incorporated into the care plan for these patients. Research has already been performed into the effectiveness of these strategies, and the results have found that these strategies can reduce the systolic blood pressure levels of patients with hypertension by 5-10 mmHg, as well as improve the medication adherence rates of those with the disorder (Branigan et al., 2024). Furthermore, various studies show that the implementation of these strategies can also reduce hospitalizations and improve the quality of life of patients with hypertension (Otto et al., 2025; Branigan et al., 2024). Thus, these interdisciplinary strategies will provide an effective and comprehensive approach to managing the blood pressure of patients with hypertension in the United States.

Team Members and Plan Rollout

The implementation of the health promotion initiative will require the formation of an interdisciplinary team. According to Otto et al. (2025), the members of such a team will include nurses, physicians, pharmacists, dietitians, community workers, and health educators. The nurses will lead the initiative while the physicians will attend to the patients’ conditions and treat them as necessary according to guidelines from the American College of Cardiology (Branigan et al., 2024). Additionally, the pharmacists will ensure that the patients take their medication as prescribed while the dietitians will provide patients with dietary advice to manage their high blood pressure. Lastly, the community workers will engage with the communities to encourage them to participate in the initiative Team Collab Assignment – Interdisciplinary Health Promotion Plan: Hypertension Prevention and Management in the United States.

Furthermore, there will be four phases in the implementation of the initiative. The first phase will be a needs assessment of the community to determine what data exists regarding their blood pressures (Richardson et al., 2024). During the second phase, the health initiative will be developed including the design of educational materials and blood pressure screening tools. In the third phase, the initiative will be implemented involving screenings of the populations’ blood pressures, education sessions, and clinic visits. Finally, during the last phase, the initiative will be evaluated using various metrics to gauge its success. According to Branigan et al. (2024), evidence suggests that forming an interdisciplinary team will be beneficial to the initiative as they can work together to achieve the goals more efficiently and with better results. As United States citizens struggle with health disparities, working together as an interdisciplinary team will ensure that this health promotion initiative is sustainable and successful.

Conclusion

Hypertension continues to be a significant health challenge in the United States. A comprehensive and collaborative approach to health promotion can assist in addressing this issue. Strategies for prevention, early detection, and management of hypertension will be incorporated into the efforts of healthcare professionals and communities to address this health challenge. These strategies will improve the health of individuals with hypertension and reduce the cardiovascular risk that is associated with the condition. Furthermore, the plan will ensure that the strategies are effectively implemented and evaluated for their sustainability and effectiveness. Finally, the role of the advanced practice nurses in leading the professionals and communities to improve health outcomes and reduce disparities in the management of hypertension will be made clear within the plan.

References

Abdalla, M., Bolen, S., Brettler, J. W., Egan, B. M., Ferdinand, K. C., Ford, C. D., Lackland, D. T., Wall, H. K., & Shimbo, D. (2023). Implementation strategies to improve blood pressure control in the United States: A scientific statement from the american heart association and american medical association.
Hypertension
,
80
(10), e143–e157. https://doi.org/10.1161/hyp.0000000000000232

Branigan, P., Duong, Y. V., Abdulfattah, A. Y., Sabu, J., Mallappallil, M., & John, S. (2024). Towards optimal cardiovascular health: A comprehensive review of preventive strategies.
Cureus
,
16
(5). https://doi.org/10.7759/cureus.60877

CDC. (2025, January 28).
High blood pressure facts
. High Blood Pressure. https://www.cdc.gov/high-blood-pressure/data-research/facts-stats/index.html

Otto, C. M., Abdullah, A. R., Davis, L. L., Ferrari, V. A., Fremes, S., Mukherjee, D., Prestera, L., & Ziaeian, B. (2025). 2025 ACC/AHA clinical practice guidelines core principles and development process: A report of the American college of cardiology/American heart association joint committee on clinical practice guidelines.
Circulation
. https://doi.org/10.1161/cir.0000000000001383

Richardson, L. C., Vaughan, A. S., Wright, J. S., & Coronado, F. (2024). Examining the hypertension control cascade in adults with uncontrolled hypertension in the US.
JAMA Network Open
,
7
(9), e2431997–e2431997. https://doi.org/10.1001/jamanetworkopen.2024.31997 Team Collab Assignment – Interdisciplinary Health Promotion Plan: Hypertension Prevention and Management in the United States

PRAC 6552 – Comprehensive History and Physical SOAP Note

Comprehensive History and Physical

 SOAP Note

 

SUBJECTIVE DATA (S):

Identifying data:

Initials
: J.J     
Age
: 18y/o     
Race
: Caucasian   
Gender
: Female   
Marital Status
: Single.

CHIEF COMPLAINT (CC):
 “Yeast infection or STD? I see a difference in my discharge and feel uncomfortable.”

HISTORY OF PRESENT ILLNESS (HPI):
 J.J. is an 18-yo sexually active female presenting with vaginal discharge and mild vaginal discomfort x2 days. Symptoms began suddenly and are localized to the vagina. Pt describes discharge as thin, white, and increased from baseline without foul odor; reports mild vulvar irritation and intermittent itching. Severity mild but concerning to pt due to a change from usual discharge. Symptoms have been constant since the onset and noticed after recent unprotected vaginal intercourse with a male partner. Denies recent antibiotic use, new hygiene products, douching, or prior similar episodes. No alleviating factors; no OTC meds attempted. No aggravating factors identified. Associated symptoms include mild vaginal itching. Denies dysuria, hematuria, pelvic/abdominal pain, fever, chills, dyspareunia, abnormal bleeding, genital lesions, or urinary frequency. Pt is concerned about a possible STI due to unprotected intercourse.

PHQ-9 score: 3, showing minimal depression.

PAST MEDICAL HISTORY (PMH):

Allergies
: NKDA

Medications
: Levetiracetam (Keppra) 1000 mg PO BID

Age/health status
: 18-yo female; generally healthy; seizure disorder well controlled on medication.

Appropriate immunization status, including human papillomavirus (HPV) vaccine as appropriate by age
: Childhood immunizations up to date as reported by pt. HPV vaccine series
incomplete/unknown.

Previous screening Current test results
:

Depression screening: PHQ-9 score 3 → minimal depression

STI screening: urine NAAT pending

UA: negative for UTI

Dates of illnesses during childhood
: Denies rheumatic fever, asthma, congenital disorders, or chronic childhood illness.

