Tag: Clinical-Nursing

  • Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies

    Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies

    Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies

    New technology—and the application of existing technology—only appears in healthcare settings after careful and significant research. The stakes are high, and new clinical systems need to offer evidence of positive impact on outcomes or efficiencies.

    ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE

    Nurse informaticists and healthcare leaders formulate clinical system strategies. As these strategies are often based on technology trends, informaticists and others have then benefited from consulting existing research to inform their thinking. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    In this Assignment, you will review existing research focused on the application of clinical systems. After reviewing, you will summarize your findings.

    To Prepare:

    Review the Resources and reflect on the impact of clinical systems on outcomes and efficiencies within the context of nursing practice and healthcare delivery.

    Conduct a search for recent (within the last 5 years) research focused on the application of clinical systems. The research should provide evidence to support the use of one type of clinical system to improve outcomes and/or efficiencies, such as “the use of personal health records or portals to support patients newly diagnosed with diabetes.” Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    Identify and select 5 peer-reviewed articles from your research.

    The Assignment: (4-5 pages)

    In a
    4- to 5-page paper, synthesize the peer-reviewed research you reviewed
    . Be sure to address the following:

    Identify the 5 peer-reviewed articles you reviewed, citing each in APA format.

    Summarize each study, explaining the improvement to outcomes, efficiencies, and lessons learned from the application of the clinical system each peer-reviewed article described. Be specific and provide examples. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies

    BUY A PLAGIARISM-FREE PAPER HERE

    Use of Clinical Systems to Improve Outcomes and Efficiencies

    Introduction

    Proper clinical systems play an important role in revitalizing the healthcare delivery system worldwide. All primary healthcare professionals need to come together to establish and implement the target clinical systems. The use of evidence-based practices, health information technology and developing clinical systems have been shown to improve patient outcomes and efficiencies. Clinical systems can be used to improve healthcare processes, identify patients at risk, improve efficiency, and advance research in order to improve patient outcomes. Electronic healthcare records (EHR) have been selected as the clinical system. accordingly, this paper will critique five research articles on the application of electronic healthcare records to improve outcomes and efficiencies. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies

    Summary 1

    Bowles, K. H., Dykes, P., & Demiris, G. (2015). The use of health information technology to improve care and outcomes for older adults.
    Research in gerontological nursing
    ,
    8
    (1), 5–10.  doi: 10.3928/19404921-20121222-01.

    According to Bowles, Dykes and Demiris, (2015), EHR are vital in improving documentation and billing in the delivery of healthcare. Healthcare organizations implement EHR to improve quality, safety, and efficiency of care. In regard to improving outcomes, Bowles et al (2015), explains that effective application of EHR can improve care outcomes. For instance, the use of EHR systems has been shown to improve documentation of pressure ulcer and fall risk assessments.  Improved documentation using EHR led to a 13% drop in the rates of nosocomial pressure ulcers. These findings clearly indicate the impact of EHR to improve outcomes. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    The study also highlights the key element of documentation and organization, which are very important in the efficient operations of daily processes with healthcare organizations. The study findings indicate that implementation of EHR led to improved teamwork, collaboration and supportive leadership which led to sustained improvement in safety and quality outcomes (Bowles et al., 2015). Bowles et al (2015), further indicate that the use of EHR supported the integration of clinical decisions for personalized treatment plans into the workflow, improving the efficiency of the workflow.

    From this article, we learn that EHR can be used to improve assessment of adverse events such as documentation of pressure ulcer and fall risk assessments. For example, organizations should ensure all patient data is stored electronically in order to facilitate easy assessment for patients at risk of adverse events.

    Summary 2

    Kruse, C. S., Stein, A., Thomas, H., & Kaur, H. (2018). The use of Electronic Health Records to Support Population Health: A Systematic Review of the Literature.
    Journal of medical systems
    ,
    42
    (11), 214. doi: 10.1007/s10916-018-1075-6. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies

    According to Kruse, Stein, Thomas and Kaur (2018), EHRs are among the clinical systems that improve the quality of care and efficiency of healthcare.  Regarding outcomes, this study found out that implementation of EHRs led to improved delivery and integration of the recommended preventative care into care practices, leading to improved care outcomes. In addition, according to Kruse et al (2018), implementation of EHRs in the ICU significantly lower central line-associated bloodstream infections and mortality rates within the surgical ICU. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    EHRs facilitate the provision of patient-centered care and more coordinated care improving efficiency. EHRs also facilitate the provision of secure access to patients’ information which leads to better outcomes in regard to the quality of care and productivity (Kruse et al., 2018). EHR systems are applied in the management of chronic diseases such as diabetes and regular utilization of the EHRs can decrease data fragmentation and hence improve continuity of care between healthcare professions if healthcare providers engage in health information exchanges. In addition, EHRS within the emergency department improves the decision-making process when utilizing a decision tree and hence improves the quality of life for the patients and is also cost-effective (Kruse et al., 2018) Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    From this article, it is evident EHRs facilitate safe continuity of care. For example, with EHRs, human errors likely to occur during handover using manual paper are eliminated.

    Summary 3

    Manca D. P. (2015). Do electronic medical records improve quality of care? Yes.
    Canadian family physician Medecin de famille canadien
    ,
    61
    (10), 846–851.
    doi
    : 10.14236/jhi. v18i1.751

    Manca (2015) explains various ways that EHRs improve outcomes and efficiency. According to Manca (2015), EHRs improve the management of chronic disease, and screening and prevention of disease, which leads to improved quality of care and outcomes. EHRs can provide treatment goals and notifications to remind healthcare providers when specific preventative and screening planned activities are due or outdated. The EHRs also facilitates access to important information and resources necessary to handle various health conditions which leads to better outcomes (Manca, 2015) Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    The structured EHRs data provide access to point-of-care information which can be utilized in informing practice and conducting research. With meaningful use, the EHR data provides healthcare providers with vital practice-level information that can be utilized for practice-level interventions like identification of patients who missed screening for specific diseases. Such data provides important feedback to the healthcare providers regarding the quality of care (Manca, 2015). Manca (2015) also explains that the use of point-of-care EHR data can provide important information regarding the efficacy of specific medications and other treatment modalities. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    It is therefore evident that EHRs improve disease outcomes. For instance, screening of patients with hypertension using an EHR intervention facilitates provision of the appropriate/specific lifestyle modification education to the target group and hence improves disease outcome, for example reduces blood pressure for the patients.

    Summary 4

    Selvaraj S, Fonarow G, Sheng S, Matsouaka R, DeVore A, Heidenreich A, Hernandez A, Yancy W & Bhatt D. (2018).  Association of Electronic Health Record Use with Quality of Care and Outcomes in Heart Failure: An Analysis of Get with the Guidelines—Heart Failure.
    Journal of the American Heart Association
    , 7(7), pii: e008158. doi: 10.1161/JAHA.117.008158. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies

    Selvaraj, Fonarow, Sheng, Matsouaka, DeVore, Heidenreich, Hernandez, Yancy and Bhatt (2018) provide that implementation of the EHRs leads to improved coordination of care and thus improves efficiency during care provision. Similarly, EHRs have been demonstrated to be effective in decreasing medical errors and hence improve the quality of care and outcomes. However, the findings of this study indicate that the use of EHRs was not attributable to improved quality of care and did not have a significant impact on heart failure-related outcomes (Selvaraj et al., 2018).

    From this article, it is evident that use of EHRs alone may not be sufficient in improving heart failure-related outcomes. Therefore, other interventions such as monitoring patient adherence to treatment and patient education should be integrated in patients’ treatment plan.

    Summary 5

    Campanella P, Lovato E, Marone C, Fallacara L & Mancuso A. (2015). The impact of electronic health records on healthcare quality: a systematic review and meta-analysis.
    European Journal of Public Health
    , 1(5), 60-4. doi: 10.1093/eurpub/ckv122

    Campanella, Lovato, Marone, Fallacara and Mancuso (2015) explore the impact of EHRs on the quality of care. The study explains that the EHR leads to reduced medical errors and thus improves the quality of care and health outcomes. In addition, EHR has been shown to improve time inefficiency and also reduces healthcare costs and thus EHR has led to improved efficiency. Campanella et al (2015) further explain that EHR has been an effective method to reduce healthcare costs and thus improve the quality of care and reduce harm to patients. The availability of the stored computerized enables computerized quality assessment and automated chart review, which is cost-effective and also a time-saving process. Evidence indicates that EHR systems improve the quality of care and outcomes by improving time efficiency and decreasing medication errors (Campanella et al., 2015). Therefore, the implementation of EHR systems significantly improves health outcomes and efficiencies of healthcare processes.

    The article demonstrates that by use of EHRs, medical errors and the consequent adverse events can be avoided. For example, EHR technologies can assist in preventing medication errors by flagging possible adverse reactions and/or drug interactions. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    Conclusion

    Clinical systems such as EHR systems have been shown to improve outcomes, efficiency, and effectiveness in health care. All the selected studies indicated that EHRs improve outcomes by reducing the rate of medical errors, improve documentation, and facilitating the provision of coordinated care: this significantly contributes to improved outcomes. On the other hand, EHRs improve efficiency by promoting teamwork and collaboration among healthcare providers which improves the efficiency of care. In addition, EHR systems save time and reduce costs further indicating the efficiency of EHRs in the healthcare system. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

     

    References

    Bowles, K. H., Dykes, P., & Demiris, G. (2015). The use of health information technology to improve care and outcomes for older adults.
    Research in gerontological nursing
    ,
    8
    (1), 5–10.  doi: 10.3928/19404921-20121222-01.

