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Applies Care for the HEENT and Integumentary Conditions The learner applies the clinical judgment

  

7093.6.1 : Applies Care for the HEENT and Integumentary Conditions

The learner applies the clinical judgment model to person-centered nursing care of diverse adults experiencing common alterations of the head, eyes, ears, nose, throat, and the integumentary system.

7093.6.2 : Applies Care for F&E, and Respiratory Conditions

The learner applies the clinical judgment model to person-centered nursing care of diverse adults experiencing common fluid and electrolyte and acid-base imbalances and alterations in respiratory functions.

7093.6.3 : Applies Care for the GU, Reproductive, GI, and Hepatic Conditions

The learner applies the clinical judgment model to person-centered nursing care of diverse adults experiencing common alterations in genitourinary, reproductive, gastrointestinal, and hepatic functions.

7093.6.4 : Applies Care for Pain, Inflammation, Immunity, and Infection

The learner applies the clinical judgment model to person-centered nursing care of diverse adults experiencing pain, inflammation, immunity, and infection.

7093.6.5 : Recognizes Diverse Adult Patient Medical Conditions

The learner recognizes the cues of diverse adult patients' body systems using the clinical judgment model.

7093.6.6 : Recognizes Medical Conditions for a Care Plan

The learner recognizes the cues of diverse adult patients' conditions to prepare a plan of care using the nursing process.

7093.6.7 : Explains Collaboration with Interdisciplinary Teams

The learner explains the importance of collaborating with interdisciplinary teams to promote safety, quality, and improved patient outcomes.

7093.6.8 : Explains Pharmacological Care Error Prevention

The learner explains how to provide pharmacological care to diverse adult patients using safe, person-centered practices based on principles of medication error prevention.

7093.6.9 : Describes How to Promote Well-Being

The learner describes strategies to promote health and well-being.

7093.6.10 : Describes How to Support Adult Patients

The learner describes professionalism, therapeutic communication, teaching, and learning strategies to use with diverse adult patients.

IntroductionThe Clinical Judgment Measurement Model (NCJMM) provides nursing students different ways to develop care plans to reinforce clinical thinking and clinical reasoning that will prepare them to apply concepts from their didactic and lab courses in the clinical setting. In this course you will select one of the patients you cared for in your clinical intensive and complete the clinical judgement concept map for your performance assessment using the “Concept Map Template” in the Web Links section. You will need to collect information during your clinical intensive using the “NCJMMT Template” in the Web Links section. Do not include patient identifiers. During your clinical intensive, your clinical instructor will serve as a resource to guide you as you complete this assignment.Requirements

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The similarity report that is provided when you submit your task can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

Tasks may not be submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc., unless specified in the task requirements. All other submissions must be file types that are uploaded and submitted as attachments (e.g., .docx, .pdf, .ppt).

Concept Map:

Create a concept map using the “Concept Map Template” in the Web Links section below. Please see “Concept Map Directions” in the Web Links section below for further detail. There is also an example provided in the Web Links section below, titled “Concept Map Example,” that you can use for reference. Note: Do NOT include patient identifiers.

A.  In the box labeled “Disease Process/Pathophysiology/Risk Factors,” describe the pathophysiology related to a disease process, disorder, or injury. Include the admitting diagnosis as well as the causes and risk factors for the disease process.
 

B.  In the box labeled “Recognizing Cues,” identify at least 4 critical cues that are relevant to the patient’s current condition. Describe what the patient looks like, their complaints, vital signs, and anything in their medical history that would indicate this could be a problem.
 

C.  Analyze the 4 critical cues from B by making 3 supporting connections between the cues and the patient’s clinical condition. Put this information in the top box labeled “Supporting,” under “Analyzing Cues/Concerns”.
 

1.  Identify 2 of the critical cues that are most concerning in regard to the patient’s overall health outcome.  Put this information in the bottom box labeled “Concerning,” under “Analyzing Cues/Concerns”.
 

D.  In the box labeled “Prioritizing Hypotheses,” determine 3 hypotheses critical to positive patient outcomes, listing them in order of priority. Utilize words such as “urgency,” “likelihood,” “risk,” “difficulty,” “time,” and “constraints”.
 