Major adult illnesses
: Seizure disorder (stable). Denies hx of: HTN, DM, asthma, TB, cardiac disease, cancer, HIV/AIDS, STIs, renal disease, psychiatric disorders, substance abuse.

Injuries
: Denies significant injuries.

Hospitalizations: Denies prior hospitalizations.

Surgeries (include hospital and year): Denies surgical history.

FAMILY HISTORY (FH):

Mother
: 42 yo, alive, healthy. No HTN, DM, cancer, or psychiatric illness.

Father
: 45 yo, alive, HTN controlled with meds.

Paternal Grandfather
: 67 yo. Alive. History of HTN managed with meds

Paternal Grandmother
: 65yo. Alive. History of Type 2 DM managed with meds

Maternal Grandfather
: 66yo. Alive. HTN managed with meds

Maternal Grandmother
: 60. Alive. 60yo. History of asthma

Siblings
: 1 younger brother (15 yo), healthy.

Children
: none.

SOCIAL HISTORY (SH):
 Patient is single and a full-time college student with no history of military service; she is a high school graduate currently pursuing higher education. She lives with her parents in a safe home environment, exercises occasionally (approximately 1–2 times per week), and follows a mixed diet with ongoing dietary counseling. She reports consistent seatbelt use, functional smoke detectors in the home, and denies firearms in the household. She has not traveled recently and reports no religious or cultural restrictions that affect medical care. She reports daily nicotine vaping and denies alcohol consumption or illicit drug use.

Resources / SDOH:
Has health insurance through parents. Denies financial barriers to care, food insecurity, transportation issues, or housing instability. No hx of postponing medical care.

Reproductive Hx
: Patient reports menarche at age 12 with regular monthly cycles lasting 2–7 days and moderate to heavy flow requiring approximately 4–6 pads per day, with mild dysmenorrhea and no intermenstrual bleeding. She is G0P0 with no history of pregnancy, miscarriage, or abortion, is not currently pregnant, and is not breastfeeding. She does not plan to become pregnant within the next 12 months. Current contraception is the withdrawal method, used inconsistently. She identifies as heterosexual and reports vaginal intercourse only, with concern about STI risk due to unprotected sex. She has never had a Pap smear, which is age-appropriate, with screening recommended starting at age 21.

REVIEW OF SYSTEMS (ROS):

 

Constitutional symptoms
: Reports overall good health; denies fever, chills, fatigue, night sweats, repeated infections, or weight change. Independent in ADLs.

Eyes
: Denies vision changes, diplopia, redness, tearing, pain, trauma. Does not use corrective lenses. Last vision screening within the past 2 yrs per pt, normal.

Ears, nose, mouth, and throat
: Ears: denies hearing loss, tinnitus, vertigo, infections, or hearing aids. Nose: denies congestion, discharge, epistaxis, sinus pain, and anosmia. Mouth/teeth: brushes daily; intermittent flossing; last dental visit 1 yr ago; denies oral lesions, gum bleeding, taste changes. Throat: denies sore throat, hoarseness, dysphagia.

Cardiovascular
: Occasional exercise 1–2x/week. Denies CP, palpitations, dyspnea on exertion, syncope, edema, claudication, murmurs, HTN hx. No prior ECG or lipid screening.

Respiratory
: Daily nicotine vaping exposure. Denies cough, wheeze, dyspnea, sputum, hemoptysis, TB exposure, night sweats. No prior CXR.

Gastrointestinal
: Mixed diet; receives dietary counseling. Denies abdominal pain, N/V, GERD, diarrhea, constipation, hematochezia, melena, jaundice. Normal bowel pattern. No supplements. CRC screening N/A.

Genitourinary
: Admits vaginal discharge and mild vulvovaginal discomfort x2 days. Denies dysuria, hematuria, urgency, nocturia, incontinence, or kidney stones. Sexually active with men; unprotected intercourse; STI screening pending.

Musculoskeletal
: Occasional exercise. Uses a seatbelt; no sports safety equipment reported. Denies joint pain, swelling, back pain, stiffness, weakness, deformities, or limited ROM. No osteoporosis screening indicated.

Integumentary (skin and/or breast)
: Denies rash, itching, lesions, hair loss, nail changes, bruising. Uses basic sun protection. Does not routinely perform skin or breast self-exams. Denies breast pain, lumps, or discharge. Mammogram N/A.

Neurologic
: Hx seizure disorder; controlled on levetiracetam. Denies HA, dizziness, syncope, paresthesia, weakness, tremors, memory loss.

Psychiatric
: PHQ-9 score 3 showing minimal depression. Patient denies anxiety, depression, delusions, hallucinations, stressors, or suicidal thoughts.

Endocrine
: Denies heat/cold intolerance, polydipsia, polyuria, polyphagia, hair/skin changes, weight changes, thyroid disease, or hormonal therapy use.

Hematologic/lymphatic
: Denies easy bruising, bleeding disorders, anemia, or swollen glands.

Allergic/immunologic
:Denies environmental or medication allergies. No history of immunologic disorders.

OBJECTIVE DATA:

Vital Signs (VS):
T 98.5°F, BP 111/69 mmHg, HR 95 bpm, RR 18/min, SpO₂ 97% RA. Ht 65 in, Wt 115.5 lb (52.4 kg), BMI 19.2 kg/m².

General
: 18-yo female, alert, oriented x3, well appearing, well hydrated, in no acute distress, cooperative. Mood and affect are appropriate. Ambulates independently without difficulty.

Skin
:  Warm, dry, intact; good turgor. No rashes, lesions, bruising, or abnormal pigmentation noted.

Hair
:  Normal texture and distribution.

Nails
:  Normal color and shape; no clubbing, cyanosis, or deformities.

HEENT
:  
Head:
Normocephalic, atraumatic, no lesions or deformities.

Eyes:
PERRLA, EOMI, conjunctiva clear, sclera non-icteric.

Ears:
External ears normal, no discharge or tenderness; hearing grossly intact.

Nose:
Mucosa pink, no discharge or congestion.

Mouth:
Mucous membranes are moist, with no lesions.

Teeth/Gums:
Good dentition, no caries or gingival inflammation.

Pharynx:
No erythema, exudate, or tonsillar enlargement.

Neck
: Supple, no lymphadenopathy, no thyromegaly, trachea midline.

Heart
:  Regular rate and rhythm, S1/S2 normal, no murmurs, rubs, or gallops. No JVD or peripheral edema.