    Campanella P, Lovato E, Marone C, Fallacara L & Mancuso A. (2015). The impact of electronic health records on healthcare quality: a systematic review and meta-analysis.
    European Journal of Public Health
    , 1(5), 60-4. doi: 10.1093/eurpub/ckv122 Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

    Kruse, C. S., Stein, A., Thomas, H., & Kaur, H. (2018). The use of Electronic Health Records to Support Population Health: A Systematic Review of the Literature.
    Journal of medical systems
    ,
    42
    (11), 214. doi: 10.1007/s10916-018-1075-6.

    Manca D. P. (2015). Do electronic medical records improve quality of care? Yes.
    Canadian family physician Medecin de famille canadien
    ,
    61
    (10), 846–851.
    doi
    : 10.14236/jhi. v18i1.751.

    Selvaraj S, Fonarow G, Sheng S, Matsouaka R, DeVore A, Heidenreich A, Hernandez A, Yancy W & Bhatt D. (2018).  Association of Electronic Health Record Use with Quality of Care and Outcomes in Heart Failure: An Analysis of Get with the Guidelines—Heart Failure.
    Journal of the American Heart Association
    , 7(7), pii: e008158. doi: 10.1161/JAHA.117.008158. Nurs 6051 Assignment: Literature Review: The Use of Clinical Systems to Improve Outcomes and Efficiencies.

  • NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends

    NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends

    Discussion: Healthcare Information Technology Trends

    Throughout history, technological advancements have appeared for one purpose before finding applications elsewhere that lead to spikes in its usage and development. The internet, for example, was originally developed to share research before becoming a staple of work and entertainment. But technology—new and repurposed—will undoubtedly continue to be a driver of healthcare information. Informaticists often stay tuned to trends to monitor what the next new technology will be or how the next new idea for applying existing technology can benefit outcomes.

    ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE

    In this NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends Discussion, you will reflect on your healthcare organization’s use of technology and offer a technology trend you observe in your environment.

     

    To Prepare:

    Reflect on the Resources related to digital information tools and technologies.

    Consider your healthcare organization’s use of healthcare technologies to manage and distribute information.

    Reflect on current and potential future trends, such as use of social media and mobile applications/telehealth, Internet of Things (IoT)-enabled asset tracking, or expert systems/artificial intelligence, and how they may impact nursing practice and healthcare delivery. NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends.

    Assignment

    Write
     
    a brief description of general healthcare technology trends
    , particularly related to data/information you have observed in use in your healthcare organization or nursing practice. Describe any potential challenges or risks that may be inherent in the technologies associated with these trends you described.
    Then, describe at least one potential benefit and one potential risk associated with data safety, legislation, and patient care for the technologies you described.
    Next,
    explain which healthcare technology trends you believe are most promising for impacting healthcare technology in nursing practice and explain why
    .
    Describe whether this promise will contribute to improvements in patient care outcomes, efficiencies, or data management. Be specific and provide examples.

     

    *Please Use APA style 6
    th
    edition. No cover page needed. No running head. References must be within the past five years to include doi and peer reviewed journals. References used must be included in the in-text citations. Please use 4-5 references and follow the instructions provided. Thank you. NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends.

     

    Discussion: healthcare information technology trends

    The healthcare information technology trend observed in my organization is the use of Voalte phones. The use of the Voalte technology application allows all healthcare providers in my organization to receive secured messages through their phones; respond to the patient call lights; make and receive direct calls, and also to receive critical alarms regarding any emergency.  This technology supports efficient workflows and allows a fast response to the patients (Hansen et al., 2018). In addition, the application has been shown to support a quite hospital atmosphere by reducing environmental noise. NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends.

    The challenge associated with the use of Voalte technology is the connectivity issue. Sometimes there are issues of inability to send messages, hanging network, interrupted calls, and dropping calls. This significantly interrupts the communication. For example, there was a time the message was being regarding a critical patient and the network hand and hence the message was not communicated. NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends. This significantly affected the communication regarding care provision for this particular patient. In addition, sometimes the staff members lack the required knowledge and skills to use the application. Evidence indicates that technology applications require education and training to ensure competency and skillfulness for the end-users (Alotaibi & Federico, 2017).

    BUY A PLAGIARISM-FREE PAPER HERE

    Telemedicine is the healthcare technology trend likely to significantly impact healthcare technology in nursing practice. Telemedicine is the provision of healthcare service remotely utilizing technology to diagnose, treat, prevent diseases, and research with the aim of improving health (Serper & Volk, 2018). Telehealth enables patient monitoring and provision of care while patients are at a distance. This significantly improves the health outcomes for patients with chronic diseases and those who are having difficulties in accessing care due to geographical location challenges (Dinesen et al., 2016). For instance, telehealth integrates family members into the care and also allows monitoring of the progress and adherence to prescribed treatments for patients with chronic diseases, which has been shown to improve health outcomes. NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends.

    References

    Alotaibi Y & Federico F. (2017. The impact of health information technology on patient safety.
    Saudi Med J
    , 38(12):1173–1180. doi: 
    10.15537/smj.2017.12.20631

    Dinesen B, Nonnecke B, David L, Toft E, Kamal J et al. (2016). Personalized Telehealth in the Future: A Global Research Agenda.
    J Med Internet Res
    ,18(3), e53. doi:10.2196/jmir.5257

    Hansen J, Lazow M & Hagedorn P. (2018). Reducing Interdisciplinary Communication Failures Through Secure Text Messaging: A Quality Improvement Project.
    Pediatr Qual Saf
    , 3(1), e053. doi: 
    10.1097/pq9.0000000000000053

    Serper M & Volk M. (2018). Current and Future Applications of Telemedicine to Optimize the Delivery of Care in Chronic Liver Disease.
    Clin Gastroenterol Hepatol
    , 16(2), 157–161.e8.  DOI:
    https://doi.org/10.1016/j.cgh.2017.10.004 
      NURS 6051C Week 6 Discussion: Healthcare Information Technology Trends

  • NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

    NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

    Assignment: The Impact of Standardized Nursing Terminology

    Among the Resources in this module is the Rutherford (2008) article 
    Standardized Nursing Language: What Does It Mean for Nursing Practice?
     In this article, the author recounts a visit to a local hospital to view the recent implementation of a new coding system.

    During the visit, one of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1).

    How would you respond to a comment such as this one? NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

    ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE

    To Prepare:

    Review the concepts of informatics as presented in the Resources, particularly Rutherford, M. (2008) 
    Standardized Nursing Language: What Does It Mean for Nursing Practice
    ?

    Reflect on the role of a nurse leader as a knowledge worker.

    Consider how knowledge may be informed by data that is collected/accessed.

    The Assignment:

    In a 2- to 3-page paper, address the following:

    Explain how you would inform this nurse (and others) of the importance of standardized nursing terminologies.

    Describe the benefits and challenges of implementing standardized nursing terminologies in nursing practice. Be specific and provide examples.

    Be sure to support your paper with peer-reviewed research on standardized nursing terminologies that you consulted from the Walden Library. NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

     

    The Impact of Standardized Nursing Terminology

    Introduction

    In the time of evidence-based nursing care, nurses are needed to demonstrate that the care they provide is connected with optimal patient outcomes, along with high level of safety and quality. By using standardized nursing terminologies in the documentation of care, nurses can generate evidence connected to nursing practice. The purpose of this paper is to address how a nurse can inform other nurses on the importance of standardized nursing terminologies and to describe the benefits and challenges in implementing standardized nursing terminologies in nursing practice. NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

    How I would inform this (nurse) and others on the importance of standardized nursing terminologies

    I would inform this nurse and others that nursing has standardized language, entailing unique terminology that aids the efficient delivery of quality care. it is crucial that nurses understand standardized nursing terminology lists, as this comprehension can possibly draw the line that divides a healthcare organization that is efficient from an organization that is inefficient. The utilization of standardized nursing language for documenting care that nurses provide to patients is a crucial tool for the profession of nursing, nurses, and clients/patients (Huard & Monsen, 2017).   When SNTs are not utilized, nurses cannot communicate the concepts they utilize with each other, with consumers and with other providers in a consistent and clear manner. Additionally, with no SNTs, it is not possible to efficiently share electronic nursing data with other settings. NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

    Standardized nursing terminologies (SNTs) provide vital information about patients and the care they receive.   SNTs contribute to improved communication among the nursing staff and other providers which improves the care provided to patients with augmented visibility of nursing interventions and supports health information exchange as well.  This in addition assists to attain the objective of improving quality of care and patient satisfaction. The utilization of SNTs is fundamental for documenting nursing interventions and outcomes, nursing research and continuity of care (Huard & Monsen, 2017; Tastan et al, 2014).