E.  In the box labeled “Generated Solutions,” develop 4 solutions with appropriate interventions that will positively impact patient outcome and are appropriate to the care of the patient. Use the hypotheses from D to define a set of interventions for the expected solutions.
 

F.  In the box labeled “Take Actions,” describe how each of the 4 solutions from E will be prioritized and implemented into the patient’s plan of care. You will have one action for each solution, and it must be the most important action for each solution.
 

G.  In the box labeled “Evaluations Outcomes,” describe how the 4 solutions from E were effective or ineffective in improving patient outcome or care. You should have four evaluations, one for each desired solution.
 

H.  Demonstrate professional communication in the content and presentation of your submission.
 

File RestrictionsFile name may contain only letters, numbers, spaces, and these symbols: ! – _ . * ' ( )
File size limit: 200 MB
File types allowed: doc, docx, rtf, xls, xlsx, ppt, pptx, odt, pdf, csv, txt, qt, mov, mpg, avi, mp3, wav, mp4, wma, flv, asf, mpeg, wmv, m4v, svg, tif, tiff, jpeg, jpg, gif, png, zip, rar, tar, 7z 

 

 A:DISEASE PROCESS/PATHOPHYSIOLOGY RISK FACTORS

Not Evident

The description does not include a review of pathophysiology related to a disease process, disorder, or injury.

Approaching Competence

The description includes an incomplete or inaccurate review of the pathophysiology related to a disease process, disorder, or injury. Or it is missing key disease components.

Competent

The description includes a complete and accurate review of the pathophysiology related to the disease process, disorder, or injury including key disease components.

B:RECOGNIZING CUES

Not Evident

The concept map is missing all 4 critical cues.

Approaching Competence

The concept map is missing 1 or more critical cues that are relevant to the patient’s current condition.

Competent

The concept map identifies at least 4 critical cues that are relevant to the patient’s current condition.

C:ANALYZING CUES

Not Evident

The analysis does not make any supporting connections between cues and patient conditions.

Approaching Competence

The analysis is missing 1 or more supporting connections between cues and patient conditions. Or one or more of the connections is inaccurate or not related to the patient’s conditions.

Competent

The analysis makes 3 accurate supporting connections between the cues and patient conditions that are related to the patient’s conditions.

C1:PATIENT OUTCOMES CUES

Not Evident

The concept map does not identify any cues of concern.

Approaching Competence

The concept map is missing identification of 1 or more cues of concern related to patient outcome. Or one or more of the cues identified is inaccurate or not related to the patient’s conditions.

Competent

The concept map accurately identifies 2 cues of concern related to patient’s conditions and outcome.

D:PRIORITIZING HYPOTHESES

Not Evident

The concept map does not include hypotheses critical to positive patient outcomes.

Approaching Competence

One or more hypotheses critical to positive patient outcomes are missing. Or one or more of the hypotheses is inaccurate. Or the hypotheses are not prioritized correctly.

Competent

The concept map includes 3 accurate hypotheses critical to positive patient outcomes that are prioritized correctly.

E:GENERATING SOLUTIONS

Not Evident

The concept map does not include 4 solutions.

Approaching Competence

One or more solutions does not have appropriate interventions that will positively impact patient outcome or is not appropriate to the care of the patient.

Competent

The concept map includes 4 solutions with appropriate interventions that will positively impact patient outcome and they are appropriate to the care of the patient.

F:TAKE ACTIONS

Not Evident

The description of how each of the 4 solutions will be prioritized and implemented into the patient’s plan of care is not included.

Approaching Competence

The description of how the 4 solutions will be prioritized and implemented into the patient’s plan of care is incomplete or inaccurate.

Competent

The description of how each of the 4 solutions will be prioritized and implemented into the patient’s plan of care is accurate and complete.

G:EVALUATING OUTCOMES

Not Evident

The concept map does not include a description of how the 4 solutions were effective or ineffective in improving patient outcome or care.