Lungs:
  Lungs clear to auscultation bilaterally; no wheezes, rales, or rhonchi. No respiratory distress.

Abdomen
:  Soft, non-tender, non-distended. Normoactive bowel sounds. No masses, guarding, or organomegaly. No CVA tenderness.

Back
:  Spine midline, no deformity or tenderness. No CVA tenderness.

Rectal:
  Normal sphincter tone, no hemorrhoids or masses palpable

Extremities:
  No edema, cyanosis, or deformities. Peripheral pulses 2+ and equal bilaterally.

Musculoskeletal:
  Full ROM in all extremities. Normal gait and station. No joint swelling, tenderness, or weakness.

Neurologic:
  Alert and oriented x3. CN II–XII grossly intact. Strength 5/5 in all extremities. Sensation intact. DTRs 2+ and symmetric. No focal deficits.

Psychiatric:
  Oriented X4, Appropriate mood and affect. Cooperative. Normal judgment, insight, and cognition. No evidence of acute distress .

Pelvic:
  External genitalia normal in appearance with no lesions, masses, or ulcerations. Mild vaginal discharge noted: Thin, white, homogenous, non-foul-smelling. Vaginal mucosa is mildly irritated. Cervix visualized, no lesions, no cervical motion tenderness. Uterus is of normal size, mobile, and non-tender. Adnexa are non-tender bilaterally with no masses.

Breast
:  Breasts symmetrical, no palpable masses, no nipple discharge, no skin changes, and no axillary or supraclavicular lymphadenopathy.

 

DIAGNOSTIC TESTING (Results)

Urinalysis (UA):
Negative for UTI; trace WBC esterase, protein 1+, nitrites negative, blood negative

Whiff test (KOH):
Positive

Urine STI panel (GC/CT/Trich NAAT):
Collected, results pending
 

ASSESSMENT (A):

Bacterial vaginosis (BV) – ICD-10: N76.0

Acute, self-limited vaginal infection characterized by a 2-day history of thin white, non-foul vaginal discharge and mild irritation with positive whiff test and absence of UTI findings. Consistent with BV (Kairys & Garg, 2024). No evidence of pelvic inflammatory disease based on the absence of pelvic pain, fever, or cervical motion tenderness. The condition is acute. Appropriate response expected with therapy. Justification for STI testing due to overlapping symptom profile and high-risk sexual behavior (unprotected intercourse).

Vaginal discharge – ICD-10: N89.8

Symptom-based diagnosis associated with abnormal vaginal discharge x2 days. Etiology most consistent with BV based on exam and diagnostic testing. Requires continued monitoring to ensure resolution and exclude co-infection (e.g., Candida, Trichomonas, GC/CT) (Lakshmi & Amrin, 2023). Additional data justified: STI NAAT results, pH confirmation, and symptom response to treatment.

Screening for sexually transmitted infections (STI) – ICD-10: Z11.3

Health maintenance diagnosis due to unprotected sexual activity with a male partner and no prior STI history. Increased risk profile warrants routine screening (Crowley et al., 2023). UA STI panel sent. Additional recommended testing: HIV, syphilis (RPR), and repeat screening in 3–6 months, depending on results and ongoing risk.

Seizure disorder – ICD-10: G40.909 (epilepsy, unspecified, not intractable, without status epilepticus)

Chronic condition, well-controlled on levetiracetam 1000 mg BID. No reported recent seizure activity or medication noncompliance. No acute neurologic concerns during visit.

Family planning / contraceptive management – ICD-10: Z30.09

Health maintenance issue. Patient is currently sexually active with inconsistent/no reliable contraception (withdrawal method). At risk for unintended pregnancy and STI exposure (World Health Organization, 2025). Condition inadequately addressed (behavioral risk factor) requiring counseling on long-acting reversible contraception (LARC), condoms, and reproductive planning.

Health education / dietary and preventive counseling – ICD-10: Z71.3

Preventive care diagnosis addressing lifestyle counseling. BMI within normal range; counseling provided on nutrition, exercise, and STI prevention. No disease present, but ongoing preventive management is indicated.

Depression screening – ICD-10: Z13.31 / Z13.89

Screening completed with PHQ-9 score of 3, indicating minimal depressive symptoms. No functional impairment or suicidal ideation. Condition well controlled / negative screening, no further psychiatric intervention required at this time.

PLAN (P) – Shared Decision Making

Bacterial Vaginosis (N76.0)

Laboratory/Diagnostics:

Whiff test already positive

STI NAAT (GC/CT/Trich) pending

No additional labs required unless symptoms persist or worsen

Medications:

Metronidazole 500 mg PO BID x 7 days, dispense #14, no refills

Ondansetron 4 mg PO q6h PRN nausea, dispense #28, no refills

Lifestyle Modifications:

Avoid douching, scented soaps, vaginal irritants

Abstain from sexual activity or use condoms until treatment is completed.

Patient Education:

Medication adherence emphasized; complete full antibiotic course

Avoid alcohol during and 24 hrs after metronidazole

Educated on BV recurrence risk and prevention strategies

Patient Responsibility:

Report worsening symptoms (odor, pelvic pain, fever)

Notify the provider if symptoms do not improve within 3–5 days

Follow-up:

Return PRN if symptoms persist or worsen; routine follow-up in 2–4 weeks if needed.

Vaginal Discharge (N89.8)

Laboratory/Diagnostics:

Await STI results (GC/CT/Trich NAAT)

Consider HIV and RPR screening if not previously done

Patient Education:

Explained that discharge is likely related to BV, but STIs must be ruled out due to risk factors

Educated on normal vs abnormal vaginal discharge characteristics

Counseling:

Reinforced safe sex practices and condom use

Follow-up:

Review lab results when available (call/portal follow-up)

STI Exposure Risk / Screening (Z11.3)

Laboratory/Diagnostics:

GC/CT/Trich NAAT (already sent)

Recommend HIV 4th generation test and RPR for syphilis

Consultation:

No specialty referral required at this time unless positive results

Patient Education:

Education on STI prevention, condom use, and partner reduction strategies

Importance of routine screening every 3–6 months if ongoing risk

Coordination of Care:

If positive results, arrange partner notification and treatment per guidelines

Follow-up:

Follow up in 1–2 weeks for results review or sooner if symptoms worsen

Seizure Disorder (G40.909)

Medications:

Continue Levetiracetam 1000 mg PO BID, no changes

Monitoring:

No recent seizure activity reported

Patient Education:

Reinforced medication adherence and seizure trigger avoidance (sleep deprivation, alcohol)

