Potential differential diagnoses for ankle pain:

Achilles tendon rupture, Achilles tendon strain, lateral ligament sprain, fracture, gout, dislocation.

Various types of ankle pain:

Ankle pain may be acute or chronic. Pain may be attributed to various differential diagnoses.

The treatment for ankle pain is largely the same. Patient should be encouraged to “protect” the joint. This may be encouraged by wearing a brace around the affected joint. “Rest” the joint by non-weight bearing, using crutches during ambulation. Applying ice to the affected area. Compressing the surrounding tissues with an ace wrap. Elevating the joint to reduce inflammation. Lastly, using oral NSAIDs for pain control.

Ankle Sprain:

Lateral ligament injuries are the most commonly reported injury to the ankle (Van Rijn et al, 2011). Lateral ligament injuries are the most common injury due to the anatomy of the ankle. The lateral ligament is the most vulnerable ligament.

Sprains are treated in phases.

1 – Protection, Rest, Ice, Compression, Elevation & NSAIDs.

2 – Introduce gentle weight bearing

Various types of treatment

Ice, compression, and elevation.

Depending on the severity of injury immobilization or surgical repair may be indicated.

Diagnostics

The mechanism of injury leading to the ankle pain is important to formulating an accurate differential diagnosis. Imaging may be required to narrow down a diagnosis. Imaging such as CT, MRI, and x-ray may be helpful.

Ankle Fractures

Risk factors which predispose patients to a higher risk of ankle fractures include: osteoporosis, diabetes, and obesity (Strauss et al, 2011).

Generally, patients with ankle fractures present with pain, swelling, deformity, and an inability to bear weight on the affected joint (Strauss et al, 2011).  Supination-external rotation fractures are the most common type of ankle fracture (Strauss et al, 2011).  

Unimalleolar – involving one side of the ankle

Bimalleolar – involving medial and lateral malleolus

Trimalleolar – Involving three areas of the malleolous.

Treatment:

Treatment of an ankle fracture is contingent upon several factors “A patient is treated nonoperatively if he/she sustains a nondisplaced, stable fracture with an intact syndesmosis or if stable anatomic reduction is achieved after a displaced fracture. ORIF is indicated in open and/or unstable fractures, and when closed reduction fails. Unstable fractures may cause widening of the mortise or displacement of the talus. The method of stabilization utilized during ORIF depends on the anatomical location of the ankle fracture and associated soft tissue injury” (Urruela et al, 2011)

Strauss, E. J., M.D., & Egol, K. A., M.D. (2011). Identifying and managing ankle fractures in older patients. The Journal of Musculoskeletal Medicine, 28(4), 137-140,145-147. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/863651469?accountid=167104

 Urruela, A., & Egol, K. (2011). Foot and ankle fractures in the elderly patient. Aging Health, 7(4), 591-605. doi:http://dx.doi.org/10.2217/ahe.11.45

van Rijn, R.,M., Willemsen, S. P., Verhagen, A. P., Koes, B. W., Bierma-Zeinstra, S., & Hush, J. M. (2011). Explanatory variables for adult patients’ self-reported recovery after acute lateral ankle Sprain/Invited commentary. Physical Therapy, 91(1), 77-84. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/846755272?accountid=167104 (Links to an external site.)Links to an external site.

Reply to Dee

Patients can have ankle pain for a variety of reasons. To formulate an accurate diagnosis and differentials, providers must be able to accurately assess physically and with assessment questions. Assessing when the pain started, exacerbating and alleviating factors, and any possible precipitating injuries. An ankle sprain, for example, is caused by sudden stress on one or more of the ligaments of the ankle (Uphold & Graham, 2013). Assessing if the patient twisted the ankle and experienced pain immediately or within the hour of the insult, an inversion injury should be suspected (Uphold & Graham, 2013). Asking the patient exactly how the injury occurred, the positioning of the foot when the injury occurred, if there was any swelling, to describe the type of pain, if ADL’s are affected, if there is any limping or night pain can aid in formulating an accurate diagnosis and treatment plan (Dains, Baumann, & Scheibel, 2016).