Approaching Competence

The concept map includes a description of how the 4 solutions were effective or ineffective in improving patient outcome or care, but the description for 1 or more interventions does not accurately explain how that intervention was effective or ineffective in improving patient outcome or care.

Competent

The concept map includes an accurate and detailed description of how each of the 4 solutions were effective or ineffective in improving patient outcome or care.

H:PROFESSIONAL COMMUNICATION

Not Evident

This submission includes professional communication errors related to spelling, grammar, punctuation, and sentence fluency. For best results, please focus on the specific Correctness errors identified by Grammarly for Education to help guide your revisions. If you need additional assistance preparing your submission, please contact your Instructor.

Approaching Competence

This submission includes professional communication errors related to spelling, grammar, punctuation, and/or sentence fluency. For best results, please focus on the specific Correctness errors identified by Grammarly for Education to help guide your revisions.

Competent

This submission demonstrates correct use of spelling, grammar, punctuation, and sentence fluency. You have demonstrated quality professional communication skills in this submission.

Disease Process/Pathophysiology/Risk Factors

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Recognizing Cues

WGU Nursing Concept Map

Analyzing Cues/Concerns

Supporting

Concerning

Prioritizing Hypotheses

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3.

Take ActionsGenerated Solutions

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4.

Evaluations Outcomes

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What are the differences that may affect Cuban-American patients who immigrated at different times?

  1. What are the differences that may affect Cuban-American patients who immigrated at different times? 
  2. What can a nurse do to make life in the hospital more culture-specific for an Amish client? 
  3. List at least two etiological reasons for the development of alcoholism within an Irish-American family. 
  • Your initial post should be at least 500 words, formatted, and cited in current APA style with support from at least 2 academic sources. 
  • Incorporate a minimum of 2 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).

Giger, J. N., & Haddad, L. (2021). Transcultural Nursing: Assessment and Intervention (8th ed.). St.
Louis, MO: Elsevier. ISBN: 9780323695541

    Of which biological variations among Korean Americans should the nurse be aware?

    1. Of which biological variations among Korean Americans should the nurse be aware? 
    2. Describe how stereotyping Puerto Ricans as similar to other Hispanic Americans can lead the nurse to errors in patient care. 
    3. Describe the geographical location of Jordan, and indicate how this region of the world and the political turmoil experienced by Jordanians may have a profound political impact on the health and well-being of recently immigrated Jordanian Americans. 

    Giger, J. N., & Haddad, L. (2021). Transcultural Nursing: Assessment and Intervention (8th ed.). St.
    Louis, MO: Elsevier. ISBN: 9780323695541Your initial post should be at least 500 words, formatted, and cited in current APA style with support from at least 2 academic sources.  Your initial post is worth 8 points.

    • primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).

      Iâm having hot flashes and mood swings

      CC: I’m having hot flashes and mood swings.

      HPI: 51-year-old Black female in menopause for 1 year. Reports frequent hot flashes and sleep disturbance. Denies vaginal bleeding. Not on HRT. Seeks non-hormonal options.

      CPT: 99214 (Established, moderate complexity)

      ICD: N95.1 (Menopausal and perimenopausal disorder)

      Complexity: Moderate

      Race: Black/African American

      Visit: Follow-up

      1

      SOAP Note Assignment Instructions

      Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.

      Sections of the SOAP note should be addressed if they are pertinent to the presenting chief complaint.

      Typhon Encounter #:

      Type of Note: Focused or Comprehensive

      Subjective (S):

      CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.

      HPI: Who is the historian? Is the historian reliable? History of Present Illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]

      Past medical history (PMH) – This should include illness/diagnosis, conditions, traumas, hospitalizations, and surgical history that is pertinent to the visit. Include dates if possible.

      Reproductive history: GTPAL, STIs, prenatal care, LMP, contraceptive methods, sexual and menstrual history. Include dates if possible.

      Allergies: State the offending medication/food and the reactions.

      Medications: Names, dosages, routes, frequency, and indications. Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work, and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.

      Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.

