Scenario:

James has a diagnosis of congestive heart failure. He presented to the emergency room in the morning complaining of a “racing heartbeat” and increasing shortness of breath during the past two months, and with marked swelling of the ankles and feet during the past three weeks. He has been waking up in the middle of the night with severe breathing problems and has been sleeping with several pillows. 

 

Soap Note 2 Chronic Conditions

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

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?

  

 
 

4-Technology play a very core role in the process of being able to implement projects. Further, through technology, projects can be sustained and maintained so that they are able to be achieved. Through the use of technology, implementation is easier and also more effective. Therefore, one has to look for the best form of technology that can help in the implementation or supporting the project to ensure that the implementation goes as smoothly as possible (Powell-Cope, Nelson, Patterson, 2008). The project that I will be handling looks to establish whether the involvement of healthcare facilities in nursing education can be able to help reduce the shortage of nurses that the country is facing currently. Technology in this project can be used in monitoring whether the involvement of healthcare facilities in nursing education will help to reduce the shortage of nurses in the country.

The best technology to use in the monitoring of the progress of this project is through use of data collection from every facility and the action they are making and the number of nurses it helps to bring to the workforce. The actions that facilities can take are very many, therefore one has to monitor which action results in a higher number of nurses to the workforce. The best action can then be selected through the evaluation and analysis of the data that is collected. However, there are barriers to the use of this technology. One of the barriers is the lack of sufficient information from the facilities on what actions they are taking and the number of nurses they are able to successfully help to bring to the workforce (Powell-Cope, Nelson, Patterson, 2008). Therefore, one of the barrier is the lack of sufficient information to help in monitoring.

References

Powell-Cope G, Nelson AL, Patterson ES. 2008. Patient Care Technology and Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); Apr. Chapter 50. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2686/

Williamson K., Fineout- Overholt E., Kent B., Hutchinson A. & MBioeoth B. (2015). Teaching EBP: Integrating Technology Into AcademicCurricula to Faciltate Evidence- Based Decision Making. World View on Evidence-Based Nursing. Fourth Quarter. Retrieved from.https://www.ncbi.nlm.nih.gov/pubmed/20456725

 

 
 

5-The use of technology is very necessary in this time and age. As healthcare continue to grow and improve, so do the use of technology need to change to improve the implementation process and the outcomes of EBP projects. In my project, I am going to be using the Electronic Health Record to collect useful data for my project. Accessing the HER will give me an overview of useful information about patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs (ANA, 2015) which are some of the issues related to fall. I will also implement the use of Information and Communication Technology to access adequate EBP evidence that pertain to my project. ICT will enable me to obtain lots of relevant information through the internet on my project.

Reference

American Nurses Association [ANA](2015.). Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings. Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-May-2015/Articles-Previous-Topics/Technology-Safety-and-Professional-Care-Documentation.html

 
 

6- it sounds like you are doing a qualitative research project and with that you will need the internet to gather material related to your study. The use of technology is essential for EBP as it help us learn new things through different ways. Before online and distant learning was not possible, today students are able to study anywhere anytime. Also we needed to go to the hospital for every little thing so the doctor or nurse can check us out; but today we can do everything in the comfort of our homes. This is amazing and I am looking forwards to see what the future holds for nursing with technology.

 

 

Respond to at least two of your colleagues who selected a different factor than you, in one of the following ways:

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Share insights based on your own experience and additional research.

                                                       Main post

Cardiovascular Alterations

It is essential to understand the typical structure and function of the cardiovascular system because alterations occur. Some changes can be pathologic and others not. Alhadheri (2005) states that 50 to 90 percent of children have a benign or functional murmur. In this post, I will explain how I would diagnose and prescribe treatment for the patient in the scenario, including how genetics impacts the diagnosis and treatment.

Diagnosis and Treatment

Making a proper diagnosis is necessary before allowing the teenager to engage in sports. The patient had no significant family history of cardiac death and an unremarkable medical history. The lack of patient medical history leads me to conclude that the problem is not acquired, but congenital. The physical assessment is not enough information to definitively determine the etiology of the murmur. It would be wise to run additional tests to rule out a pathological murmur. Appropriate tests include a chest x-ray, electrocardiogram, blood work, and echocardiogram (Alhadheri, 2005). The patient is asymptomatic, so I would order an echocardiogram looking for structural abnormalities. I suspect that the patient has mitral regurgitation based on the location and description of the sound in the scenario. Hammer and McPhee (2019) state that a murmur can be heard best at the apex of the heart with mitral regurgitation. Another possibility is coarctation of the aorta, but this is unlikely because the patient does not have diminished blood pressure nor pulses in the lower extremities. If mitral regurgitation is the case, the treatment may be surgical intervention. Either way, I would refer the patient for treatment to a pediatric cardiologist knowing that it is outside of my scope. A registered nurse practitioner is required to make a referral to a physician for a patient condition that is beyond their knowledge or experience (Arizona State Board of Nursing, 2018, p. 46).

Genetics

Genetics could impact the diagnosis. There is a high incidence of congenital heart defects with trisomies 13 and 18, Turner syndrome, and Down syndrome (Huether & McCance, 2017). The diagnosis could be a ventricular septal defect instead. However, I do not think the treatment would change if genetics were a factor. Usually, surgery is the intervention when the problem is pathological regardless of origin. 

References

Alhadheri, S. A. (2005). Children with Heart Murmurs…When to be Concerned?. Retrieved from https://apcardio.com/wp-content/themes/advancedpedia/pdf/Heart_Murmurs.pdf

Arizona State Board of Nursing. (2018, May 23). Rules of the State Board of Nursing. Retrieved June 24, 2019, from https://www.azbn.gov/media/2880/ruleseffectivemay232018.pdf

Hammer, G. D., & McPhee, S. J. (2019). Pathophysiology of disease: An introduction to clinical medicine (8th ed.). New York, NY: McGraw-Hill Education.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.

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