Follow-up:

Neurology follow-up as scheduled or PRN breakthrough seizures

Family Planning / Contraception Needs (Z30.09)

Laboratory/Diagnostics:

Pregnancy test recommended if clinically indicated

Patient Education:

Counseling on LARC options (IUD, implant) and barrier protection

Discussed the failure risk of the withdrawal method

Emphasized dual protection (condoms + hormonal/LARC method)

Lifestyle Modification:

Encourage consistent condom use for STI and pregnancy prevention

Coordination of Care:

Offered referral to a gynecology and family planning clinic for contraceptive counseling/placement

Follow-up:

Reassess contraception plan at next visit or within 1 month

Preventive Health / Depression Screening (Z13.31)

Patient Education:

PHQ-9 reviewed; minimal symptoms, no intervention required

Discussed sleep hygiene strategies due to intermittent insomnia symptoms

Lifestyle Modification:

Encouraged regular sleep schedule, exercise ≥150 min/week

Follow-up:

Repeat screening annually or sooner if mood changes occur

Reflection

My “aha” moment in this encounter was recognizing how easily vaginal discharge complaints in young sexually active patients can be misinterpreted by patients as a “yeast infection or STD,” yet clinically require a structured, evidence-based approach to avoid assumptions and ensure accurate diagnosis. The key turning point was aligning the symptom pattern (thin, white discharge, mild irritation) with the positive whiff test, which strongly supported bacterial vaginosis over other etiologies. I agree with the diagnostic process and treatment regimen, particularly the use of metronidazole as first-line therapy and the inclusion of STI screening, given the patient’s risk profile, as this reflects appropriate adherence to clinical guidelines and preventive care principles. If I were to manage this case again, I would ensure a documented point-of-care pregnancy test is explicitly completed, strengthen the assessment of the reported breast symptoms noted in the ROS for consistency, and place even greater emphasis on structured contraceptive counseling earlier in the visit, including a more detailed discussion of long-acting reversible contraception options rather than focusing primarily on withdrawal method correction. I would also consider earlier reinforcement of partner treatment and sexual health communication strategies to reduce reinfection risk and improve outcomes. While the patient appears to have stable housing, insurance coverage, and family support, key concerns include high-risk sexual behavior without barrier protection, daily nicotine vaping, and potential gaps in sexual health literacy, all of which may influence recurrence risk and long-term reproductive health outcomes.

 
References

Crowley, J. S., Geller, A. B., & Vermund, S. H. (2023). STI screening and treatment guidelines issued by health professional societies. In
www.ncbi.nlm.nih.gov
. National Academies Press (US).
https://www.ncbi.nlm.nih.gov/books/NBK573163/

Kairys, N., & Garg, M. (2024).
Bacterial vaginosis
. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK459216/

Lakshmi, Gj., & Amrin, S. (2023). Vaginal discharge: The diagnostic enigma.
Indian Journal of Sexually Transmitted Diseases and AIDS
,
0
(0), 0.
https://doi.org/10.4103/ijstd.ijstd_92_18

World Health Organization. (2025, July 3).
Family planning/contraception
. Who.int; World Health Organization: WHO.
https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception

 

PRAC 6552 – Comprehensive History and Physical SOAP Note
 

Guidelines for a Comprehensive History and Physical

 SOAP Note

 

     
Label each section of the SOAP note (each body part and system).

     
Do 
not
use unnecessary words or complete sentences.

     
Use standard abbreviations.

 

 

SUBJECTIVE DATA (S):
 
(information the patient/caregiver tells you)

 

Includes all of the information the patient tells you. Identifying data: Initials, age, race, gender, marital status. Name of informant, if not patient.

 

CHIEF COMPLAINT (CC):
 The reason for this health care visit. A statement describing the symptom(s), problem, condition, diagnosis, physician-recommended return, or other factors that are the reason for this patient visit (even if they bring no specific problem). If possible, use the patient’s own words in quotation marks.

 

HISTORY OF PRESENT ILLNESS (HPI):
 If the patient presents with specific problems, symptoms, or complaints, a chronological description of the development of the patient’s present illness from the first sign of each symptom to the current visit is recorded using the elements of 
a symptom analysis.
 Those elements are:

Location
: Where it started, where it is located now

Quality
: Unique properties or characteristics of the symptom

Severity
: Intensity, quantity, or impact on life activities; duration: length of episode

Timing
: When symptom started, frequency (patient’s “story” of the symptom), context (under what conditions it occurs)

Setting
: Under what conditions the symptoms occur, activities that produce the symptoms

Alleviating and aggravating factors
: What makes it better and/or worse, what meds have been taken to relieve symptoms, did the meds help or not, does food make symptoms worse or better

Associated signs and symptoms
: Presence or absence of other symptoms or problems occurring with their complaint; include pertinent negatives and information from the patient’s charts (e.g., lab data or previous visit information)

 

In the case of a 
well visit
, describe the patient’s usual health and summarize health maintenance needs and activities.

 

PAST MEDICAL HISTORY (PMH):

Allergies

Current medications: prescription and over the counter

Age/health status

Appropriate immunization status, including human papilloma virus (HPV) vaccine as appropriate by age.

Previous screening tests result

Dates of illnesses during childhood (may not be very important in adults; exceptions may include rheumatic fever or chronic illnesses continuing into adulthood)

Major adult illnesses (include history of diabetes, hypertension, gastrointestinal diseases, pulmonary disease, cardiovascular disease, cancer, tuberculosis, sexually transmitted infections (STIs), HIV/AIDS, gynecological or urological problems, drug and/or alcohol abuse, and psychiatric illness)

Injuries

Hospitalizations (reason, hospital, attending physician [if known])

Surgeries (include hospital and year)

 

FAMILY HISTORY (FH):
 Age and current health status or age at death and cause of death of each family member (parents, siblings, and children) is recorded. Occurrence within the family of illnesses of an environmental, genetic, or familial nature are recorded in family history. Ask about the presence in the family of any of the following conditions: asthma, glaucoma, myocardial infarctions, heart failure, hypertension, cancer, tuberculosis, diabetes, kidney disease, hemophilia, sickle cell trait or disease, psychiatric diseases, alcoholism allergies, family violence, intellectual disabilities, epilepsy, and congenital abnormalities.

 

Record any specific diseases related to problems identified in CC, HPI, or review of symptoms (ROS).