      Health Maintenance/Promotion – Required for all SOAP notes: Immunizations, exercise, diet, screening, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age-appropriate indicators, Healthy People 2030, and Centers for Disease Control and Prevention (CDC). This should reflect patient’s current recommendations. Up to date on health maintenance/promotion will NOT be accepted. Requires references.

      Review of systems (ROS) –

      • [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms,

      2

      particularly in areas that you have not already thoroughly explored while discussing the history of present illness.]

      You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic or follow-up visits (focused note) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. As opposed to a comprehensive visit which would address each system.

      Perform either a focused or comprehensive ROS based on the visit type.

      General: May include if patient has had a fever, chills, fatigue, malaise, etc.

      Skin:

      HEENT: head, eyes, ears, nose, and throat

      Neck:

      Breast:

      CV: cardiovascular

      Resp: respiratory

      GI: gastrointestinal

      GYN: gynecologic

      GU: genito-urinary

      PV: peripheral vascular

      MSK: musculoskeletal

      Neuro: neurological

      Endo: endocrine

      Psych:

      Objective (O):

      Physical exam (PE) – • [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when

      determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]

      Perform either a focused or comprehensive exam based on the visit type.

      This area should confirm your findings related to the diagnosis. For acute episodic or follow-up visits (focused) you may be omitting certain areas such as GYN, Rectal, Abd, etc. While a comprehensive visit will exam each area.

      Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the

      3

      same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory. Gen: general statement of appearance if there is any acute distress.

      VS: vital signs, height and weight, BMI

      Skin:

      HEENT: head, eyes, ears, nose, and throat

      Neck:

      Breast:

      CV: cardiovascular

      Resp: respiratory

      GI: gastrointestinal

      GU: genito-urinary

      Gyn: gynecologic

      PV: peripheral vascular

      MSK: musculoskeletal

      Neuro: neurological

      Endo: endocrine

      Psych:

      Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).

      Assessment (A): This section should be a write-up utilizing your clinical decision-making with your diagnosis/diagnoses being supported by your ‘S’ data set and the ‘O’ data set. Pertinent positives and negatives must be found in the write-up. References required.

      Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.

      Remember to include the appropriate ICD-10 code for each diagnosis.

      A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e., HTN-well managed on medication).

      Plan (P):

      Your plan should be supported by evidence-based guidelines with appropriate citations utilizing APA formatting. Your evidence-based plan may be deviated from your preceptor’s plan. Be sure to comment if there is a deviation in standard of care.

      4

      Document individual plans directly after each corresponding assessment (i.e., Diagnosis #1 found in the assessment should correlate with Plan #1). Address the following aspects (it should be separated out as listed below):

      Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint. Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including the name of the medication, dose, route, quantity, and number of refills for any new or refilled medications.

      Educational: information clients need in order to address their health problems including the diagnosis itself, education on diagnostics, and therapies. Include follow-up care. Anticipatory guidance and counseling.

      Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.

      CPT: References Reference should support your patient’s management plan, including evidence-based practice, and utilize APA formatting.

      Competency Apply Concepts of Professional Writing to Prewriting, Drafting, Revising, and Editing

       

      Competency

      Apply Concepts of Professional Writing to Prewriting, Drafting, Revising, and Editing.

      Instructions

      Below are two professional emails. Read through each of the emails copy and paste them to a Word Document. Edit them utilizing the Review tab in Microsoft Word. Please review each email, finding all errors in grammar, vocabulary, spelling, punctuation and professionalism.

      After you have completed editing and revising the email, pick one of the two and re-write the email so that it is free of all spelling, grammar and content errors and is professional and informative.

      Email #1

      From: Tricia Marcus

      To: Allison Brown

      Subject: Today’s Meeting

      Hey Allison!

      I am looking forward to seeing you today for our meeting. I’ve attached the materials needed for our discussion. Let me know if you have any questions.

      Regards,

      Tricia Marcus

      Marketer Extraordinaire

      [email protected]

      (555) 545-5656

      “Be so good they can’t ignore you.” – Steve Martin

      Email #2

      To: Bob Pope

      From: Gabrielle Mendes

      Subject: Job?