Physical assessment should include observing the patient’s gait for any limp, assessing for any deformities, inspection of the skin and nails (for inflammation or the possibility of ingrown toenails causing gait abnormality) (Dains, Baumann, & Scheibel, 2016); measuring limb circumference and length to assess for atrophy and to ascertain if this is a chronic or acute problem; palpation of the joints and performing range of motion is also important in formulation of the diagnosis and treatment.

Performing the anterior drawer test, to assess the anterior talofibular ligaments of the lateral side of the ankle; the talar tilt test to assess the stability of the calcaneofibular ligament; and the squeeze test to assess if medial or lateral damage has occurred (Uphold & Graham, 2013). Differentials include muscle strain, tendonitis, peroneal tendon dislocation, tendon rupture, fracture, gout or arthritis (Uphold & Graham, 2013). Diagnostics that should be included are xray, if there is pain near the malleoli, inability to bear weight, bone tenderness, according to Ottawa rules (Uphold & Graham, 2013). CBC can be obtained to rule out infection, uric acid to rule out gout, RA, ANA and CRP to rule out rheumatoid arthritis, arthritis, and infection, respectively (Dains, Baumann, & Scheibel, 2016).

Treatment is dependent upon diagnosis. If patient has a strain/sprain, rest, ice, compression, and elevation is the appropriate treatment. Patient can also be treated with short term NSAID’s for pain relief. If there is no improvement within 2-3 weeks, or if symptoms worsen, patient may need to be referred to an orthopedist (Uphold & Graham, 2013).

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced Health Assessment and Clinical Diagnosis in Primary Care (5th ed.). St. Louis, MO: Elsevier.

Uphold, C. R., & Graham, M. V. (2013). Clinical Guidelines in Family Practice (5th ed.). Gainesville, FL: Barmarrae Books, Inc.

This Performance Task Assessment is based on a case study set in Brooklyn Presbyterian Hospital, in the Park Slope neighborhood of Brooklyn, New York, as the hospital confronts the new quality standards set by the Patient Protection and Affordable Care Act (PPACA) for Medicare patients. To complete this Assessment, read the scenario below, and then complete Parts I and II that follow. You will use information from the scenario, along with the supporting documents, to demonstrate your ability to adapt internal policies and practices to align with changes to healthcare laws and regulations.

Professional Skills: Written Communication, Technology, and Critical Thinking and Problem Solving are assessed in this Competency.

Your response to this Assessment should:

• Download the Academic Writing Expectations Checklist to use as a guide when completing your Assessment. Responses that do not meet the expectations of scholarly writing will be returned without scoring. Properly formatted APA citations and references must be provided, where appropriate.
• Be sure to use scholarly academic resources as specified in the rubric. This means using Walden Library databases to obtain peer reviewed articles. Additionally, .gov (government expert sources) are a quality resource option. Note: Internet and .com sources do not meet this requirement. Contact your coach or SME for guidance on using Library Databases.
• Carefully review the rubric for the Assessment as part of your preparation to complete your Assessment work.

Assessment requires submission of one (1) document (Part I) and one (1) PowerPoint presentation (Part II). Save the Word document as LE003_PartI_firstinitial_lastname (for example, LE003_PartI_J_Smith). Save the PowerPoint Presentation as LE003_PartII_firstinitial_lastname. When you are ready to upload your completed Assessment, use the Assessment tab on the top navigation menu. 

Instructions

Before submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.

Rubric

Imagine you are an administrator at Brooklyn Presbyterian Hospital in Brooklyn. One day you arrive at work to find an urgent memo from your CEO: Medicare has released its data on unplanned 30-day hospital readmission rates, and your hospital is being penalized at the maximum rate for having an exceptionally high rate of unplanned 30-day readmissions. Alarmed by these statistics, your CEO gives you a special project, outlined in Part I and Part II below.