    The benefits and challenges in implementing standardized nursing terminologies in nursing practice

    The implementation of SNTs in nursing practice can be beneficial in organizing patient care, care planning, generation of suitable interventions and generation of appropriated outcomes.  In this era, nurses are required to provide evidence-based care and demonstrate that the care they provide is connected with optimal patient outcomes, along with a high level of safety and quality. By using standardized nursing terminologies in the documentation of care, nurses can generate evidence connected to nursing practice (Strudwick & Hardiker, 2016). NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

    Utilization of SNTs can augment the visibility of nursing and produce the data required to show how nursing care influences patient implementation of SNTs improves the superiority of documented nursing diagnoses and interventions as well as patient outcomes (Huard & Monsen 2017).  For example, nursing intervention classification entails collaborative and independent interventions that a nurse performs or directs others to undertake, on behalf of patients. It involves treatments that a nurse carries out in all specialties and settings. NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay. Since every intervention possesses a coded number, the utilization of nursing intervention classification interventions enhances t electronic gathering of standardized nursing information to assess how effective interventions are.

    Optimal communication among health care provides is essential for the safety of the patient and continuity of care.  Nurses are at the frontline in planning care and communicating crucial information. The utilization of SNTs in documenting care can lead to better care continuity by improving how nurses communicate with one another and with providers and capturing of additional nursing procedures to determine the costs of nursing, offer standards for improving care quality and permit collection of data which enables evaluation of patient outcomes (Adubi et al, 2018). For example, the nursing outcome classification lists the can understand the measures, definitions, and concepts that define patient outcomes affected by nursing interventions. A nurse can identify and measure how her nursing practice impacts patient outcomes when she chooses a nursing outcome classification outcome. NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay.

    BUY A PLAGIARISM-FREE PAPER HERE

    The implementation of SNTs has several benefits to patients, nurses and the nursing profession. However, there are several challenges in implementing SNTs in nursing practice. A key barrier to the implementation of SNTs is the absence of hospital policy concerning the utilization of standardized nursing terminologies.  Another challenge to the adoption of SNTs in nursing practice is the nurses’ lack of know-how on standardized nursing language (Sani & Sani, 2017). The majority of nurses do not adequately understand what standardized nursing language really is, which impedes its use.  Additionally, decision-makers and nurse leaders find it to implement sets of standardized nursing terminology because of lack of comprehensible selection criteria along with directions for utilization (Tastan et al, 2014) NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay.

    Conclusion

    The utilization of standardized nursing terminologies in documenting nursing care is crucial to both nurses and the nursing profession. Utilizing standardized nursing terminologies has numerous essential and significant benefits. These benefits include optimal communication among nurses and other health care team members and improved visibility of nursing intervention and resulting in patient outcomes. NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

     

    References

    Adubi, I., Olaogun, A., & Adejumo, P. (2018). Effects of standardized nursing language continuing education programme on nurses’ documentation of care at University College Hospital, Ibadan.
    Nursing Open
    , 5(1), 37-44. doi: 10.1002/nop2.108

    Huard, R., & Monsen, K. (2017). Standardized Nursing Terminology Use in Electronic Health Records in Minnesota.
    Modern Clinical Medicine Research
    , 1(1), 13-19. doi: 10.22606/mcmr.2017.11003

    Sani, A., & Sani, S.   (2017). Nurses Attitudes and Barriers toward Utilization of Standardized Nursing Language in Sokoto State, Nigeria. 
    Asian Journal of Medicine and Health
    , 2(2), 1-6.   doi:
    10.9734/AJMAH/2017/29433

    Strudwick, G., & Hardiker, N. (2016). Understanding the use of standardized nursing terminology and classification systems in published research: A case study using the Internal Classification for Nursing Practice.
    International Journal of Medical Informatics,
    94, 215-221. doi: 10.1016/j.ijmedinf.2016.06.012.

    Tastan, S., Linch, G., & Keenan, G et al. (2014). Evidence for the Existing American Nurses Association-Recognized Standardized Nursing Terminologies: A Systematic Review.
    International Journal of Nursing Studies
    , 51(8), 1160-1170. doi: 10.1016/j.ijnurstu.2013.12.004 NURS 6051C Assignment: The Impact of Standardized Nursing Terminology Essay

  • NURS 6051C Discussion: Big Data Risks and Rewards Essay

    NURS 6051C Discussion: Big Data Risks and Rewards Essay

    Discussion: Big Data Risks and Rewards

    When you wake in the morning, you may reach for your cell phone to reply to a few text or email messages that you missed overnight. On your drive to work, you may stop to refuel your car. Upon your arrival, you might swipe a key card at the door to gain entrance to the facility. And before finally reaching your workstation, you may stop by the cafeteria to purchase a coffee.

    ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE

    From the moment you wake, you are in fact a data-generation machine. Each use of your phone, every transaction you make using a debit or credit card, even your entrance to your place of work, creates data. It begs the question: How much data do you generate each day? Many studies have been conducted on this, and the numbers are staggering: Estimates suggest that nearly 1 million bytes of data are generated every second for every person on earth.

    As the volume of data increases, information professionals have looked for ways to use big data—large, complex sets of data that require specialized approaches to use effectively. Big data has the potential for significant rewards—and significant risks—to healthcare. In this Discussion, you will consider these risks and rewards.

    To Prepare:

    Review the Resources and reflect on the web article
    Big Data Means Big Potential, Challenges for Nurse Execs
    .

    Reflect on your own experience with complex health information access and management and consider potential challenges and risks you may have experienced or observed. NURS 6051C Discussion: Big Data Risks and Rewards Essay

    By Day 3 of Week 4

    Post
    a description of at least one potential benefit of using big data as part of a clinical system and explain why. Then, describe at least one potential challenge or risk of using big data as part of a clinical system and explain why. Propose at least one strategy you have experienced, observed, or researched that may effectively mitigate the challenges or risks of using big data you described. Be specific and provide examples. NURS 6051C Discussion: Big Data Risks and Rewards Essay

    Big data risks and rewards

    Big data within the context of health care refers to all the data generated from interactions between stakeholders and health care systems. In fact, they are information collected from medical devices, pharmaceutical research, mayor records, genomic sequencing, medical imaging, and electronic health records. Other sources of big data include public records, search engines, smart phones, government agencies, patient portals, and research studies (Tavazzi, 2019). Big data is useful for the health care industry. In this case, appropriate software and data analysis tools can be leveraged to determine trends and themes in the big data, which would then act as actionable information that informs advancements such as cost reduction, improved safety, better care outcomes, and value-based health care. With the wealth of analytics information from big data, stakeholders in the health care industry can make better financial and medical information as increasing quality of health care is delivered (Dash et al., 2019). Still, the use of big data is hindered by some challenges. NURS 6051C Discussion: Big Data Risks and Rewards Essay. The first challenge is the privacy of health information since most medical data is protected and its use in analytics without the express permission of the patient could be construed as violation of existing confidentiality and privacy regulations. The second challenge is data security since there is always a potential for unauthorized persons to access the data. The third challenge is budget constraints since analyzing big data could require substantial resources and time. The fourth challenge is data siloes that isolate the data thus making it difficult to access. The final challenge is the diversity in data context, type and format that makes it difficult to process big data and harness its potential. The mentioned challenges can be addressed through targeted approaches that acknowledge the existence of these challenges and proactively addresses them (Adibuzzaman et al., 2017; Hong et al., 2018). For instance, ensuring that data is presented in the same context, type and format to facility processing efforts. Overall, big data has value for the health care industry through delivering evidence-based information to improve the performance of clinical systems. NURS 6051C Discussion: Big Data Risks and Rewards Essay.

    BUY A PLAGIARISM-FREE PAPER HERE

    References

    Adibuzzaman, M., DeLaurentis, P., Hill, J. & Benneyworth, B. (2017). Big data in healthcare – the promises, challenges and opportunities from a research perspective: A case study with a model database.
    AMIA Annual Symposium Proceedings Archive
    , 2017, 384-392. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977694/pdf/2731403.pdf NURS 6051C Discussion: Big Data Risks and Rewards Essay

    Dash, S., Shakyawar, S. K., Sharma, M. & Kaushik, S. (2019). Big data in healthcare: management, analysis and future prospects.
    Journal of Big Data
    , 6, Article number 54. DOI: 10.1186/s40537-019-0217-0. Retrieved from https://journalofbigdata.springeropen.com/articles/10.1186/s40537-019-0217-0

    Hong, L., Luo, M., Wang, R., Lu, P., Lu, W. & Lu, L. (2018). Big data in health care: applications and challenges.
    Data and Information Management
    , 2(3), 175-197. DOI: 10.2478/dim-2018-0014

    Tavazzi, L. (2019). Big data: is clinical practice changing?
    European Heart Journal Supplements
    , 21(Suppl. B), B98–B102. DOI: 10.1093/eurheartj/suz034 NURS 6051C Discussion: Big Data Risks and Rewards Essay

  • NURS 6051C Discussion Week 3 – nurse informaticists Essay

    NURS 6051C Discussion Week 3 – nurse informaticists Essay

    NURS 6051C Discussion Week 3

    In this Discussion, you will reflect on your own observations of and/or experiences with informaticist collaboration. You will also propose strategies for how these collaborative experiences might be improved.

    To Prepare:

    Review the Resources and reflect on the evolution of nursing informatics from a science to a nursing specialty.

