Soap Note 2 Chronic Conditions Soap Note  Chronic Conditions (15 Points) Pick any Chronic Disease from Weeks 6-10 Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Follow the MRU Soap Note Rubric as a guide Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement Please use one of the templates provided to format your soap note. Keep these templates for future clinical rotations. SAMPLE Block format Soap Note   Template.docx Sample Soap Note Template.docx PATIENT INFORMATION Name: Mr. W.S. Age: 65-year-old Sex: Male Source: Patient Allergies: None Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago. Surgical History: Appendectomy 47 years ago. Family History: Father- died 81 does not report information Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone. SUBJECTIVE: Chief complain : “headaches” that started two weeks ago Symptom analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. ROS: CONSTITUTIONAL : Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC : Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT : HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. Respiratory : Patient denies shortness of breath, cough or hemoptysis. Cardiovascular : No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. Gastrointestinal : Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. Genitourinary : Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL : Denies falls or pain. Denies hearing a clicking or snapping sound. Skin : No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data CONSTITUTIONAL : Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10. General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time . Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race. Neck: supple without cervical lymphadenopathy, no jug…

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Fill in the concept map linked below with the information you have on your most recent patient. Then look at opportunities, real or imagined, for collaborative and/or interdisciplinary care. What could you do to make everything and everyone work together for the good of the patient? Evaluation may be real or imagined as well. Think “outside” the realm of the clinical picture you’re presented. If you believe the suggested improvements to care will benefit the patient, say so! If you are not convinced that the prescribed collaboration will be effective, say that as well. Concept Map

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Complete a 250-350-word reflection of what you have learned during this topic. Include the following in your reflection: Think about an experience you’ve encountered when viewing or completing the particular assessment. Discuss difficulties that could potentially arise or specific questions related to completing this type of assessment. Include illustrative examples of potential strategies used to overcome the difficulties encountered when completing (the particular) assessment. Describe how the Christian worldview and compassion for all plays a role in this type of assessment. Solid academic writing is expected. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

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Using the case study below, prepare a 3-5 page paper. A 21-year old female (A.M) presents to the urgent care clinic with symptoms of nausea, vomiting, diarrhea, and a fever for 3 days. She states that she has Type I diabetes and has not been managing her blood sugars since she’s been ill and unable to keep any food down. She’s only tolerated sips of water and juices. Since she’s also been unable to eat, she hasn’t taken any insulin as directed. While helping A.M. from the lobby to the examining room you note that she’s unsteady, note that her skin in warm and flushed and that she’s drowsy. You also note that she’s breathing rapidly and smell a slight sweet/fruity odor. A.M. has a challenge answering questions but keeps asking for water to drink. You get more information from A.M. and learn She had some readings on her glucometer which were reading ‘high’ She vomits almost every time she takes in fluid She hasn’t voided for a day but voided a great deal the day before She’s been sleeping long hours and finally woke up this morning and decided to seek care Current labs and vital signs: What is the pathophysiology for the condition you believe A.M. has? Relate the etiology and clinical manifestations for the condition you identified for A.M. The practitioner at the urgent care facility makes the decision that A.M. needs to go to the hospital by ambulance. Once at the Emergency Department (ED), the ED physician orders these items: 1000 ml Lactated Ringer’s (LR) IV stat 36 units NPH (Humulin N) and 20 units regular (Humulin R) insulin SQ now CBC with differential; CMP: blood cultures X2 sites; clean-catch urine for UA and C&S; stool for ova and parasites; Clostridium difficile toxin, and C&S; serum lactate; ketone; osmolality; ABGs on room air 1800 calorie, carbohydrate controlled diet Bed rest Acetaminophen (Tylenol) 650 mg orally Q4 hrs PRN Furosemide (Lasix) 60 mg IV push now Urinary output every hour VS every shift The orders above — which are questionable related to her condition and which are appropriate? What are the expected treatments for this condition?

