Benchmark – Academic Clinical History and Physical Note

Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating evidence-based plans of care.

Complete an academic clinical history and physical note based on a patient seen during clinical. In your assessment, provide the following. ( Acute Care Hospital)

History and Physical Note

1. Chief complaint/reason for admission/visit/consult.

2. HPI for the H&P or consult notes.

3. Medical, surgical, family, social, and allergy history.

4. Home medications, including dosages, route, frequency, and current medications, if a consultation note

5. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).

6. Vital signs and weight.

7. Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.

8. Lab/Imaging/Diagnostic test results (including date). (CPT codes)

Assessment and Clinical Impressions

1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale. (ICD-10 codes)

2. Include a complete list of all diagnoses that are both acute and chronic.

3. List the differential diagnoses and chronic conditions in order of priority.

Plan Component Management and Plan Criteria Incorporation

1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.

2. Discuss disposition and expected outcomes.

3. Identify and address health education, health promotion, and disease prevention.

4. Provide case summary with ethical, legal, and geriatric considerations. Consider potential issues, even if they are not evident.

General Requirements

Incorporate at least three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

Benchmark Information

This benchmark assignment assesses the following programmatic competency:

MSN Acute Care Nurse Practitioner

6.1: Determine differential diagnoses using physiological and pathophysiological evidence.

  

Translation Models

Diabetes is an international crisis and considered to be one of the Global Burden Diseases (The U.S. Burden of Disease Collaborators, 2018). In the primary care setting, translating the evidence of preventing Diabetic Foot Ulcers is done by introducing self-care education to primary care patients with a transitional Model. Almost 1/3 of people with diabetes acquire foot ulcers, and of these ulcers, 3/4 are avoidable (Bus & Van Netten, 2016). Therefore, it is incredibly essential to translate this evidence into action to prevent foot loss by amputation and, ultimately, early mortality. The Knowledge to Action Model (KTA) is used to translate all the evidence-based research knowledge on diabetic foot care into action in the clinic setting. KTA has two main components, “Knowledge Creation” and the “Action Cycle.” Using KTA, we already have numerous research available on diabetic foot care, funneled to identify a knowledge gap or problem. Knowing the problem, we must implement the second phase, which has seven stages called the Action Cycle. It can be continuous and go in either direction if necessary.

Stage One: The problem of poor diabetic foot care education on one-third of diabetics has been identified, and a knowledge gap exists between patients and caregivers.

Stage Two: The local setting of primary care with a high population of Hispanic patients with diabetes.

Stage Three: One of the possible barriers to this self-care program will be staffing and proper nurses’ training as educators. Also, the time it takes to teach patients. Another obstacle will be the patient’s willingness to learn and perform appropriate foot care daily.  This project’s facilitators will be the primary care providers and management at a micro, meso, and macro-level. The facilitators would help ensure proper staffing and more time allotted in the clinic for foot care sessions during diabetic visits.

Stage Four: Implement the project by educating nurses on diabetes and its effect on the body. The second part of implementation would be having the nurses teach foot care to Hispanic Diabetic patients at every visit. Using a transtheoretical Change Model at this stage would be appropriate.

Stage Five: In this stage, we would monitor the nurses’ knowledge using surveys and observation. We would measure the patients learning with a teach-back method and questionnaire.

Stage Six: Evaluating the outcomes might take a little longer to see results. Still, we should assess feedback from the nurses, podiatrist providers, and patients on the knowledge and care provided through surveys and questionnaires.

Stage Seven: This stage is not a final step but rather a step where knowledge is sustained with continuous updates and reassessments. This stage would keep the program fresh, and the key stakeholders would play the role of being receptive to the new norm and not become disengaged.

The resources needed for this project would be a clinical educator to train nurses on the effects and care of diabetic patients, mostly on foot self-care: foot care literature, handouts, and a small foot care kit for patients.  The kit would consist of a lotion, liquid soap, Emory boards, monofilament, and a mirror. This kit would cost about 12-15 dollars per unit. Key stakeholders such as pharmaceutical companies or diabetic organizations and community leaders would be instrumental in funding each diabetic patient with a self-care kit.

References

Bus, S. A., & van Netten, J. J. (2016). A shift in priority in diabetic foot care and research: 75% of foot ulcers are preventable. Diabetes/metabolism research and reviews, 32 Suppl 1, 195–200. https://doi.org/10.1002/dmrr.2738

The U.S. Burden of Disease Collaborators. (2018). The state of U.S. health, 1990–2016 burden of diseases, injuries, and risk factors among U.S. states. JAMA, 319(14), 1444–1472. https://doi.org/10.1001/jama.2018.0158 (Links to an external site.)

I NEED A COMMENT FOR THIS POST WITH AT LEAST TWO-THREE  PARAGRAPH AND TWO SOURCES NO LATER THAN FIVE YEARS

There are two parts to this:

 1. Self-evaluation paper that addresses your growth as a nurse in relation to clinical experiences, education, maturity, and professionalism and how the PRICE (Professionalism, Respect, Integrity, Caring, Engagement) model has impacted you. This should be one to two pages long. 

2.  Professional Goals, how will you achieve them? One short term, One long term. This should be a page long.

No references needed.