    Consider your experiences with nurse Informaticists or technology specialists within your healthcare organization. NURS 6051C Discussion Week 3 – nurse informaticists Essay

    ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE

    Post
     a description of experiences or observations about how nurse informaticists and/or data or technology specialists interact with other professionals within your healthcare organization. Suggest at least one strategy on how these interactions might be improved. Be specific and provide examples. Then, explain the impact you believe the continued evolution of nursing informatics as a specialty and/or the continued emergence of new technologies might have on professional interactions.

     

    NURS 6051C

    How Nurse Informaticists Interact with other Professionals

    In my healthcare organization, nurse informaticists and other technology specialists work to improve the accuracy, improve efficiency, eliminate unnecessary work, and ensure that the data analysis is meaningful in order to help other healthcare providers improve the quality of patient care (Darvish et al., 2014). Technology specialists and nurse informaticists in my organization belong to the IT department where they facilitate data integration, knowledge and information to support nurses, patients, and other healthcare providers during decision-making. Since they mostly spend most of their time in the IT department, the interactions with other healthcare providers are minimal. However, there are open lines where healthcare providers can directly contact the IT specialists in case of any technology hiccup such system breakdown. The main interactions between technology specialists, nurse informaticists, and other healthcare professionals occur electronically or when there is a scheduled physical meeting. This means that interactions are relatively minimal (Mi et al., 2017). However, nurse informaticists, IT specialists and other healthcare professionals in the organization share the organizational vision and understand the role of each other, towards achieving better patient outcomes.

    Strategies to Improve the Interactions

    Since technology specialists are located in a different office, and hence there are minimal interactions with other healthcare providers, interactions can be improved by implementing software that can facilitate interactions between healthcare providers and IT specialists. This can promote information sharing and assist team members to interact often even without physical meetings. The interactions can improve collaboration between healthcare professionals with technology specialists and nurse informaticists. The applications should have automated notifications to ensure that the appropriate team members get suitable communications at the appropriate time. In addition, social media platforms such as Facebook and WhatsApp can be used to facilitate interactions between technology specialists and other professionals. Through WhatsApp and Facebook groups, information can be shared about the latest technology developments and other professionals get a platform to ask questions and raise their concerns and challenges they might be facing with the technology (Smailhodzic et al., 2016). It is important to encourage different departments, and particularly the technology department to regularly post on the organizational blog page and share updates and news on their activities and latest developments. This will keep all staff members up-to-date and at the same time promote interactions. NURS 6051C Discussion Week 3 – nurse informaticists Essay

    Impact of Evolution of Nursing Informatics and New Technologies on Professional Interactions

    The continued evolution of nursing informatics and technologies are likely to reduce physical interactions among professionals. For instance, the technologies are likely to reduce physical meetings because information can be communicated electronically. Moreover, nurses and other healthcare providers use computers and information technologies to communicate and document clinical data, which is finally sent to the target audience electronically. This significantly minimizes physical interactions and hence reduces professional interactions (Mi et al., 2017). However, new technologies are likely to improve interactions electronically where professionals can even interact remotely and even discuss important clinical decisions while located in different geographical locations (Ramundo, 2015).

    BUY A PLAGIARISM-FREE PAPER HERE

    References

    Darvish A, Fatemeh B, Sara K & Mojdeh N. (2014). The Role of Nursing Informatics on Promoting Quality of Health Care and the Need for Appropriate Education.
    Glob J Health Sci
    , 6(6), 11–18.

    Mi K, Coiera E & Magrabi F. (2017). Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review,
    Journal of the American Medical Informatics Association
    , 24(2), 246–250.

    Ramundo D. (2015). New technologies to enhance nursing practice.
    NursCrit Care
    , 7(3), 40-42.

    Smailhodzic, E., Hooijsma, W., Boonstra, A. et al. (2016).  Social media use in healthcare: A systematic review of effects on patients and on their relationship with healthcare professionals.
    BMC Health Serv Res
    , 16(442). doi:10.1186/s12913-016-1691-0. NURS 6051C Discussion Week 3 – nurse informaticists Essay

  • Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

    Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

    Transcript

    Started:
     Apr 08, 2020 | 
    Total Time:
    74 min

    All Lines (176)
    Interview Questions (58)
    Statements (19)
    Exam Actions (99)

    Hello. My name is Pam and I will be interviewing today and later do a physical examination.

    Greet

    04/08/20 9:01 PM PDT

    Hi.

    What is your name?

    Question

    04/08/20 9:01 PM PDT

    My name is Daniel Rivera, but I just go by Danny.

    What brings you to the clinic today?

     SCORE 100% ON YOUR SHADOW HEALTH ASSESSMENT

    Question

    04/08/20 9:01 PM PDT

    My Abuela brought me here because I’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired.

    Am sorry to hear that you are sick .

    Empathize

    04/08/20 9:02 PM PDT

    Thank you.

    Do you have a cough?

    Question

    04/08/20 9:03 PM PDT

    I guess I’m kind of sick. . . I’ve been coughing a lot.

    How long have you had a cough?

    Question

    04/08/20 9:03 PM PDT

    I think the cough started four. . . No, it started five days ago. Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

    Is your cough a wet or a dry one?

    Question

    04/08/20 9:03 PM PDT

    My cough seems kind of gurgly and watery.

    That sounds like a wet cough

    Educate

    04/08/20 9:04 PM PDT

    Oh, OK.

    Do yxxx

    Question

    04/08/20 9:05 PM PDT

    Isxxx

    Am sorry to hear this.

    Empathize

    04/08/20 9:05 PM PDT

    Thank you.

    Howxxx

    Question

    04/08/20 9:06 PM PDT

    I jxx

    Do thexxx

    Question

    04/08/20 9:07 PM PDT

    Most timesxxx

    Am sorry to hear this.

    Empathize

    04/08/20 9:08 PM PDT

    Thank you.

    Do youxxx

    Question

    04/08/20 9:08 PM PDT

    No way! I knowxxx

    True, xxx

    Educate

    04/08/20 9:09 PM PDT

    Oh, OK.

    Are you ever aroundxxxx

    Question

    04/08/20 9:13 PM PDT

    Well . . . sometimes xxx

    Am sorry about that, i xxx

    Question

    04/08/20 9:14 PM PDT

    Am sorry about that, i understand your concerns.

    Empathize

    04/08/20 9:14 PM PDT

    Thank you.

    What makes your coughs worse?

    Question

    04/08/20 9:15 PM PDT

    My cough mostly stays the same no matter what I do. It seems to get worse at night though.

    Have you triedxxx

    Question

    04/08/20 9:15 PM PDT

    I had somexxx. [AUDIO COMING SOON]

    What is the xxx

    Question

    04/08/20 9:16 PM PDT

    I don’t know whatxxx

    Who xxx

    Question

    04/08/20 9:17 PM PDT

    My xxx

    how muchxxx

    Question

    04/08/20 9:17 PM PDT

    I just hadxxx

    How xxx

    Question

    04/08/20 9:18 PM PDT

    I only xxx. [AUDIO COMING SOON]

    Apart from thexxx

    Question

    04/08/20 9:18 PM PDT

    Do youxxx

    Question

    04/08/20 9:20 PM PDT

    Oh yeah, I xxx

    I understand, its xxx

    Educate

    04/08/20 9:21 PM PDT

    Oh, OK.

    Are you usually active?

    Question

    04/08/20 9:22 PM PDT

    I have gym class every day. I do all my exercises there. And there’s a park right next to my house where I play after school, or sometimes on the weekends, if it’s nice outside. [AUDIO COMING SOON]

    Great, keep exercising, its healthy.

    Educate

    04/08/20 9:23 PM PDT

    Oh, OK.

    Does the cough make you less active?

    Question

    04/08/20 9:24 PM PDT

    No, that doesn’t help my cough.

    Are you able to focus in class?

    Question

    04/08/20 9:24 PM PDT

    I can focus normally, but I couldn’t sleep very well last night because of my coughing, so it was harder than normal. Plus, it’s harder to pay attention when you keep having to cough. [AUDIO COMING SOON]

    Am sorry to hear that the cough is disturbing you sometimes. (No matching questions found.)

    Question

    04/08/20 9:24 PM PDT

    Am sorry to hear that the cough is disturbing you sometimes.

    Empathize

    04/08/20 9:25 PM PDT

    Thank you.

    Do you xxx

    Question

    04/08/20 9:28 PM PDT

    My xx

    Am sorry about this

    Empathize

    04/08/20 9:28 PM PDT

    Thank you.

    Have you xxx

    Question

    04/08/20 9:28 PM PDT

    I don’t xxx

    what xxx

    Question

    04/08/20 9:29 PM PDT

    You mean likexxxx

    Yes, that one. Ok, thanks.

    Educate

    04/08/20 9:30 PM PDT

    Oh, OK.

    How consistent is xxx

    Question

    04/08/20 9:38 PM PDT

    It’s kind of xxx

    xx

    Question

    04/08/20 9:41 PM PDT

    My xxx . . . my left one is OK though.

    Am sorry to hear this Danny

    Empathize

    04/08/20 9:42 PM PDT

    Thank you.

    Do you havexxx

    Question

    04/08/20 9:42 PM PDT

    No, xxxkind of hurts.

    Do you have xxx problems?

    Question

    04/08/20 9:42 PM PDT

    A lady came to my school to xx . . . Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

    Great, its good to have a test done whenever there is a chance.

    Educate

    04/08/20 9:43 PM PDT

    Oh, OK.

    Do you have soar throat?