SOCIAL HISTORY (SH):
 Record important life events: marital status, occupational history, military service, level of education. Record lifestyle and current health habits (may be here or in ROS): exercise, diet, safety (smoke alarms, seatbelts, firearms, sports), living arrangements, hobbies, travel. Record religious preference relevant to health, illness, or treatment. Record habits: use of drugs, alcohol, and tobacco.

 

Resources: resources to pay for care, insurance, worries about cost of care, history of postponing care, other Social Determinants of Health (SDOH) affecting care

 

Reproductive Hx
: Menstrual history (date of last menstrual period [LMP]), age of menarche, cycle frequency, duration, flow (number of pads/ tampons used on heaviest day), symptoms that occur with menses (e.g., dysmenorrhea, migraine headaches), intermenstrual bleeding. Pregnancy (gravida, para), duration of pregnancy, type of delivery, complications (e.g., gestational diabetes, hypertension, preeclampsia), elective abortions, miscarriages, living children. Plan to become pregnancy in the next 12 months (yes or no), nursing/lactating (yes or no), contraceptive use, past and current (method used- satisfaction with current method), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns. Menopause (if applicable, use of hormone replacement therapy).  Last pap smear (date and result),

 

 

REVIEW OF SYSTEMS (ROS):
 There are 14 systems for review. Record a summary for each system. 
Unexpected or positive findings need complete symptom analysis.

 

Constitutional symptoms
: Overall health, weight gain or loss, ideal weight, fever, fatigue, repeated infections, ability to carry out activities of daily living.

Eyes
: eye care, poor eyesight, double or blurred vision, use of corrective lenses or medications, redness, excessive tearing, pain, trauma, date and results of last vision screening or eye exam

Ears, nose, mouth, and throat
: Ears: hearing acuity, exposure to high noise level, tinnitus, and presence of infection or pain, vertigo, use of assistive hearing device. Nose: sense of smell, discharge, obstruction, epistaxis, sinus trouble. Mouth and teeth: use of oral tobacco or smoking cigarettes, last dental exam date and result, pattern of brushing and use of dental floss and fluoride toothpaste, dentures, bleeding of gums, sense of taste, mouth odor or ulcers, sore tongue. Throat: sore throat, hoarseness, dysphagia.

Cardiovascular
: Exercise pattern to maintain cardiovascular health. History of abnormal heart sounds (including murmur), chest pains, palpitations, dyspnea, activity intolerance, usual blood pressure, ECG (date, reason), cholesterol level (date), edema, claudication, varicose veins.

Respiratory
: Exposure to passive smoke. History of respiratory infections, usual self-treatment, cough, last chest x-ray (date, result), exposure to tuberculosis (TB) and last TB skin test (date and result), difficult breathing, wheezing, hemoptysis, sputum production (character, amount), night sweats.

Gastrointestinal
: Dietary pattern, fiber and fat in diet, use of nutritional supplements (vitamins, herbs), heartburn, epigastric pain, abdominal pain, nausea and vomiting, food intolerance, flatulence, diarrhea, constipation, usual bowel pattern, change in stools, hemorrhoids, jaundice. Date of last colorectal cancer screening (if applicable).

Genitourinary
: Nocturia, dysuria, incontinence, sexual practices, sexual difficulty, vaginal discharge and or/ pain, history of kidney stones.

Musculoskeletal
: Exercise pattern, use of seatbelts, use of safety equipment with sports, neck pain or stiffness, joint pain or swelling, incapacitating back pain, paralysis, deformities, changes in range of motion of activity, screening for osteoporosis, knowledge of back injury/pain prevention. Date of last bone density scan if applicable.

Integumentary (skin and/or breast)
: Use of skin protection with sun exposure, self-examination practices in assessing skin, general skin condition and care, changes in skin, rash, itching, nail deformity, hair loss, moles, open areas, bruising. Breast: practice of self-breast exam, lumps, pain, discharge, dimpling, last mammogram (date and result).

Neurologic
: Muscle weakness, syncope, stroke, seizures, paresthesia, involuntary movements or tremors, loss of memory, severe headaches.

Psychiatric
: Nightmares, mood changes, depression, anxiety, nervousness, insomnia, suicidal thoughts, potential for exposure to violence.

Endocrine
: Thyroid problems, cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained weight change, changes in facial or body hair, change in hat or glove size, use of hormonal therapy.

Hematologic/lymphatic
: Bruising, unusual bleeding, fatigue, history of anemia, last HCT and result, history of blood transfusions, swollen and/or tender glands.

Allergic/immunologic
:Seasonal allergies, previous allergy testing, potential for exposure to blood and body fluids, immunized for hepatitis B, immunosuppression in self or family member, use of steroids.

 

OBJECTIVE DATA:

A concise report of physical exam findings. Examples of systems and conclusions are below.

General
: (VS: Temp, BP, pulse, Ht, Wt, BMI). Well appearing, well nourished, in no distress.  Oriented x 3, everyday mood and affect. Ambulating without difficulty.

Skin
:  Good turgor, no rash, unusual bruising or prominent lesions

Hair:  Normal texture and distribution.

Nails:  Normal color, no deformities

HEENT
:   Head:  Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.

Eyes:  Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have standard optic discs and vessels, no exudates or hemorrhages.

Ears:  EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.

Nose:  No external lesions, mucosa non-inflamed, septum and turbinates normal. Mouth:  Mucous membranes are moist, and there are no mucosal lesions.

Teeth/Gums:  No apparent caries or periodontal disease. No gingival inflammation or significant resorption.

Pharynx:  Mucosa non-inflamed, no tonsillar hypertrophy or exudate

Neck:  Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender

Heart
:  No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop

Lungs:
  Clear to auscultation and percussion

Abdomen
:  Bowel sounds normal, no tenderness, organomegaly, masses, or hernia.

Back
:  Spine normal without deformity or tenderness, no CVA tenderness

Rectal:
  Normal sphincter tone, no hemorrhoids or masses palpable

Extremities:
  No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact

Musculoskeletal:
  Normal gait and station.  No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities.

Neurologic:
  CN 2-12 normal.  Sensation to pain, touch, and proprioception regular.  DTRs normal in upper and lower extremities. No pathologic reflexes.

Psychiatric:
  Oriented X3, intact recent and remote memory, judgment and insight, normal mood and affect.