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clinical decision support system, healthcare reimbursement, health-related views and laws are shaped by social, political, and historical factors discussion 1. (100 words) How does clinical decision support system CDS fit in with the goal of rewarding “quality over quantity” in healthcare reimbursement? 2. (200 words) Provide an example of how healthcare informatics can enhance quality over quantity within the healthcare setting use evidence-based practice to support your reasoning. 3. (200 words) If the answer to lowering healthcare costs is payment based on “value over volume,” then does this favor the adoption of clinical decision support system CDS or argue against it? What is your rationale? The United States’ health-related views and laws are shaped by social, political, and historical factors that are often part of the larger debate over individual rights versus the collective good. Based on this idea please discuss your thoughts on the following public health topics. 1. (100 words) Should childhood immunizations be mandatory or optional and why ? 2. (100 words) What are the benefits and risk associated with childhood immunizations? 3. (200 words) Should higher insurance rates or taxes be used to punish poor health choices (e.g., cigarettes, “junk” food)? Would this be unfair to individuals, or is this fair since all Americans pay a portion of the healthcare costs to care for people who make these choices? 4. (200 words) Should, in light of the current Covid-19 situation, should we be required to social distance, wear masks when we are in public, and be on lockdown when community numbers are higher? Use APA 7th edition to support your discussion and at least three reference including the textbook

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In this assignment, you will be writing a 1,000-1,250 word paper describing the differing approaches of nursing leaders and managers to issues in practice. To complete this assignment, do the following: Select an issue from the following list: bullying, unit closers and restructuring, floating, nurse turnover, nurse staffing ratios, use of contract employees (i.e., registry and travel nurses), or magnet designation. Describe the selected issue. Discuss how it impacts quality of care and patient safety in the setting in which it occurs. Discuss how professional standards of practice should be demonstrated in this situation to help rectify the issue or maintain professional conduct. Explain the differing roles of nursing leaders and nursing managers in this instance and discuss the different approaches they take to address the selected issue and promote patient safety and quality care. Support your rationale by using the theories, principles, skills, and roles of the leader versus manager described in your readings. Discuss what additional aspects mangers and leaders would need to initiate in order to ensure professionalism throughout diverse health care settings while addressing the selected issue. Describe a leadership style that would best address the chosen issue. Explain why this style could be successful in this setting. Use at least three peer-reviewed journal articles other than those presented in your text or provided in the course. Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance. This benchmark assignment assesses the following programmatic competencies: RN to BSN 1.1:       Exemplify professionalism in diverse health care settings. 1.3:       Exercise professional nursing leadership and management roles in the promotion of patient safety and quality care. 3.4:       Demonstrate professional standards of practice .

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Post a comparison of the mission and vision statements of the three organizations selected. Explain how specific elements of each organization’s mission and vision statements might inform planning in that organization. Include references/links for the organizations’ mission and vision statements in your post.

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Write a 4–6-page report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance, with respect to prescribed benchmarks set forth by government laws and policies at the local, state, and federal levels. In addition, advocate for ethical action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on a performance dashboard. In the era of health care reform, many of the laws and policies set forth by government at the local, state, and federal levels have specific performance benchmarks related to care delivery outcomes that organizations must achieve. It is critical for organizational success that the interprofessional care team is able to understand reports and dashboards that display the metrics related to performance and compliance benchmarks. Maintaining standards and promoting quality in modern health care are crucial, not only for the care of patients, but also for the continuing success and financial viability of health care organizations. In the era of health care reform, health care leaders must understand what quality care entails and how quality in health care connects to the standards set forth by relevant federal, state, and local laws and policies. An understanding of relevant benchmarks that result from these laws and policies, and how they relate to quality care and regulatory standards, is also vitally important. Health care is a dynamic, complex, and heavily regulated industry. For this reason, you will be expected to constantly scan the external environment for emerging laws, new regulations, and changing industry standards. You may discover that as new policies are enacted into law, ambiguity in interpretation of various facets of the law may occur. Sometimes, new laws conflict with preexisting laws and regulations, or unexpected implementation issues arise, which may warrant further clarification from lawmakers. Adding partisan politics and social media to the mix can further complicate understanding of the process and buy-in from stakeholders. Assessment Instructions Note : Your evaluation of dashboard metrics for this assessment is the foundation on which all subsequent assessments are based. Therefore, you must complete this assessment first. Write a report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance with respect to prescribed benchmarks set forth by government laws and policies at the local, state, and federal levels. In addition, advocate for ethical action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on a performance dashboard. Review the performance dashboard metrics, as well as relevant local, state, and federal laws and policies. Consider the metrics that are falling short of the prescribed benchmarks. Structure your report so that it will be easy for a colleague or supervisor to locate the information they need, and be sure to cite the relevant health care policies or laws when evaluating metric performance against established benchmarks. Note : Remember that you can submit all, or a portion of, your draft report to Smarthinking for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback. Preparation Choose one of the following three options for a performance dashboard to use as the basis for your evaluation: Option 1: Dashboard Metrics Evaluation Simulation Use the data presented in the Dashboard and Health Care Benchmark Evaluation multimedia activity as the basis for your evaluation. Note : The writing that you do as part of the simulation could serve as a starting point to build upon for this assessment. Option 2: Actual Dashboard Use an actual dashboard fr…