    Question

    04/08/20 9:44 PM PDT

    It feels a little bit sore, yeah.

    Does it xxx

    Question

    04/08/20 9:45 PM PDT

    No, I can xxxx

    Sorry about that Danny

    Empathize

    04/08/20 9:45 PM PDT

    Thank you.

    Have you xxx

    Question

    04/08/20 9:46 PM PDT

     

    Do you have difficulty breathing?

    Question

    04/08/20 9:58 PM PDT

    I can breathe OK, yeah . . . my nose is a little bit runny though.

    Thank you for answering the questions Danny. I will now do the physical examination.

    Question

    04/08/20 9:59 PM PDT

    I don’t have any questions really.

    Thank you for answering the questions, i will now do the physical examination on you.

    Educate

    04/08/20 10:00 PM PDT

    Oh, OK.

     Checked vitals

    Exam Action

    04/09/20 11:08 AM PDT

     Tested lung capacity with spirometer: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%) Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

    Exam Action

    04/09/20 11:12 AM PDT

     Inspected upper conjunctiva

    Exam Action

    04/09/20 11:14 AM PDT

     Inspected upper conjunctiva

    Exam Action

    04/09/20 11:14 AM PDT

     Inspected upper conjunctiva

    Exam Action

    04/09/20 11:14 AM PDT

     Inspected lower conjunctiva

    Exam Action

    04/09/20 11:14 AM PDT

     Inspected right orbital area and sclera

    Exam Action

    04/09/20 11:14 AM PDT

     Inspected left orbital area and sclera

    Exam Action

    04/09/20 11:15 AM PDT

     Performed otoscopic examination of right naris

    Exam Action

    04/09/20 11:15 AM PDT

     Performed otoscopic examination of left naris

    Exam Action

    04/09/20 11:15 AM PDT

     Performed otoscopic examination of right ear

    Exam Action

    04/09/20 11:16 AM PDT

     Performed otoscopic examination of left ear

    Exam Action

    04/09/20 11:16 AM PDT

     Inspected mouth

    Exam Action

    04/09/20 11:16 AM PDT

     Inspected front of neck

    Exam Action

    04/09/20 11:16 AM PDT

     Inspected right side of neck

    Exam Action

    04/09/20 11:17 AM PDT

     Inspected front of neck

    Exam Action

    04/09/20 11:17 AM PDT

     Inspected left side of neck

    Exam Action

    04/09/20 11:17 AM PDT

     Inspected back of neck

    Exam Action

    04/09/20 11:17 AM PDT

     Inspected anterior chest wall

    Exam Action

    04/09/20 11:17 AM PDT

     Inspected posterior chest wall

    Exam Action

    04/09/20 11:17 AM PDT

     Inspected anterior chest wall

    Exam Action

    04/09/20 11:17 AM PDT

     Palpated frontal sinuses: No tenderness reported

    Exam Action

    04/09/20 11:19 AM PDT

     Palpated maxillary sinuses: No tenderness reported

    Exam Action

    04/09/20 11:20 AM PDT

     Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side

    Exam Action

    04/09/20 11:23 AM PDT

     Palpated supraclavicular lymph nodes: Not palpable

    Exam Action

    04/09/20 11:23 AM PDT

     Palpated axillary lymph nodes: Not palpable

    Exam Action

    04/09/20 11:23 AM PDT

     Palpated axillary lymph nodes: Not palpable

    Exam Action

    04/09/20 11:23 AM PDT

     Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally

    Exam Action

    04/09/20 11:24 AM PDT

    Ninety-nine.

     Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally

    Exam Action

    04/09/20 11:24 AM PDT

    Ninety-nine.

     Palpated fremitus in posterior upper chest wall: Expected fremitus, equal bilaterally

    Exam Action

    04/09/20 11:24 AM PDT

    Ninety-nine.

     SCORE 100% ON YOUR SHADOW HEALTH ASSESSMENT 

     Palpated fremitus in posterior middle chest wall: Expected fremitus, equal bilaterally

    Exam Action

    04/09/20 11:24 AM PDT

    Ninety-nine.

     Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally

    Exam Action

    04/09/20 11:24 AM PDT

    Ninety-nine.

     Auscultated breath sounds in anterior left upper lobe

    Exam Action

    04/09/20 11:25 AM PDT

     Auscultated breath sounds in anterior right upper lobe

    Exam Action

    04/09/20 11:25 AM PDT

     Auscultated breath sounds in anterior right middle lobe

    Exam Action

    04/09/20 11:26 AM PDT

     Auscultated breath sounds in anterior left mid-chest (upper lobe)

    Exam Action

    04/09/20 11:26 AM PDT

     Auscultated breath sounds in anterior left mid-chest (upper lobe)

    Exam Action

    04/09/20 11:26 AM PDT

     Auscultated breath sounds in anterior right middle lobe

    Exam Action

    04/09/20 11:26 AM PDT

     Auscultated breath sounds in anterior right lower lobe

    Exam Action

    04/09/20 11:26 AM PDT

     Auscultated breath sounds in anterior left lower lobe

    Exam Action

    04/09/20 11:27 AM PDT

     Auscultated breath sounds in posterior left upper lobe

    Exam Action

    04/09/20 11:27 AM PDT

     Auscultated breath sounds in posterior right upper lobe

    Exam Action

    04/09/20 11:27 AM PDT

     Auscultated breath sounds in posterior right mid-back (lower lobe)

    Exam Action

    04/09/20 11:27 AM PDT

     Auscultated breath sounds in posterior left mid-back (lower lobe)

    Exam Action

    04/09/20 11:27 AM PDT

     Auscultated breath sounds in posterior right lower lobe near spine

    Exam Action

    04/09/20 11:28 AM PDT

     Auscultated breath sounds in posterior left lower lobe near spine

    Exam Action

    04/09/20 11:28 AM PDT

     Auscultated breath sounds in posterior left lower lobe on side

    Exam Action

    04/09/20 11:28 AM PDT

     Auscultated breath sounds in posterior left lower lobe

    Exam Action

    04/09/20 11:28 AM PDT

     Auscultated breath sounds in posterior right lower lobe

    Exam Action

    04/09/20 11:28 AM PDT

     Auscultated breath sounds in posterior right lower lobe on side

    Exam Action

    04/09/20 11:28 AM PDT

     Auscultated voice sounds in anterior right upper lobe

    Exam Action

    04/09/20 11:29 AM PDT

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in anterior left upper lobe

    Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

    Exam Action

    04/09/20 11:29 AM PDT

    Ninety-nine.

    Ninety-nine.

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in anterior left mid-chest (upper lobe)

    Exam Action

    04/09/20 11:29 AM PDT

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in anterior right middle lobe

    Exam Action

    04/09/20 11:29 AM PDT

    Ninety-nine.

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in anterior right middle lobe

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in anterior left mid-chest (upper lobe)

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

     Auscultated voice sounds in anterior left lower lobe

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

     Auscultated voice sounds in anterior right lower lobe

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in posterior left upper lobe

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in posterior right upper lobe

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

     Auscultated voice sounds in posterior right mid-back (lower lobe)

    Exam Action

    04/09/20 11:30 AM PDT

     Auscultated voice sounds in posterior left mid-back (lower lobe)

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in posterior left lower lobe near spine

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

     Auscultated voice sounds in posterior right lower lobe near spine

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in posterior right lower lobe on side

    Exam Action

    04/09/20 11:30 AM PDT

    Ninety-nine.

     Auscultated voice sounds in posterior right lower lobe

    Exam Action

    04/09/20 11:31 AM PDT

    Ninety-nine.

     Auscultated voice sounds in posterior left lower lobe

    Exam Action

    04/09/20 11:31 AM PDT

    Ninety-nine.

    Ninety-nine.

     Auscultated voice sounds in posterior left lower lobe on side

    Exam Action

    04/09/20 11:31 AM PDT

    Ninety-nine.

    Ninety-nine.

    Ninety-nine.

     Auscultated aortic area with the bell

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated aortic area with the diaphragm

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated aortic area with the bell

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated aortic area with the diaphragm

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated aortic area with the bell

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated aortic area with the diaphragm

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated pulmonic area with the diaphragm

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated pulmonic area with the bell

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated Erb’s point with the bell

    Exam Action

    04/09/20 11:31 AM PDT

     Auscultated Erb’s point with the diaphragm

    Exam Action

    04/09/20 11:32 AM PDT

     Auscultated tricuspid area with the diaphragm

    Exam Action

    04/09/20 11:32 AM PDT

     Auscultated tricuspid area with the bell

    Exam Action

    04/09/20 11:32 AM PDT

     Auscultated mitral area with the bell

    Exam Action

    04/09/20 11:32 AM PDT

     Auscultated mitral area with the diaphragm

    Exam Action

    04/09/20 11:32 AM PDT

     Percussed anterior right upper lobe

    Exam Action

    04/09/20 11:32 AM PDT

     Percussed anterior right middle lobe

    Exam Action

    04/09/20 11:32 AM PDT

     Percussed anterior left upper lobe

    Exam Action

    04/09/20 11:32 AM PDT

     Percussed anterior left mid-chest (upper lobe)

    Exam Action

    04/09/20 11:32 AM PDT

     Percussed anterior left lower lobe

    Exam Action

    04/09/20 11:32 AM PDT

     Percussed anterior right lower lobe

    Exam Action

    04/09/20 11:32 AM PDT

     Percussed posterior left upper lobe

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior left mid-back (lower lobe)

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior right mid-back (lower lobe)

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior right upper lobe

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior left lower lobe

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior left lower lobe on side

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior left lower lobe near spine

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior right lower lobe near spine

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior right lower lobe

    Exam Action

    04/09/20 11:33 AM PDT

     Percussed posterior left right lobe on side

    Exam Action

    04/09/20 11:33 AM PDT

     Inspected mouth

    Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

    Exam Action

    04/09/20 11:58 AM PDT

  • NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

    NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

    NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

    Week Seven: Assessment of Abdomen and Gastrointestinal System

    Review of case study #2

    Scenario: A 50-year-old male complains of burning pain starting at the abdomen and rising to the middle of his chest. He describes the pain as a gnawing feeling that begins after meals, especially when lying down.