Pelvic:
  External genitalia with symmetric labia, no visible lesions. Labia majora and minora are without erythema or masses. Clitoris is normal in appearance. Perineum intact with no visible tears or scarring. No tenderness noted upon palpation of the external genitalia. Vagina and cervix without lesions or discharge. No cervical motion tenderness. Uterus, smooth, appropriate size, mobile, non- tender, adnexa (ovaries) /parametria nontender without masses.

Breast:  Symmetrical, no nipple abnormality, dominant masses, tenderness to palpation, axillary or supraclavicular adenopathy.

 

Results of any diagnostic testing available during patient visit.

 

ASSESSMENT (A):

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

Diagnosis must be codable (CPT codes).

Provide adequate information to justify ordering additional data (e.g., lab, x-ray).

Do not write that a diagnosis is to be “ruled out.” State the working definitions (symptoms, probable diagnoses) of patient problems in the following areas:

Health maintenance

Acute self-limited problems

Chronic health problems

 

In cases where the diagnosis is 
already established
, indicate whether the diagnosis has the following characteristics: improved, well controlled, resolving, resolved, inadequately controlled, worsening or failing to change as expected.

Note
: Inadequately controlled chronic conditions should have a possible etiology written (e.g., exacerbation, progression, side effects of treatment) if known.

 

 

PLAN (P):
 (The patient should discuss and agree on the plan.) Shared decision- making.

 

The treatment plan includes a wide range of management actions:

Laboratory test

Consultation requested and justification

Medications prescribed (name, dose, route, amount, refills)

Appliances prescribed

Lifestyle modifications: diet, activity modification

Patient education and patient responsibilities (e.g., keeping food diary or BP record)

Patient counseling related to lab/diagnostic results, impression, or recommendations

Family education

Details concerning coordination of care: arranging and organizing patient’s care with other providers and agencies

Follow-up should be specified with time (in days, weeks, months) and/or circumstances of return or noted as PRN

 

 

Note: Number the plan to correlate with the problem list in the Assessment.

 

Include your reflection per the assignment rubric

 

Include references per the assignment rubric

 

 

 

Allowed Attempts
 2

Back to Week at a Glance

Comprehensive Well-Woman Paper

For a wide variety of medical conditions, early detection of the problem enables timely and more effective  treatment. Annual well-woman

exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.

Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.

For this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.

Note
: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.

Note
: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

tO prepare

Reflect on your practicum experience and select a female patient whom you have examined with the support and guidance of your Preceptor.

Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.

Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.

Assignment:

Write an 8- to 10-page Comprehensive Well-Woman Paper that addresses the following:

Age, race and ethnicity, and partner status of the patient

Current health status, including chief concern or complaint of the patient

Contraception method (if any)

Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)

Review of systems

Physical exam

Labs, tests, and other diagnostics

Differential diagnoses

Management plan, including diagnosis, treatment, patient education, and follow-up care

Provide evidence-based guidelines to support treatment plan. 
Note
: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.

Reflection

Reflect on some additional factors for your patient:

What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?

Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.

Reminder
Links to an external site.
: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm).

Note
: Your Comprehensive Well-Woman Paper must be signed by Day 7 of Week 10.

By Day 7

Submit 
your Comprehensive Well-Woman Paper
 by Day 7
. (
Note
: You will submit two files, your Comprehensive Well-Woman Paper, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 10.)

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the 
Turnitin Drafts
 from the 
Start Here
 area.

To submit your completed assignment, save your Assignment as 
WK10Assgn2_LastName_Firstinitial

Then, click on 
Start Assignment
 near the top of the page.

Next, click on 
Upload File
 and select 
Submit Assignment
 for review.

Rubric

PRAC_6552_Week10_Assignment2_Rubric – PRAC 6552 – Comprehensive History and Physical SOAP Note

PRAC_6552_Week10_Assignment2_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeWrite an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following: • Age, race and ethnicity, and partner status of the patient• Current health status, including chief concern or complaint of the patient• Contraception method (if any) • Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem) • Social Determinants of Health assessment• Review of systems• Physical exam• Labs, tests, and other diagnostics• Differential diagnoses• Management plan, including diagnosis, treatment, patient education, and follow-up care• Provide evidence-based guidelines to support treatment plan.

45 to >40.0 ptsExcellent
All required points are addressed, with results that are presented fully and clearly … Provides 5 current and credible scholarly sources to support the treatment plan of care.

40 to >35.0 ptsGood
At least 8 points are addressed with results that are presented clearly. … Provides at least 4 current and credible scholarly sources to support the treatment plan of care.

35 to >34.0 ptsFair
No fewer than 7 points are addressed. One or more results presented in a manner that is vague or incomplete. … Provides at least 3 current and credible scholarly sources to support the treatment plan of care.

34 to >0 ptsPoor
Fewer than 7 points are addressed. One or more results are presented in a manner that is vague, incomplete, or inaccurate. … Provides at least 2 current and credible scholarly sources to support the treatment plan of care.

45 pts

This criterion is linked to a Learning OutcomeReflect on the following: Reflect on some additional factors for your patient: • What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?

40 to >39.0 ptsExcellent
Reflection is clearly presented, with implications that are well-formed, clear, and fully expressed. … Provides at least 3 current and credible scholarly sources to support reflection.

39 to >31.0 ptsGood
Reflection is clearly presented, with implications that are clearly expressed. … Provides at least 3 current and credible scholarly sources to support reflection.

31 to >30.0 ptsFair
Reflection is presented in manner that is vague or unclear. Implications are not fully or clearly expressed. … Provides at least 2 current and credible scholarly source to support reflection.

30 to >0 ptsPoor
Reflection is presented in manner that is vague or unclear. Implications are unclear, or one or both implications not expressed. … Provides at least 1 current and credible scholarly source to support reflection.

40 pts

This criterion is linked to a Learning OutcomeWritten 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. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.

5 to >4.0 ptsExcellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. … A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.

4 to >3.5 ptsGood
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. … Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive.

3.5 to >3.0 ptsFair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60–79% of the time. … Purpose, introduction, and conclusion of the assignment is vague or off topic.

3 to >0 ptsPoor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time. … No purpose statement, introduction, or conclusion was provided. 5 pts This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 ptsExcellent
Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.5 ptsGood
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3.5 to >3.0 ptsFair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

3 to >0 ptsPoor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.

5 to >4.0 ptsExcellent
Uses correct APA format with no errors.

4 to >3.5 ptsGood
Contains a few (1 or 2) APA format errors.

3.5 to >3.0 ptsFair
Contains several (3 or 4) APA format errors.

3 to >0 ptsPoor
Contains many (≥5) APA format errors.