Access the following to complete this Assessment:

• Brooklyn Presbyterian Hospital Acute Inpatient Hospital Admissions Payment Policy
• Brooklyn Presbyterian Hospital—Unplanned Readmission Rates (from Medicare Hospital Compare)
• James, J. (2013). Medicare Hospital Readmissions Reduction Program. Retrieved from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=102

This assessment has two-parts.  Click each of the items below to complete this assessment.

Part I: Analyzing HRRP Policy and Evaluating Hospital Performance

Read the Health Affairs Policy Brief on the “Medicare Hospital Readmissions Reduction Program.” Then, analyze the document “Brooklyn Presbyterian Hospital—Unplanned Readmission Rates,” which presents statistics on the unplanned readmission rates at the hospital and how they compare to the national averages. Also, review the current, “Acute Inpatient Hospital Admissions Payment Policy” document.

Use these resources to develop a report (4–5 pages) to the CEO that completes the following:

• Describe the key elements of the Medicare Hospital Readmissions Reduction Program (HRRP) established in the Affordable Care Act (ACA).
• Identify two factors at Brooklyn Presbyterian Hospital based on the current policy that contribute to the risk of failing to meet HRRP criteria.
• Explain how current internal practices and the changes in policy might positively impact alignment to current and future healthcare laws.
• Suggest one revision to the current policy to help Brooklyn Presbyterian Hospital meet HRRP criteria.
• Suggest one change in current practice across the hospital’s organization in order to help Brooklyn Presbyterian Hospital meet changes in Medicare reimbursement. Include 2–3 sentences explaining the importance of adapting internal policies and practices to align with changes in healthcare laws and regulations.
• Describe at least three key elements needed in a new program to earn the maximum reimbursement under HRRP by reducing readmission rates.
• Create five goals for Brooklyn Presbyterian Hospital for earning the maximum reimbursement by following the HRRP criteria. These goals may focus on processes or outcomes.

Part II: Developing an Action Plan to Maximize Reimbursements and Adapt to Change

Political pressure will result in changes to Centers for Medicare and Medicaid Services (CMS) policy and reimbursements. Develop a 10- to 12-slide presentation, to senior management, proposing strategies for executing a plan for earning maximum reimbursement under HRRP, specifically by changing the behavior of providers and patients. Your goal is to secure resources to put your plan into action. In this presentation, explain your approach, your plan for implementation, at least two ways you will prepare and monitor for change in CMS policy, and your education plan for staff.

Write a scholarly paper in which you apply the concepts of epidemiology and nursing research to a communicable disease. Choose one communicable disease (HIV)

Epidemiology Paper Requirements

Include the following in your assignment:

1. A thorough description of the disease including causes, mode of transmission, symptoms, treatment and complications. Discuss the demographic most affected-incidence, prevalence, morbidity and mortality.
2. What are the determinants of health affecting this disease? https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health.
3. Identify the epidemiologic triad including host, agent and environmental factors as related to this disease.
4. Discuss the role of the public health nurse in relation to this disease. How is the public health nurse involved in finding, reporting, collection and analysis of data and follow up?

A minimum of three references is required. The written essay should be at least 1250 words in length.

APA format is required.

Discussion: Comparing Frameworks for Analyzing Organizations

Avedis Donabedian’s work generated a pivotal means of assessing organizational performance relative to structure, process, and outcomes. However, it is clearly not sufficient to view health care quality merely in terms of outcomes—the structures and processes that facilitate these outcomes are equally as important.

In this Discussion, you consider multiple frameworks that can be used to analyze an organization. As you proceed, consider how these frameworks allow you to examine the interplay of interdependent and related parts and processes that comprise the systems within an organization, as well as the arrangements or structures that connect these parts.