    Episodic/Focused SOAP Note for Throat Exam

    Patient Information: V.S.     Age: 50 y.o.        Sex: Male          DOB: 8/7/1967

    S
    .

    ORDER A PLAGIARISM-FREE PAPER HERE

    Chief Complaint/Reason for Visit:

    The patient reported abdominal discomfort for the past two days that feels like “burning sensation in his chest.”

    History of Present Illness:

    Mr. V.S. is a 50 y/o Caucasian male with h/o hyperlipidemia, hypothyroidism, hypertension, DM Type II, presenting with c/o abdominal discomfort ranging from 5 to 6 out of 10 for two days. According to the patient, his stomach discomfort has however been ongoing for the past two days and describes it as burning pain starting at the mid-abdomen and rising to the middle of his chest. He reported that the pain usually begins when he eats and worsens when lying down but subsides when he walks. Patient denies constipation or diarrhea. His last meal was at 14:00 today. According to the patient, he recently started taking aspirin once a day as advised by his primary care physician. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

    Current Medications:

    Atorvastatin (Lipitor) 40 mg tablet Take 40 mg nightly

    Levothyroxine (SYNTHROID) 100 mcg once daily

    Metformin (GLUCOPHAGE) 500 mg tablet two times daily (with breakfast & dinner)

    Aspirin 81mg once daily

    Allergies: No known allergies

    PMHx:

    Diabetes mellitus (managed by diet and medication)

    Diabetes type 2, controlled with diet and medication

    Hyperlipidemia (currently on medication)

    Hypothyroidism (managed by medication)

    Fam Hx: Reported both parents are alive, father with hypertension, mother with diabetes.

    Personal/Social History: Drinks ETOH occasionally. Consumes 2-3 cans of beer two times per week. Denies smoking, and illicit drug use.

    Review of Systems:

    Constitutional:  A&O x4, pleasant and cooperative. Reports abdominal pain 5-6/10. No acute distress. Denies weight loss, weakness, or fatigue.

    HEENT:  Denies headache, sore throat or changes in hearing.

    SKIN:  No rash or itching.

    CARDIOVASCULAR:  Reported burning sensation on his chest when lying down.

    RESPIRATORY:  Denies shortness of breath or cough.

    GASTROINTESTINAL:  Reported abdominal discomfort for the past two days ranging from 5-6/10. Described as “gnawing” and “burning.” Denies nausea or vomiting. No change in bowel pattern.

    GENITOURINARY:  Denies dysuria or hematuria.

    NEUROLOGICAL:  Denies focal loss of strength or loss of sensation.

    MUSCULOSKELETAL:  Denies focal weakness, facial droop, or joint swelling.

    HEMATOLOGIC:  No anemia, bleeding or bruising. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

    LYMPHATICS:  No enlarged nodes. No cervical lymphadenopathy

    ALL OTHER SYSTEMS REVIEWED AND NEGATIVE OF PERTINENT FINDINGS

    O.

    Physical exam: Vital signs: B/P 117/59, Pulse 108 (strong and regular); Temp 98.3F orally; RR 18; non-labored; SpO2: 96% room air;

    Height 1.575 m (5′ 2″), weight 73.5 kg (162 lb),

    General: A&O x4, pleasant and cooperative. Not in any acute distress.

    HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

    Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules.

    Chest/Lungs: Clear to auscultation bilaterally. No wheezing, crackles or rhonchi. No accessory muscle use.

    Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.  NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

    ABD: Reports of 5-6/10 pain. Soft, nontender, nondistended. Hyperactive BS. No palpable hepatosplenomegaly

    Genital/Rectal: continent of bladder and bowel.

    Musculoskeletal: Normal range of motion. Regular muscle mass for age. No swelling or joint deformities.

    Neuro: Alert and oriented x4. Strength and sensation intact.

    Skin/Lymph Nodes: No cervical lymphadenopathy. No rashes, or erythema. No lesions. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

    Diagnostic results:

    EKG: NSR

    Laboratory studies:

    CBC – WBC 9.4; H/H: 14.3/41.0; PLT: 289.

    Chemistry Panel: BUN/Crea: 19/0.52; Glucose: 117*

    Pylori serology: negative

    Esophageal pH Test: pending

    NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

     

    A
    .

    Differential Diagnoses (DD):

    Gastroesophageal Reflux Disease (GERD): backward flow of gastric contents, which are typically acidic, into the esophagus (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 400).

    –    Patient with reports of burning, gnawing pain in the mid-epigastrium that worsens with recumbency (Baumann, Dains, & Scheibel, 2016, p. 27).

    –    Risk factors for GERD include obesity, pregnancy, smoking, eating large meals or eating late at night, eating certain foods (triggers) such as fatty or fried foods, drinking certain beverages such as alcohol or coffee, taking certain medications, such as aspirin (Mayo Foundation for Medical Education and Research, 2017).

    –    Due to the reported symptoms, alcohol consumption, and recent changes in the patient’s medication, GERD is the primary diagnosis for the patient. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

    Acute coronary syndrome: may have heartburn or a bitter taste in the mouth due to stomach fluid “coming up” which usually occurs after eating and gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain (The Cleveland Clinic Foundation, 2015).

    Peptic Ulcer: associated with reports of burning or gnawing pain that occurs most often with an empty stomach, stress, and alcohol intake which is relieved with food intake (Baumann, Dains, & Scheibel, 2016, p. 27).

    Achalasia: a condition where the esophagus is unable to move food into the stomach as the lower esophageal sphincter stays closed during swallowing, back up of food results and symptoms include vomiting undigested food, chest pain, heartburn and weight loss (The Cleveland Clinic Foundation, 2017).

    Gastritis: is a constant burning pain in the epigastric area that can be accompanied by nausea, vomiting, diarrhea, or fever and alcohol, nonsteroidal inflammatory drugs and salicylates make the pain worse (Baumann, Dains, & Scheibel, 2016, p. 27).

    Hiatal Hernia with esophagitis: is a condition where part of the stomach passes through the esophageal hiatus in the diaphragm and into the chest cavity with symptoms of epigastric pain or heartburn that worsens with lying down and is resolved by sitting up or antacids (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 401).

     

    References

    Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

    Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

    Mayo Foundation for Medical Education and Research. (2017, November). Gastroesophageal reflux disease (GERD). Retrieved from https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940

    The Cleveland Clinic Foundation. (2015, June). Non-Cardiac Chest Pain: GERD. Retrieved from https://my.clevelandclinic.org/health/diseases/15851-gerd-non-cardiac-chest-pain

    The Cleveland Clinic Foundation. (2017, July). Swallowing Problems: Achalasia. Retrieved from https://my.clevelandclinic.org/health/diseases/17534-swallowing-problems-achalasia/symptoms–diagnosis?view=print NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

  • Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Subjective Data Collection: 20 of 20 (100.0%)

    Hover To Reveal…

    Hover over the 
    Patient Data
     items below to reveal important information, including 
    Pro Tips
     and 
    Example Questions
    .

    Found:

     Indicates an item that you found.

    Available:

     Indicates an item that is available to be found.

    Category

    Scored Items

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

    WE ARE THE SHADOW HEALTH EXPERTS,

    WE WILL HAVE YOU SCORE 100%,

    CHAT US NOW

    Patient Data

    Not Scored

    A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Chief Complaint

     SCORE 100% ON YOUR SHADOW HEALTH ASSESSMENT

     

    Finding:

    Established chief complaint

    Finding:

    Reports cough

    (Found)

    Pro Tip: Asking about the characteristics of your patient’s cough and voice quality should guide your assessment. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Example Question:

    Do you have a cough?

    History of Present Illness

    Finding:

    Asked about onset of cough

    Finding:

    Reports cough started 5 days ago

    (Found)

    Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem.

    Example Question:

    How long have you had a cough?

    Finding:

    Asked about frequency and duration of cough

    Finding:

    Reports coughing every couple minutes

    (Found)

    Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Example Question:

    How frequently have you been coughing?

    Finding:

    Asked about character of cough

    Finding:

    Reports cough is wet

    (Found)

    Pro Tip: Asking about the characteristics of your patient’s cough and voice quality should guide your assessment. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Example Question:

    Is your cough a wet cough?

    Finding:

    Reports clear sputum with cough

    (Found)

    Pro Tip: Asking if your patient’s cough is productive should guide your assessment.