5 pts

Total Points: 100

FPX 4025 Assessment 1 – Evidence Based Research Modalities and Pt assessment on Jose Sanchez Diabetic Ketoacidosis (DKA)

Analyzing a Research Paper: Diabetic Ketoacidosis (DKA)

The diagnosis of interest for this Sentinel U simulation is diabetic ketoacidosis (DKA) as seen in Jose Sanchez’s case. DKA symptoms include hyperglycemia, acidosis, ketosis, and confusion. Evidence-based practice (EBP) is essential in the care of high-acuity patients to inform practice with the best available evidence to improve patient outcomes. The article by Elendu et al. (2023) provides a review of DKA, and this paper assesses its validity and clinical relevance.

Evaluation of Credibility

Fig. 1: Abstract

Table for Article Evaluation

Criteria

Analysis

Type of Study & Level of Evidence

This is a comprehensive review (secondary research study). It’s a Level I evidence on the Johns Hopkins Evidence-Based Practice (JHEBP) model, high in the evidence hierarchy due to multiple studies. The research method is a literature analysis of DKA.

Credibility Factors

The article is peer-reviewed, published in a credible journal, is up-to-date (2023), has multiple expert authors, and includes a DOI. It refers to evidence-based sources and adheres to a scholarly writing format.

Importance of Diagnosis (DKA)

The article describes the key factors of DKA (hyperglycemia, ketosis, and metabolic acidosis), which are present in Jose Sanchez. It discusses common precipitating factors, including infection and diabetes, and the need for rapid treatment, which fits the patient’s symptoms.

Application to Practice/Patient Population

The findings apply to acute care settings, including emergency and critical care units. For example, interventions such as IV fluids, insulin therapy, and electrolyte monitoring can be directly applied to Jose Sanchez. The article also supports patient education and prevention strategies, including culturally appropriate care (e.g., interpreter use).

 

Summary of Findings and Relevance to Diagnosis

DKA is the most common hyperglycemic crisis and a common cause of death in people with diabetes, according to the article. It notes some of the classic signs and symptoms, such as hyperglycemia, metabolic acidosis, and ketosis, all of which are evident in Jose Sanchez. It also describes the usual precipitating factors, which include infection and insulin deficiency, both of which are present in the patient’s case. Crucially, it stresses the need for prompt hospitalization, administration of intravenous fluid, insulin, and electrolyte replacement, which are all part of the patient’s management. In addition, the article cites altered mental status, which is associated with serum osmolality, as related to the patient’s confusion. The results also confirm that DKA is potentially life-threatening if incorrectly diagnosed or improperly managed, and the need for continuous monitoring. This information is important as it supports the care being delivered to Jose Sanchez and emphasizes the need to identify and rapidly treat DKA.

Generalizability to Practice and Patient Population

This article is very generalizable for clinical practice, acute care, and emergency departments. The protocols for management, including fluid replacement, insulin administration, and electrolyte monitoring, can be applied to many patients presenting with DKA, regardless of where they live. This is particularly important in a variety of health care settings, including resource-poor settings where mortality from DKA remains high. The article also highlights the importance of education and the prevention of recurrent DKA. In the Sentinel U scenario, Jose Sanchez needs an education translation into Spanish to understand the management of diabetes and the importance of insulin. This article justifies culturally sensitive discharge and follow-up arrangements. It also emphasizes the need to identify triggers, such as infection, which can help nurses to prevent such triggers in other patients. Therefore, the results of the article can be readily applied to improve patient care and reduce hospital readmissions.

Conclusion

The article discussed is credible, has a high level of evidence, and is relevant to a diagnosis of diabetic ketoacidosis. The article’s conclusions align with the diagnosis and treatment of Jose Sanchez and highlight the need for evidence-based care, including fluid replacement, insulin administration, and monitoring. Additionally, the article offers valuable insights that can be applied across the spectrum of health care and is a useful resource for nursing. Using credible evidence to guide patient care supports sound clinical practice, patient safety, and positive outcomes.

References

Elendu, C., David, J. A., Udoyen, A.-O., Egbunu, E. O., Ogbuiyi-Chima, I. C., Unakalamba, L. O., Temitope, A. I., Ibhiedu, J. O., Ibhiedu, A. O., Nwosu, P. U., Koroyin, M. O., Eze, C., Boluwatife, A. I., Alabi, O., Okabekwa, O. S., Fatoye, J. O., & Ramon-Yusuf, H. I. (2023). Comprehensive review of diabetic ketoacidosis: An update.
Annals of Medicine and Surgery
,
85
(6), 2802–2807.
https://doi.org/10.1097/ms9.0000000000000894

 

FPX 4025 Assessment 1 – Evidence Based Research Modalities and Pt assessment on Jose Sanchez Diabetic Ketoacidosis (DKA)

Assessment 1 – Analyzing a Research Paper

Instructions:

Identify and write a summary of the various factors that contribute to the credibility of a research article related to a diagnosis of interest that you identified from the Sentinel U simulation on Patient Management & Delegation. In the module, there are 10 patients listed with various diagnosis. Select one diagnosis of interest to you from the simulation.

Collapse All

Introduction

Evidence-based practice (EBP) integrates the best evidence available to guide optimal nursing care, with a goal to enhance safety and quality. EBP is crucial to nursing practice because it incorporates the best evidence from current literature, along with the expertise of the practicing nurse. The concern for quality care that flows from EBP generates a desired outcome. Without these factors, a nurse cannot be an effective leader. It is important to lead not only from this position but from knowledge and expertise. To gain the knowledge, you require a good understanding of how to search for scholarly resources, as well as make decisions regarding the content of the scholarly resources.

Professional Context

As a baccalaureate-prepared nurse, you will be responsible for providing patient-centered, competent care based on current evidence-based best practices. You will be required to do research, analysis, and dissemination of best evidence to stay abreast of these best practices. Understanding where to go to find credible evidence, determining the type of evidence and being able to make decisions based on the findings of credible evidence is the foundation of evidence-based care.

Preparation

Review the 
What Is Scholarly?
 Campus page. Specifically, look at the following two items on the page:

What Are Peer-Reviewed Articles?

Anatomy of a Scholarly Article.

These will give you the factors that contribute to credibility, which you will need to identify in the article you choose for this assessment.

Also, look at the “Find EPB Articles” section of the 
Evidence-Based Practice in Nursing & Health Sciences
 library guide (found in the guide’s left-hand menu). This may help you locate an article to use for this assessment.