      Hey Bob, We talked a couple weeks back at the chamber of commerce event. (I was the one looking for a summer internship and had a zit on my lip that could have passed for a cold soar. Lol. Whew. It was not. You’re probably like, “uh.. What?” Maybe that helps you recall, maybe not. Not completely important, I suppose.

      I’d really like to come work for you at your IT business. You seemed like a cool person to work for, I liked ur striped pants. I’m available to start working on Monday, but I am taking my driver’s test in June and have to study and go an hour and half away to take it at an easier place cause I’m not a great driver so I’ll miss a few days. I am also going to the beach with friends for a week in July. Oh, and my grandmother has bad gas (OMG IT’S TERRIBLE) and sometimes I have to take her to the doctor.

      I’ve attached my resume, it’s the bomb dot com. Let me know if you have a job opening for me. I can’t wait to play on some computers. If I don’t respond to your email, I’m always on FB, snapchat or insta!

      Peace out,

      Gabrielle Mendes

        Opioid pharmacology post: Opioids for chronic pain

        Other Resources

        Evidence Based Practice Guidelines

        Patient rounds involve various disciplines coming together to discuss the patient’s condition and coordinate care. They are used as an educational tool and also help keep everyone on the same page when it comes to the treatment plan. The following case is found in the textbook (Pharmacotherapy: Principles and Practices. Chisholm-Burns et al, eds.  6th edition.  McGraw-Hill.  New York 2022. ISBN: 978-1-260-46027-8; Chapter 35. "Patient encounter").

        After reading the assigned chapters in the textbook, resources identified in Dynamed and Evidence based practice guidelines, please present the case to your peers in the form of a discussion. This will be your initial post. Please be sure to address all parts of the case and ensure your responses are well researched [including supporting, evidence based guidelines such those of the WHO, CDC, APS, etc.]. It is recommended this be complete between weeks 4-6.

        Your response post(s), to at least one peer, shall be based upon your research and references citing circumstances where you may either endorse or refute the information your peer has presented in their case workup.  The response post(s) must be completed by week 12

        Part 3:

        She was discharged to a skilled nursing facility and is receiving physical therapy and occupational therapy 6 days each week.

        Current Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; sertraline 50 mg daily, hydrocodone/acetaminophen 10/325 mg every 6 hours as needed for pain.

        Pain Assessment: Patient reports pain of 7 out of 10; worse with movement. She complains of pain “everywhere, but my shoulder is really bothering me.” Physical therapy notes indicate patient is unable to complete therapy goals due to complaints of pain in her shoulder.

        • Based on this information, what would you recommend to optimize pain control?
        • Prescribers play a critical role in prescription drug misuse and abuse prevention. What steps can be taken to identify signs of dependence and abuse and what education can you provide to the patient regarding the negative effects of medication misuse?

        Part 4:

        The patient has been at the skilled nursing facility for 2 weeks and is making progress toward rehabilitation goals; however, during a follow-up appointment to her surgeon, she learned that she has metastatic ovarian cancer.

        She states that she has not been sleeping well and has lost 7 lb (3.2 kg) since admission. She also states that she hates waiting for her pain pills and requests something longer acting.

        Pain Assessment: 8 out of 10

        Current Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; sertraline 50 mg daily; diclofenac transdermal gel 1% to neck and left shoulder four times daily; hydrocodone/acetaminophen 10/325 mg every 4 hours as needed for pain (uses 6 doses per day).

        • What additional recommendations would you have at this time regarding pain management?
        • Are there any other therapeutic issues that should be addressed?

        Part 5:

        The patient was discharged to her home, but 3 months after discharge was admitted to hospice service. She is no longer able to swallow her tablets and requires them to be crushed. The hospice nurse requests your advice on an equivalent regimen using transdermal fentanyl and oxycodone for breakthrough pain.

        Pain Assessment: 8 out of 10

        Current Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; diclofenac transdermal gel 1% to neck and left shoulder four times daily; morphine sulfate ER 30 mg twice daily; mirtazapine 15 mg at bedtime.

        • What additional recommendations would you have at this time regarding pain management?
        • Are there any other therapeutic issues that should be addressed?
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