    Example Question:

    Do you produce any phlegm or sputum with your cough? Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Finding:

    Asked about aggravating factors for cough

    Finding:

    Reports cough is worse at night

    (Found)

    Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.

    Example Question:

    Is your cough worse at night?

    Finding:

    Reports exposure to secondhand smoke

    (Found)

    Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking about all types of tobacco products assesses this risk factor.

    Example Question:

    Do you smoke?

    Finding:

    Reports not knowing specific triggers that make the cough worse

    (Found)

    Pro Tip: Follow-up questions will enable Danny to more fully and specifically describe his condition, experience, or symptoms. Establishing what makes Danny’s cough worse will allow you to more effectively treat his symptoms.

    Example Question:

    What makes your cough worse?

    Finding:

    Asked about relieving factors for cough

    Finding:

    Reports cough “stays the same” with rest

    (Available)

    Pro Tip: Asking what relieves the patient’s chief complaint will determine the efficacy of possible treatment and may provide important insight into the condition itself.

    Example Question:

    Does resting help your cough?

    Finding:

    Reports cough “stays the same” despite drinking water

    (Available)

    Pro Tip: Asking what relieves the patient’s chief complaint will determine the efficacy of possible treatment and may provide important insight into the condition itself. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Example Question:

    Does drinking water help your cough?

    Finding:

    Asked about nasal symptoms

    Finding:

    Reports current runny nose

    (Found)

    Pro Tip: Asking your patient if his nose is running will allow you to determine the symptoms he is experiencing and possible triggers. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Example Question:

    Do you have a runny nose?

    Finding:

    Denies sneezing

    (Found)

    Pro Tip: Asking your patient if he has been sneezing will allow you to determine the symptoms he is experiencing and possible triggers.

    Example Question:

    Have you been sneezing?

    Finding:

    Reports frequent rhinorrhea

    (Found)

    Pro Tip: Establishing how frequently your patient experiences symptoms, like a runny nose, will most effectively enable you to treat your patient’s symptoms.

    Example Question:

    Do you get runny noses often?

    Finding:

    Followed up on nasal discharge

    Finding:

    Reports nasal discharge is clear

    (Found)

    Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like the character of his nasal discharge, will help you to understand his symptoms.

    Example Question:

    What color is your snot?

    Finding:

    Reports nasal discharge is thin

    (Found)

    Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like the character of his nasal discharge, will help you to understand his symptoms.

    Example Question:

    Is your snot thin?

    Finding:

    Asked about ear symptoms

    Finding:

    Reports pain in right ear

    (Found)

    Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data. Asking Danny if he has ear pain might indicate a possible ear infection and a reason for changes in his hearing.

    Example Question:

    Do you have any ear pain?

    Finding:

    Followed up on ear pain

    Finding:

    Reports ear pain started yesterday

    (Available)

    Pro Tip: It is important to know how long your patient has suffered pain to determine how urgently treatment is needed.

    Example Question:

    How long have you had ear pain?

    Finding:

    Reports pain rating of 3 for ear pain

    (Available)

    Pro Tip: It is important to determine the severity of your patient’s paint to determine how urgently treatment is needed and how best to address it.

    Example Question:

    How bad is your ear pain?

    Finding:

    Denies ear discharge

    (Found)

    Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has ear discharge, will help you to understand his symptoms. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

    Example Question:

    Do you have any ear discharge?

    Finding:

    Asked about throat symptoms

    Finding:

    Reports sore throat

    (Found)

    Pro Tip: Asking about the patient’s mouth and throat should guide your assessment.

    Example Question:

    Is your throat sore?

    Finding:

    Reports “a little” pain with swallowing

    (Found)

    Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has ear discharge, will help you to understand his symptoms.

    Example Question:

    Does it hurt when you swallow?

    Medical History

    Finding:

    Confirmed use of medications

    Finding:

    Confirms medications

    (Found)

    Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.

    Example Question:

    What medications do you take?

    Finding:

    Reports taking a daily vitamin

    (Found)

    Pro Tip: Asking specifically about vitamin or supplement use is important, because patients don’t always consider these a “medication.”

    Example Question:

    Do you take vitamins?

    Finding:

    Reports taking cough medicine

    (Found)

    Pro Tip: Asking specifically about medications to relieve a condition is a good way to check that a patient is remembering all of his medications Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

    Example Question:

    Are you taking medication for your cough?

    Finding:

    Followed up on cough medicine

    Finding:

    Reports cough medicine was purple

    (Found)

    Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.

    Example Question:

    What color was the cough medicine?

    Finding:

    Reports taking one spoonful of cough medicine

    (Found)

    Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.

    Example Question:

    How much cough medicine did you take?

    Finding:

    Reports mother gave him the medicine

    (Found)

    Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.

    Example Question:

    Who gave you the cough medicine?

    Finding:

    Reports cough medicine provided temporary relief

    (Available)

    Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

    Example Question:

    Did the cough medicine make you feel better?

    Finding:

    Asked about allergies

    Finding:

    Denies seasonal allergies

    (Found)

    Pro Tip: Seasonal allergies can cause symptoms like runny nose, cough, and discomfort. Asking Danny if he has seasonal allergies can help you to ascertain possible triggers for symptoms.

    Example Question:

    Do you have seasonal allergies?

    Finding:

    Denies food allergies

    (Found)

    Pro Tip: Knowing if your patient has food allergies is important and relevant medical history. Asking your patient about food allergies will allow you to most effectively treat him.

    Example Question:

    Do you have food allergies?

    Finding:

    Denies medication allergies

    (Found)

    Pro Tip: Knowing if your patient has allergies to medicine is important and relevant medical history. Asking your patient about medicine allergies will allow you to most effectively treat him.

    Example Question:

    Are you allergic to any medicine?

    Finding:

    Denies allergies to animals

    (Available)

    Pro Tip: Asking about allergies to animals is important for a child with respiratory problems, because the issue could be caused or exacerbated by a family pet or recent exposure to an animal.

    Example Question:

    Are you allergic to animals?

    Finding:

    Denies latex allergy

    (Available)

    Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts.

    Example Question:

    Are you allergic to latex?

    Finding:

    Asked about relevant medical history

    Finding:

    Denies asthma diagnosis

    (Found)

    Pro Tip: Asthma is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.

    Example Question:

    Do you have asthma?

    Finding:

    Reports immunizations as current

    (Found)

    Pro Tip: A health assessment should include an evaluation of the patient’s immunization status in order to identify diseases to which the patient is vulnerable.

    Example Question:

    Do you have current immunizations?

    Finding:

    Reports past pneumonia and frequent coughs

    (Found)

    Pro Tip: Respiratory conditions extremely limit one’s ability to function in normal life activities. It’s important to identify the patient’s health conditions in order to care for her safely and effectively. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

    Example Question:

    Do you have a history of respiratory problems?

    Finding:

    Denies past hospitalizations

    (Available)

    Pro Tip: Asking about previous hospitalizations will give you a broader understanding of the patient’s medical history in addition to guiding your assessment of their chief complaint.

    Example Question:

    Have you ever been to the hospital?

    Social History

    Finding:

    Asked about exposure to secondhand smoke

    Finding:

    Reports father smokes cigars

    (Found)

    Pro Tip: Secondhand smoke puts the patient at risk for many medical conditions may exacerbate breathing problems associated with a respiratory complaint. Knowing about household exposure to irritants such as smoke will help you know about potential sources of Danny’s complaint.

    Example Question:

    Who smokes at home?

    Finding:

    Reports father sometimes forgets to take cigars outside

    (Available)

    Pro Tip: Secondhand smoke puts the patient at risk for many medical conditions may exacerbate breathing problems associated with a respiratory complaint. Knowing about household exposure to irritants such as smoke will help you know about potential sources of Danny’s complaint.

    Example Question:

    Where does your father smoke?

    Review of Systems

    Finding:

    Asked about general symptoms

    Finding:

    Reports frequent colds

    (Found)

    Pro Tip: Asking about the patient’s susceptibility to colds is should guide your assessment.

    Example Question:

    Do you have unusually frequent colds?

    Finding:

    Denies fever

    (Found)

    Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has a fever will illustrate the way his symptoms manifest.

    Example Question:

    Do you have a fever?

    Finding:

    Denies chills

    (Found)

    Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has chills will illustrate the way his symptoms manifest. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

    Example Question:

    Do you have chills?

    Finding:

    Reports reports feeling “kind of tired”

    (Found)

    Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has fatigue will illustrate the way his symptoms manifest.

    Example Question:

    Do you have fatigue?

    Finding:

    Denies night sweats

    (Found)

    Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has night sweats will illustrate the way his symptoms manifest.

    Example Question:

    Do you have night sweats?

    Finding:

    Denies weight loss

    (Available)

    Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has lost weight will illustrate the way his symptoms manifest.

    Example Question:

    Have you lost weight?

    Finding:

    Denies appetite loss

    (Available)

    Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny about his appetite will illustrate the way his symptoms manifest.

    Example Question:

    Have you lost your appetite?

    Finding:

    Asked about review of systems for HEENT

    Finding:

    Denies ear popping or crackling

    (Available)

    Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has any ear popping, will help you to understand his symptoms.

    Example Question:

    Do you hear any popping sounds?

    Finding:

    Reports history of frequent ear infections

    (Available)

    Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has ear infections, will help you to understand his symptoms.

    Example Question:

    Have you ever had ear infections?