Instructions

Write a 2-page analysis of a scholarly research article, demonstrating your ability to locate credible, useful evidence related to a diagnosis of interest selected from the Sentinel U simulation on Patient Management & Delegation. There are 10 patients, each with a different medical diagnosis. Select one patient with a diagnosis of interest to you.

Once you have chosen your diagnosis of interest from the Sentinel U simulation, complete the following:

Use a credible search engine to locate a research article on your topic.

Review the article for the following criteria:

Type of study (quantitative or qualitative, the level on the pyramid of evidence, methodology).

Credibility factors.

Importance of content to selected diagnosis.

The ability to apply the content in your current workplace or patient population.

Take a screenshot of the abstract and paste it into a Word document (see the 
Example of Screenshot [PDF]
document). You can refer to the instructions in the 
Taking Screenshots [PDF]

Create a table or series of text boxes next to or below the screenshot and use that to label each criterion.

Also take a screenshot of the patient and the diagnosis from Sentinel U simulation you used.

Write up a summary of your findings on the second page. Note what information is important to your specified diagnosis. How credible is the article you’ve found and how useful is it related to your specified diagnosis and your ability to apply it?

Include a link to your article. FPX 4025 Assessment 1 – Evidence Based Research Modalities and Pt assessment on Jose Sanchez Diabetic Ketoacidosis (DKA)

Include a reference to your article in APA format.

Review the Analyzing a Research Paper scoring guide for specific details of grading prior to submission.

Competencies Measured

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

Competency 1: Interpret findings from scholarly quantitative, qualitative, and outcomes research articles and studies.

Determine the type of study and the level of evidence according to the pyramid of evidence.

Identify the credibility factors of an article.

Summarize the findings of an article, noting what information is important to a specified diagnosis.

Competency 2: Analyze the relevance and potential effectiveness of evidence when making a decision.

Summarize the ability to generalize article findings in a specified work space and patient population.

Competency 5: Apply professional, scholarly communication strategies to lead practice changes based on evidence.

Provide an APA-formatted reference and link to an article.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

 

Criterion 1

Determine the type of study and the level of evidence according to the pyramid of evidence.

Distinguished

Determines the type of study and the level of evidence according to the pyramid of evidence, providing reasons for the determinations.

 

Criterion 2

Identify the credibility factors of an article.

Distinguished

Identifies the credibility factors of an article, including if the article is peer-reviewed.

 

Criterion 3

Summarize the findings of an article, noting what information is important to a specified diagnosis.

Distinguished

Summarizes the findings of an article, noting what information is important to a specified diagnosis, and the information’s implications.

 

Criterion 4

Summarize the ability to generalize article findings in a specified work space and patient population.

Distinguished

Summarizes the ability to generalize article findings in a specified work space and patient population, providing examples.

 

Criterion 5

Provide an APA-formatted reference and link to an article.

Distinguished

Provides a flawless APA-formatted reference and link to an article. FPX 4025 Assessment 1 – Evidence Based Research Modalities and Pt assessment on Jose Sanchez Diabetic Ketoacidosis (DKA)

Autism Spectrum Disorders and Emotions Essay

Discussion: People with certain disorders like autism spectrum disorders may have difficulty identifying people’s emotions from their faces. What kind of challenges might this problem create?

 

Autism Spectrum Disorders and Emotions Essay

People with certain disorders like autism spectrum disorders may have difficulty identifying people’s emotions from their faces. What kind of challenges might this problem create?

Individuals with autism spectrum disorders (ASD) and related developmental disorders may experience some difficulties in recognizing people’s emotions from their facial expressions. This has a significant impact, creating occupational, academic, emotional, and social difficulties as facial expressions are an essential aspect of human communication. People typically rely on facial expressions and cues to understand emotions such as confusion, fear, anger, sadness, and happiness. Individuals are likely to face communication barriers and misunderstandings when they struggle to interpret facial expressions accurately (Tamas et al., 2024).

A major challenge faced by individuals with ASD involves relationship development and social interactions. They may misinterpret the emotional states of others, leading to inappropriate responses during conversations. For instance, they may fail to recognize when someone is joking, uncomfortable, or upset. As a result, others may perceive them as socially disconnected or insensitive. These misunderstandings can contribute to social isolation, difficulties forming friendships, and reduced opportunities for meaningful interpersonal relationships (Riddiford et al., 2022). Recent research reveals that emotional recognition impairments may increase anxiety in social situations as the interactions become difficult to navigate and unpredictable (Meyer-Lindenberg et al., 2022).

In addition, difficulties interpreting facial expressions and recognizing emotions can affect educational and workplace functioning. Classmates, teachers, coworkers, and supervisors frequently communicate non-verbally through facial cues. A person who cannot accurately interpret facial expressions may misunderstand instructions, fail to recognize encouragement or criticism, or respond inappropriately in group settings. Consequently, it becomes more difficult to participate in academic collaboration and workplace teamwork. Individuals may also experience reduced self-confidence, stress, or frustration because of repeated social misunderstandings (Zhao et al., 2026).

Yet another important concern is emotional well-being and personal safety. Recognizing discomfort, anger, or fear in another person’s face helps individuals to identify manipulative or dangerous situations. People who struggle with emotional recognition may be more vulnerable to unsafe social interactions, exploitation, or bullying. In family settings, misunderstanding emotional expressions can create tensions between persons with ASD and caregivers, affecting communication and emotional support (Masoomi et al., 2025) Autism Spectrum Disorders and Emotions Essay.

Recent studies suggest that the challenges in recognizing and interpreting facial expressions are not solely experienced by individuals with ASD. Non-autistic individuals may face similar challenges as they misunderstand the communication styles and emotional expressions of individuals with ASD. This is a “double empathy problem”, which highlights the need for mutual understanding and supportive interventions rather than blaming any single group – autistic or non-autistic individuals (Riddiford et al., 2022). Therapies such as technology-assisted emotional-recognition programs, behavioral interventions, and social skills training may help improve communication and social functioning for individuals with ASD (Liu et al., 2025; Nejati et al., 2024).

References

Liu, Y., Li, S., Huang, Y., & Li, D. (2025). Information Technology-Based Intervention on the Socio-Emotional Competence of Individuals with Autism Spectrum Disorders: A Systematic Review and Meta-Analysis.
Journal of Intelligence, 13
(8), 98.
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 Autism Spectrum Disorders and Emotions Essay