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Management Orientation Program Proposal You have the opportunity to create a proposal to present to the leadership team for the orientation of new nurse managers. This project will include the creation of an orientation using leadership and management topics that will be selected to support the nurse manager as he or she transitions into the new role.  This project will compile specific topics, resources and facilitators to support a new nurse manager as they get acclimated to the organization or unit. APA citations expected. Your proposal should include: Introductory and concluding remarks Identify 8 specific topics to support the new nurse manager Learning objectives for the lesson(s) Rationale for including each topic with a synthesis of professional literature Recommendation of internal and or external materials for each topic Recommendation of a facilitator for each topic Rationale listing why the materials and facilitator(s) are the most appropriate choice for that topic Two or more scholarly resources to support the rationales Support your discussion and opinions with facts, relevant examples from personal nursing practice. All submissions must have a minimum of two scholarly references to support your work. Examples of work to show mastery: 10-12 slide PowerPoint presentation – APA format

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Write a 4-5 page evidence-based proposal to support the need for a nurse informaticist in an organization who would focus on improving health care outcomes. As you begin to prepare this assessment, you are encouraged to complete the Team Perspectives of the Nurse Informaticist activity. Completion of this will help you succeed with the assessment as you explore the nurse informaticist’s role from the different perspectives of the health care team. Completing activities is also a way to demonstrate engagement. Nurses at the baccalaureate level in all practice areas are involved in nursing informatics through interaction with information management and patient care technologies. Nurses must not only demonstrate knowledge of and skills in health information and patient care technologies, but also how to use these tools at the bedside and organizational levels. Moreover, nurses need to recognize how information gathered from various health information sources can impact decision making at the national and state regulatory levels. Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: Competency 1: Describe nurses’ and the interdisciplinary team’s role in informatics with a focus on electronic health information and patient care technology to support decision making. Define nursing informatics and the role of the nurse informaticist. Explain how the nurse collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care. Justify the need for a nurse informaticist in a health care organization. Competency 2: Implement evidence-based strategies to effectively manage protected health information. Explain evidence-based strategies that the nurse and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality). Competency 5: Apply professional, scholarly communication to facilitate use of health information and patient care technologies. Follow APA style and formatting guidelines for citations and references. Create a clear, well-organized, and professional proposal that is generally free from errors in grammar, punctuation, and spelling. Scenario For this assessment, assume you are a nurse attending a meeting of your state’s nurses’ association. A nurse informaticist conducted a presentation on her role and its impact on positive patient and organizational outcomes in her workplace. You realize that your organization is undergoing many technological changes. You believe this type of role could provide many benefits to your organization. You decide to pursue proposing a nurse informaticist role in your organization. You speak to your chief nursing officer (CNO) and human resources (HR) manager. These individuals ask you to prepare a 4–5 page evidence-based proposal to support the new role. In this way, they can make an informed decision as to whether the addition of such a role could justify the return on investment (ROI). They need your proposal before an upcoming fiscal meeting. Preparation To successfully prepare for this assessment, you will need to complete these preparatory activities: Review assessment resources and activities. Conduct independent research on the nursing knowledge and skills necessary to interact with health information and patient care technology. Focus your research on current resources available through peer-reviewed articles, professional websites, government websites, professional blogs, wiki pages, job boards, et cetera. Consult the BSN Program Library Research Guide for help in identifying scholarly and authoritative sources. Interview peers in your network who are considered information technology experts. Ask them about how information technology advances are impacting patient care at the bedside, at the organizational level, and beyond. Pr…

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