 

rt by reading and following these instructions:

1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.
2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
3. Consider the course discussions so far and any insights gained from it.
4. Create your Assignment submission and be sure to cite your sources if needed, use APA style as required, and check your spelling.

Assignment:

Leininger and Watson

Write a 1500-1750 word APA paper addressing each of the following points. Be sure to completely answer all the questions for each bullet point. Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least two (2) sources and the textbook using citations in your essay. Make sure to cite using the APA writing style for the essay. The cover page and reference page in correct APA do not count towards the minimum word amount. Review the rubric criteria for this assignment.

Case study #1 

Mrs. Franklin-Jones was admitted from the Emergency Room to Cardiac Intensive Care one week ago with a diagnosis of acute myocardial infarction. She has recovered as expected and is moving to the cardiac step down unit today. She is talking with Nurse Julie Hernandez, as she gets settled in her new room, “I was really surprised when I got that bad pain in my chest! I knew I had high pressure but I just didn’t think it was that bad. I try to take my medicine like they told me to in the clinic but sometimes I forget. I guess that I need to study those papers they gave me about what foods I should eat and not eat. I better take care of myself! Momma had bad pressure and it killed her! Who knows—I may even have to learn to cook different than I was taught in Jamaica! I may have to let Tomas do the cooking. He’s got more time at home now than I do since he lost his job. There isn’t too much time between my shifts at the school cafeteria and my new housecleaning job. You know my sister is coming up from Jamaica to see me. I think she is bringing me some bush tea. That’ll set me right!”

• Using Leininger’s Culture Care Model, what factors in the story shared by Mrs. Franklin-Jones should be considered by Nurse Hernandez when planning for the patient’s discharge?
• Why is the theory of Culture Care Diversity important in the delivery of nursing care for all patients?
• Using Leininger’s Theory of Culture Care Diversity and Universality, develop a plan of care for Mrs. Franklin-Jones.
• Discuss the strengths and limits to Leininger’s Theory.

Case Study #2

Claude Jean-Baptiste is recovering from post-hip replacement surgery and has been transferred to the Rehabilitation Institute adjacent to the hospital. When he enters the unit, he sees welcoming signs written in several languages including his own, Creole. Since there are no nurses on that shift that speak Creole, they use a language line to ask for translation services. During this initial nursing assessment, the translator informs Mr. Jean-Baptiste that the nurses invite him to have a relative at his side so that they can be sure to understand and meet his needs. He is asked about Haitian customs and beliefs that they might honor. Mr. Jean-Baptiste is encouraged to bring food and spiritual care items, and to share the warmth of his culture with the nursing staff.

• Discuss assumptions of the Transpersonal Caring relationship. What is the nurse’s role?
• How is love, as defined by Watson, evident in this caring moment?
• How can the nurse creatively use self to create a healing environment?
• Discuss the strengths and limits to Watson’s Theory.

Assignment Expectations:

Length: 1500 – 1750 words

Structure: Include a title page and reference page in APA format.  These do not count towards the minimum word count for this assignment. Your essay must include an introduction and a conclusion.

References: Use appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of two (2) outside scholarly sources and the textbook are required for this assignment.

 What type of drug should you prescribe based on your patient’s diagnosis? How much of the drug should the patient receive? How often should the drug be administered? When should the drug not be prescribed? Are there individual patient factors that could create complications when taking the drug? Should you be prescribing drugs to this patient? How might different state regulations affect the prescribing of this drug to this patient?

These are some of the questions you might consider when selecting a treatment plan for a patient.  

As an advanced practice nurse prescribing drugs, you are held accountable for people’s lives every day. Patients and their families will often place trust in you because of your position. With this trust comes power and responsibility, as well as an ethical and legal obligation to “do no harm.” It is important that you are aware of current professional, legal, and ethical standards for advanced practice nurses with prescriptive authority. Additionally, it is important to ensure that the treatment plans and administration/prescribing of drugs is in accordance with the regulations of the state in which you practice. Understanding how these regulations may affect the prescribing of certain drugs in different states may have a significant impact on your patient’s treatment plan. In this Assignment, you explore ethical and legal implications of scenarios and consider how to appropriately respond.

To Prepare

 Scenario 1:    You see another nurse practitioner writing a prescription for her husband, who is not a patient of the nurse practitioner.  The prescription is for a narcotic.  You can’t decide whether or not to report the incident. 

• Review the scenario assigned.
• Search specific laws and standards for prescribing prescription drugs and for addressing medication errors for your state (Texas) or region, and reflect on these as you review the scenario assigned by your Instructor.
• Consider the ethical and legal implications of the scenario for all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.
• Think about two strategies that you, as an advanced practice nurse, would use to guide your ethically and legally responsible decision-making in this scenario, including whether you would disclose any medication errors.

Write a 2- to 3-page paper that addresses the following:

• Explain the ethical and legal implications of the scenario you selected on all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.
• Describe strategies to address disclosure and nondisclosure as identified in the scenario you selected. Be sure to reference laws specific to your state (Texas)
• Explain two strategies that you, as an advanced practice nurse, would use to guide your decision making in this scenario, including whether you would disclose your error. Be sure to justify your explanation. 
• Explain the process of writing prescriptions, including strategies to minimize medication errors.