To prepare:

• Investigate and reflect on the systems and structures of an organization with which you are familiar. Consider the following:
  • What is the reporting structure?
  • Who holds formal and informal authority?
  • How many layers of management are there between the frontline and the highest office-holders of the organization?
  • How are interdisciplinary teams organized?
  • How is communication facilitated?
  • How well integrated is decision making among clinical personnel and administrative professionals?
  • How are particular service lines organized?
  • Which departments, groups, and/or individuals within the organization are responsible for monitoring matters related to performance, such as quality and finances?
• Select two of the following frameworks:
  • Learning organizations, presented in the Elkin, Haina, and Cone article
  • Complex adaptive systems (CAS), presented in the Nesse, Kutcher, Wood, and Rummans article
  • Clinical microsystems, presented in the Sabino, Friel, Deitrick, and Sales-Lopez article
  • Good to great, presented in the Geller article
  • The 5 Ps, presented in the ASHP Foundation article
• Review the Learning Resources for each of the frameworks that you selected. Also conduct additional research to strengthen your understanding of how to use each framework to assess an organization.
• Compare the two frameworks. How could each framework be used to identify opportunities to improve performance? In particular, how would you use each of these frameworks to analyze the organization that you have selected?

By Day 3

Post an analysis of the systems and structures of the organization you selected, sharing specific examples. Explain insights that you gained by comparing the two frameworks, and how each can be used to assess an organization, identify a need for improvement, and, ultimately, enhance the performance of an organization.

Hickey, J. V., & Brosnan, C. A. (2017). Evaluation  of health care quality in for DNPs (2nd  ed.). New York, NY: Springer Publishing Company.
Chapter 1, “Evaluation and DNPs: The Mandate for Evaluation” (pp. 3-36)
Chapter 3, “Conceptual Models for Evaluation in Advanced Nursing Practice” (pp. 61-86)
Chapter 6, “Evaluating Organizations and Systems” (pp. 127-142)Chapter 1 defines microsystem, mesosystem, and macrosystem and notes that evaluation can focus on one of these levels or all three. Chapter 5 examines the evaluation of organizations and systems.

Sadeghi, S., Barzi, A., Mikhail, O., & Shabot, M. M. (2013). Integrating quality and strategy in health care organizations, Burlington, MA: Jones & Bartlett Publishers.
Chapter 2, “Understanding the Healthcare Organization” (pp. 31–43)Although this chapter focuses on hospitals, the authors provide information about strategic planning and organizational structure that is applicable in many health care settings. The authors examine financial and quality issues as key aspects of performance measurement.

Elkin, G., Zhang, H., & Cone, M. (2011). The acceptance of Senge’s learning organisation model among managers in China: An interview study. International Journal of Management, 28(4), 354–364.
Retrieved from the Walden Library databases.

This article outlines the five disciplines that Senge argued could be found in a learning organization. The authors also discuss the worldview that is inherent in business organizations in China and explain how this relates to Senge’s theory.

Geller, E. S. (2006). From good to great in safety: What does it take to be world class? Professional Safety, 51(6), 35–40.
Retrieved from the Walden Library databases.

Geller reviews and applies Collin’s foundational Good to Great theory from its focus on financial success to safety.

Nesse, R. E., Kutcher, G., Wood, D., & Rummans, T. (2010). Framing change for high-value healthcare systems. Journal for Healthcare Quality, 32(1), 23–28.
Retrieved from the Walden Library databases.

This article explores how to implement change in complex adaptive systems (CAS) such as health care. The authors purport that an understanding of the principles of change management in CAS is critical for success.

Sabino, J. N., Friel, T., Deitrick, L. M., & Salas-Lopez, D. (2009). Striving for cultural competence in an HIV program: The transformative impact of a microsystem in a larger health network. Health & Social Work, 34(4), 309–313.
Retrieved from the Walden Library databases.

The authors discuss cultural competence as part of a patient-centered perspective on health care delivery. They examine an approach to creating innovation that originates at the unit (microsystem) level and can be diffused to the larger health care environment (macrosystem).