In this written assignment, identify one specific contemporary issue or trend that you are interested in learning more about. Choose from the categories below. For example you might want to learn more about why it is more difficult for some groups to receive care than others, which would fall under Client Access to Care. Or, you might want to compare nursing practice in the U.S. with how nurses practice in Japan, which would fall under the category of Global Healthcare and Nursing.

• Global Healthcare and Nursing
• Healthcare Reform
• U.S. Healthcare Financing
• Nursing’s Role in the U.S. Healthcare System
• Integrative Healthcare
• Nursing Leadership and Management
• Nursing Education
• Nursing Practice
• Nursing Professionalism
• Advancing Nursing as a Profession
• Client Access to Care
• Delivering Client Care
• Interdisciplinary Teamwork and Collaboration
• Ethical Practices in Healthcare
• Quality and Safety in Healthcare Delivery
• Health/Nursing Informatics

Soap Note 1 Acute Conditions (15 Points)

Pick any Acute Disease from Weeks 1-5 (see syllabus)

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

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.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions 

Follow the MRU Soap Note Rubric as a guide:

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1)      Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2)      Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3)      Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a)      Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b)      Pertinent positives and negatives must be documented for each relevant system.

c)        Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4)      Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5)      Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6)      Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7)      Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

• Soap Note 1 Acute ConditionsAssignment

Lyme Disease Case Study A 38-year-old male had a 3-week history of fatigue and lethargy with intermittent complaints of headache, fever, chills, myalgia, and arthralgia. According to the history, the patient’s symptoms began shortly after a camping vacation. He recalled a bug bite and rash on his thigh immediately after the trip. 

The following studies were ordered: Studies Results Lyme disease test, Elevated IgM antibody titers against Borrelia burgdorferi (normal: low) Erythrocyte sedimentation rate (ESR), 30 mm/hour (normal: ≤15 mm/hour) Aspartate aminotransferase (AST), 32 units/L (normal: 8-20 units/L) Hemoglobin (Hgb), 12 g/dL (normal: 14-18 g/dL) Hematocrit (Hct), 36% (normal: 42%-52%) Rheumatoid factor (RF), Negative (normal: negative) Antinuclear antibodies (ANA), Negative (normal: negative) Diagnostic Analysis Based on the patient’s history of camping in the woods and an insect bite and rash on the thigh, Lyme disease was suspected. Early in the course of this disease, testing for specific immunoglobulin (Ig) M antibodies against B. burgdorferi is the most helpful in diagnosing Lyme disease. An elevated ESR, increased AST levels, and mild anemia are frequently seen early in this disease. RF and ANA abnormalities are usually absent. Critical Thinking Questions 1. What is the cardinal sign of Lyme disease? (always on the boards)

 2. At what stages of Lyme disease are the IgG and IgM antibodies elevated?

 3. Why was the ESR elevated? 

4. What is the Therapeutic goal for Lyme Disease and what is the recommended treatment.

1-One of the issues that is facing the small community hospital where I live is nursing shortage. Around the world, it seems that larger hospitals are more immune to this problem versus small community hospitals (Cha B. & Choi J., 2015). One way that this affects nurses is in the ED setting. The ED was just added onto to make 23 beds. This is up from 8 beds. Travellers were used for a short time but staff was told that this was not sustainable and the decision was made to only use the correct amount of beds for the amount of nurses that were on shift. The MD’s and other providers insist on filling every room. Two implications for nurses are safety and staff retainability. It is hard for the nurses to feel safe when patient ratios are far above recommended national guidelines. This in turn puts patient’s wellbeing at risk. Secondly, the hospital is having a hard time hiring new staff and retaining current staff. Staff satisfaction has dramatically declined and the word is travelling through the nursing community that it is not a good place to work. 

References

Cha B. & Choi J. (2015).  A Comparative Study on Perception of Patient Safety Culture and Safety Care Activities: Comparing University Hospital Nurses and Small Hospital Nurses. Journal of Korean Academy of Nursing Administration21(4), 405-416. https://doi.org/10.11111/jkana.2015.21.4.405

2-Developing Pediatric Transfer Guidelines based on our available resources and Evidence based practice.

“Additionally, inappropriate transfers to trauma centers may be impacting this finding as well. In a study of patients with orthopedic injuries transferred to Level I trauma centers, Thakur, et al. reported that 52% were inappropriate transfers, and that the majority of inappropriate transfers were uninsured. This transfer effect was not found in Level III or IV trauma centers. Hospitals receiving a larger percentage of transferred patients also have higher proportions of patients requiring critical trauma resources. This is not surprising, as severely injured patients are typically transferred to higher levels of care for specialty expertise and for the management of complex injuries” (Faul, 2015). Nursing staff should be able to ensure the accepting facility has the right resources for the patient.

Developing a Simple SBAR type tool with Standards of Practice for use in outlying facilities and our ED during Transfer Calls. The concept is to improve communication and continuation of care for transferring patients. (ie: if they have give 3 units of RBC, we need to start with plasma.)

“The Joint Commission (2008) has identified effective communication as one of its National Patient Safety Goals. Communication tools like SBAR (Situation, Background, Assessment and Recommendation) can help nurses focus communication to improve the effectiveness of information transfer. SBAR is especially important in urgent or high-acuity situations where clear and effective interpersonal communication is critical to patient outcome” In high acuity, fast paced scenarios a lot of information can be lost or forgotten leading to patient harm (Dunsford, 2009).

Implementing PECARN Imaging guidelines for trauma in the ED & inpatient settings. Leadership from Radiology has asked to be a part of this project.

These are the 3 clinical problems our organization would like us to research and gain positive outcomes from. Clear communication plays a big part in all of these.

Dunsford, J. ( 2015). PubMed. Structured communication: improving patient safety with SBAR. retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/19821914

Faul, Mark (2015). PMS. Trauma Center Staffing, Infrastructure, and Patient Characteristics that Influence Trauma Center Need. retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307735/#b34-wjem-16-98

3-During this practicum, the clinical problem identified within the organization is a lack of musical intervention to reduce agitation, anxiety, and aggression associated with dementia. The first nursing implication for this topic is non-pharmacological musical intervention to reduce behaviors in dementia patients to improve their quality of life (Millan-Calenti, Lorenzo-Lopez, Alonso-Búa, de Labra, González-Abraldes, & Maseda., 2016) The second nursing implication is a reduction of negative side effects associated with the use of pharmacological interventions to treat agitation, anxiety, and aggression in dementia patients (Ridder, Stige, Gunnhild, & Gold, 2013). Current research supports positive outcomes when musical intervention is utilized as a non-pharmacological intervention in the reduction of negative behaviors seen in dementia patients and this organization and its residents could benefit from the implementation of this evidence-based practice.

References

Millán-Calenti, J. C., Lorenzo-López, L., Alonso-Búa, B., de Labra, C., González-Abraldes, I., & Maseda, A. (2016). Optimal nonpharmacological management of agitation in Alzheimer’s disease: challenges and solutions. Clinical interventions in aging, 11, 175–184. doi:10.2147/CIA.S69484

Ridder, H. O., Stige, B., Gunnhild, L., & Gold, C. (2013). Individual music therapy for agitation in dementia: an exploratory randomized controlled trial. Aging & Mental Health, 17(6), 667–678. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4685573/