    Finding:

    Denies ear surgery or ear tubes

    (Available)

    Pro Tip: It is important to ask your patient about past surgeries to better understand the scope of previous treatment as well as rule out possible complications that may be resulting in the patient’s condition.

    Example Question:

    Have you ever had surgery on your ears?

    Finding:

    Denies headaches

    (Found)

    Pro Tip: Headaches are a common complaint that can be caused by a variety of benign conditions. However, headaches can be an indicator of serious underlying neurological conditions such as cerebral hemorrhage, meningitis, or brain tumors. They may also be a symptom of sinus infection.

    Example Question:

    Do you get headaches?

    Finding:

    Denies nosebleeds

    (Found)

    Pro Tip: Infected sinuses can manifest as nose problems. Asking Danny about his nasal symptoms solicits information about his sinuses and possible sinus problems. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

    Example Question:

    Do you have nosebleeds?

    Finding:

    Denies vision problems

    (Found)

    Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.

    Example Question:

    Do you have any problems with your vision?

    Finding:

    Denies dizziness

    (Found)

    Pro Tip: Asking about dizziness assesses for inner ear, neurological, or cardiovascular problems.

    Example Question:

    Do you have any dizziness?

    Finding:

    Denies watery eyes

    (Found)

    Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.

    Example Question:

    Do you have watery eyes?

    Finding:

    Denies eye redness

    (Found)

    Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.

    Example Question:

    Do you have eye redness?

    Finding:

    Denies eye pain

    (Found)

    Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Danny whether he is experiencing eye pain solicits information about possible symptoms.

    Example Question:

    Do you have any eye pain?

    Finding:

    Denies sinus pain

    (Found)

    Pro Tip: Infected sinuses can manifest as nose problems. Asking Danny about his nasal symptoms solicits information about his sinuses and possible sinus problems.

    Example Question:

    Do you have any sinus pain?

    Finding:

    Denies hearing problems

    (Found)

    Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has hearing problems, will help you to understand his symptoms.

    Example Question:

    Do you have any hearing problems?

    Finding:

    Asked about review of systems for respiratory

    Finding:

    Denies difficulty breathing

    (Found)

    Pro Tip: It’s important to ask about episodes of shortness of breath because ineffective breathing can be life-threatening. Shortness of breath can be caused by respiratory or cardiac conditions, allergies, or exercise.

    Example Question:

    Do you have difficulty breathing?

    Finding:

    Denies chest tightness

    (Found)

    Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest tightness is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

    Example Question:

    Do you have chest tightness?

    Finding:

    Denies chest pain

    (Found)

    Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest pain is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.

    Example Question:

    Do you have any chest pain?

    Finding:

    Reports no history of inhaler use or breathing treatments

    (Available)

    Pro Tip: Respiratory conditions extremely limit one’s ability to function in normal life activities. It’s important to identify the patient’s health conditions in order to care for her safely and effectively.

    Example Question:

    Have you ever used a medicine that you inhaled?

    Family History

    Finding:

    Asked about relevant family history

    Finding:

    Reports not being around anyone ill at home

    (Available)

    Pro Tip:

    Example Question:

    Is anyone sick at your house?

    Finding:

    Reports father had asthma as a child

    (Found)

    Pro Tip: Medical problems that are present in a patient’s immediate family can represent increased risk factors to many medical conditions for the patient.

    Example Question:

    Do you have a family history of asthma?

    Finding:

    Denies family history of allergies

    (Found)

    Pro Tip: Medical problems that are present in a patient’s immediate family can represent increased risk factors to many medical conditions for the patient. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

    Example Question:

    Do you have a family history of allergies?

    Finding:

    Denies pets at home

    Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

  • NR451 – Apply the components of the iCARE concept to interprofessional teams

    NR451 – Apply the components of the iCARE concept to interprofessional teams

    Title

    Your Name

    Chamberlain College of Nursing

    NR451 RN Capstone Course

    Term and Year

    ORDER A PLAGIARISM-FREE PAPER HERE

    Your title here

    This paragraph(s) is to introduce the paper.
    Explain the type of work setting you are discussing and whether interprofessional teams are present. If present, indicate a team function that could be improved.  If not present, indicate what type of team you think might work well in this setting and how it might function.
    Remember this is a scholarly APA assignment so you cannot use first person. Remember also that you will keep all the bolded headings and just remove the non-bolded content when you start your paper. NR451 – Apply the components of the iCARE concept to interprofessional teams

    Compassion

    In this paragraph, describe
    a nursing action that could contribute to compassion
    through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

    Advocacy

    In this paragraph, describe
    a nursing action that could contribute to advocacy
    through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes. NR451 – Apply the components of the iCARE concept to interprofessional teams

    Resilience

    In this paragraph, describe
    a nursing action that could contribute to resilience
    through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

    Evidence-Based Practice

    In this paragraph, describe
    a nursing action that could contribute to evidence-based

    practice
    through interprofessional team support; how this might impact the culture of your unit or organization; and possible impact on patient outcomes. NR451 – Apply the components of the iCARE concept to interprofessional teams

    Summary

    Provide a clear and concise summary. Include a summary statement of how iCARE components can support interprofessional teams and patient outcomes through nursing actions.  Address how you may be able to influence this process of support for interprofessional teams on your unit or in your organization.

     

    References

    Select at least one scholarly nursing article from CINAHL as a resource for your paper. Additional scholarly sources can be used but are optional.

     

    Purpose

    The purpose of the iCARE Paper assignment is to explore the concept of interprofessional teams and patient outcomes. Nursing supportive actions of compassion, advocacy, resilience, and evidence-based practice will serve as a way to apply care concepts.

    Course Outcomes

    This assignment enables the student to meet the following course outcomes:

    CO1: Applies principles of nursing, theories, and the care philosophies to self, colleagues, individuals, families, aggregates and communities throughout the healthcare system. (PO#1)

    CO6: Plans clinical practice activities that integrate professional nursing standards in accordance with the Nursing Code of Ethics and the American Nurses’ Association (ANA) standards of practice. (PO#6) NR451 – Apply the components of the iCARE concept to interprofessional teams

    Points

    The assignment is worth 200 points.

    Due Date

    Submit your completed assignment by Sunday end of Week 5 by 11:59 p.m. MT.

    Directions

    Please review the infographic as way to guide you in getting started with your assignment: Developing an Assignment with Integrity (Links to an external site.)

    Getting Started: Interprofessional teams are part of practice trends we see developing in all aspects of care delivery. Consider you own work environment (or recent clinical setting).

    • For this assignment, consider the concept of interprofessional teamwork and patient outcomes.

    • Look to your current workplace as an example. (If you are not currently employed, look to a past workplace or clinical practice area.) NR451 – Apply the components of the iCARE concept to interprofessional teams

    • Apply the components of the iCARE concept to interprofessional teams in a short paper. (Body of the paper to be 3 pages, excluding the title page and references page)

    • iCARE components are:

    C ompassion

    A dvocacy

    ORDER A PLAGIARISM-FREE PAPER HERE

    R esilience

    E vidence-Based Practice (EBP)

    • How could you contribute to an interprofessional team and patient outcomes through nursing actions of: compassion, advocacy, resilience, and evidence-based practice?

    • Select one scholarly nursing article from CINAHL as a resource for your paper. Additional scholarly sources can be used but are optional. When searching in the CINAHL database, please limit your search word to one component of the paper you wish to emphasize, such as ‘Resilience’. Searching for the term iCARE will not produce the results you need. NR451 – Apply the components of the iCARE concept to interprofessional teams

    • Use APA format throughout, particularly in citations and on the References page.

    • Please paraphrase throughout. One short quote is permitted.

    • The prepared paper template is RECOMMENDED for this assignment.

    Download the assignment template here:

    iCare Assignment Template (Links to an external site.) – APA 6th edition

    iCare Assignment Template (Links to an external site.) – APA 7th edition

    A short tutorial with tips for completing this assignment may be viewed here: iCARE Paper Tutorial (Links to an external site.)

    Elements of iCARE paper

    • Title page

    • Below are the headings to be used for this assignment.

    • Introduction: (No heading needed here in APA) Explain the type of work setting you are discussing and whether interprofessional teams are currently present. If interprofessional teams are present, indicate a team function that could be improved. If interprofessional teams are NOT present, indicate what type of team you think might be possible in the setting. NR451 – Apply the components of the iCARE concept to interprofessional teams

    Describe a nursing action item for each component below that could contribute to: interprofessional team support; how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

    • Compassion

    • Advocacy

    • Resilience

    • Evidence-Based Practice

    • Summary: Include a summary statement of how iCARE components can support interprofessional teams and patient outcomes. Address how you may be able to influence this process of support for interprofessional teams overall in your unit or organization.

    • References page: List any references used in APA format. NR451 – Apply the components of the iCARE concept to interprofessional teams

  • Supportive Psychotherapy Versus Interpersonal Psychotherapy

    Supportive Psychotherapy Versus Interpersonal Psychotherapy

    Briefly describe how supportive and interpersonal psychotherapies are similar.

    Explain at least three differences between these therapies. Include how these differences might impact your practice as a mental health counselor.

    BUY A PLAGIARISM-FREE PAPER HERE

    Explain which therapeutic approach you might use with clients and why. Support your approach with evidence-based literature. Supportive Psychotherapy Versus Interpersonal Psychotherapy.