APA format Please follow directions below need to have done by 10/10/18 at 9 pm. 

3 peer review references.  

Today 10/10/18 is the third day

 This week we have lots to do.  First off you have a discussion.  This should be a SOAP note posted based on the case of your choice.  Please pick the one that you feel you will learn the most from 

here is the SOAP note template

 

his template is for a full history and physical. For this course include only areas that are related to the case.

Patient Initials: _______                Age: _______                                   Gender: _______

Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

L =location

O= onset

C= character

A= associated signs and symptoms

T= timing

E= exacerbating/relieving factors

S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdap, Flu, pneumonia, etc.

Significant Family History: Include history of parents, grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

            HEENT:

Neck:

            Breasts:

            Respiratory:

            Cardiovascular/Peripheral Vascular:

            Gastrointestinal:

            Genitourinary:

            Musculoskeletal:

            Psychiatric:

            Neurological:

            Skin:  

Hematologic:

            Endocrine:

            Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P- only in this course. Do not use “WNL” or “normal.” You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, and BMI.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things.

HEENT:

Neck:

Chest

Lungs:

Heart

Peripheral Vascular: Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.

ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

REFLECTION: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?

 

Discussion: Assessing the Heart, Lungs, and Peripheral Vascular System

Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?

In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.

In this Discussion, you will consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the Episodic/Focused SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

To prepare:

With regard to the case study you were assigned:

• Review this week’s Learning Resources and consider the insights they provide.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Note: Before you submit your initial post, replace the subject line (“Discussion – Week 6”) with “Review of Case Study” identifying the number of the case study you were assigned.

By Day 3

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each. 

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

 

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APA format 3 peer review references Please follow instructions on assignment 

Due 10/3/18 at 4pm EST

   

Assesment 1: Assessing the A 

Assesment 1: Assessing the Abdomenbdomen

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.
Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time-consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.

In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

Abdominal Assessment

SUBJECTIVE:

• CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
• HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
• PMH: HTN, Diabetes, hx of GI bleed 4 years ago
• Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
• Allergies: NKDA
• FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

OBJECTIVE:

• VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Skin: Intact without lesions, no urticaria
• Abd: soft, hyperctive bowel sounds, pos pain in the LLQ
• Diagnostics: None

ASSESSMENT:

• Left lower quadrant pain
• Gastroenteritis
• PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP note case study provided:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• Consider what history would be necessary to collect from the patient in the case study.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

To complete:

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or Why not?
4. What diagnostic tests would be appropriate for this case and how would the results be used to make a diagnosis?
5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature.

A 

Assesment 1: Assessing the Abdomen

 

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APA format 2 pages 3 reference 1 from Walden University Library Due 10/1/19 8pm EST

Discussion: Clinical Labs and Instructional Videos

Consider the following scenario:

You have been teaching a clinical lab for a few months. During each session, you have noticed that learners spend more time participating in the introductory part of the lesson and less time involved in problem-based, hands-on activities. After consulting current literature on teaching best-practices, you learn that many instructors require learners to watch introductory videos before participating in clinical labs. These videos ‘set the stage’ for the lesson while also demonstrating the skills in which students will engage during their lab. You know that you will still need to review material at the start of the lab but are excited about the advantages that this video could bring. As such, you begin to search the Internet for a video that will introduce your clinical lab.

To prepare

• Review this week’s Learning Resources. Reflect on the strategies and methods nurse educators use to elicit critical thinking and problem-based learning in clinical lab environments.
• Consider a psychomotor or skills-based technique that an individual might learn in a clinical lab. (Note: Clinical labs are not just for nursing students. Nursing staff and patients might also engage in this environment.)
• With these ideas in mind, search the Internet for a short video demonstration of a clinical lab. (Suggested search key words are clinical nursing skills videos). Once selected, carefully review the video, provide the link to the video, and identify the learning objectives and intended audience of learners. If these are not explicitly stated, use the content of the video to determine the objectives and intended audience.
• Consider how you might use this video demonstration to better prepare learners for an upcoming clinical lab.
• Use the Lesson Plan Template document as a guide to critique, create a lab-based lesson that could accompany the video demonstration that you have selected. 

 

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APA format 2 pages 3 references

Discussion Topic 1: Creating Online Quizzes

You will be assigned to Discussion Topic Group 1 or 2 to post your initial assignment and will be posting your responses to your colleagues in the other Discussion Group. For example, students assigned to Discussion Topic 1 will be posting their initial assignment in the Discussion Topic Group 1 Forum and post their responses to their colleagues in the Discussion Topic Group 2 Forum.

The testing and assessment process is often a struggle for educators. For many, finding the balance between a seemingly “hard” or “easy” question takes much practice. Furthermore, the development of question formats and stems can be a difficult concept to master. To aid in quiz development, nurse educators can use models such as The 3Cs (illustrated below) to focus more on the content of their questions and less on the actual construction. Nurse educators can also use prompts and templates provided at quiz development websites to assist quiz design. These websites can also help instructors easily administer quizzes in the online environment.

The 3Cs Model of Test Item Writing:

• Content, concepts, and criterion. Use the content of the lesson as well as overarching concepts and nursing criterion (like NCLEX and other formal assessments) as a blueprint for your questions. In addition, consider the ideas and teachable moments that have occurred in the classroom or during clinical rotations.
• Clarity and complexity. Be sure that your question stems are clear, straightforward, and use simple language. In addition, write your questions at the application or analysis level of Bloom’s Taxonomy. This will prompt students to move beyond basic comprehension and memorization.
• Critique. Always go back and examine the questions that you have created. This process should be completed both before and after examinations. As with all teaching strategies, evaluation and revision is imperative to ensure the effectiveness of instruction.

To prepare

• Review this week’s Learning Resources on developing multiple-choice quiz questions. How might you use the 3Cs and other best practices to craft your own quiz questions?
• Reflect on a Lesson Plan that you have created in this course. Which lesson might lend itself towards a pre- or post-quiz?
• Select one Lesson Plan you will use as the focus of your online quiz. Then, craft three quiz questions that are closely linked to the learning objectives and learning need of the lesson.
• Consider the challenges that you experienced in developing your quiz questions.
• Browse the available websites that educators can use to create online quizzes. After reviewing the format and capabilities of various sites, select one to upload your three questions.
• Be sure to copy the web address (URL link) that your colleagues will need to view your quiz.
• Update your Lesson Plan with your three quiz questions and resave with the word “updated” at the end of the file name.
• Consider any challenges that you may have experienced in using the platform that you chose and how you dealt with those challenges.

 

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