As nurses we complete physical assessment on a routine basis, but typically these are focused assessments. Which components of the head-to-toe physical assessment are not routine for you (ones you do not use on a regular basis)? Why is it important for you to still be familiar with these components and skilled at completing the 

Write 4 pages in which you discuss how a current information system used in the delivery of patient care contributes to improved patient outcomes.

In using information system technology, nurses are able to track and measure data to improve patient outcomes.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Describe the importance of effective scholarship and evidence-based information to advance the profession of nursing.
  • Describe how an information system used in nursing contributes to evidence-based nursing practices.
• Competency 2: Identify strategies and best practices for using informatics in nursing and health care.
  • Describe how a nurse researcher uses information technology to define patient safety within the context of outcomes.
• Competency 3: Explain the use of information management tools and technologies to monitor and improve health care delivery and patient outcomes.
  • Describe how nurse leaders and nurse informaticists use technology and evidence-based practice to contribute to improved patient outcomes.
• Competency 4: Communicate in a manner that is consistent with the expectations of a nursing professional.
  • Write coherently to support a central idea in appropriate format with correct grammar, usage, and mechanics
    .
• Write a paper in which you analyze an information system for its effectiveness in improving patient care.
  Preparation
  Select an example of a current information system used in the delivery of patient care. Note: Ideally, select a system from your workplace to examine. If you are not currently working, select a system from an organization close to where you live. This technology should be used for data management designed to improve patient care.
  Familiarize yourself with the technology. Do some personal research to gain a deeper understanding about the technology. Visit the Web site of the company who markets the technology to familiarize with how the company positions the technology in the market. Read articles online and in the library related to your chosen system. Remember to take notes to keep track of what you discover. Examine the following aspects of the technology:
  1. How is the information system designed to contribute to safety and quality in the care of patients?
  2. What types of data are tracked, monitored, stored, and trended in the system?
  3. How well does it accomplish what it is designed to do in your chosen real-world setting?
  4. How is this information system used to support research or action by nurse researchers, leaders, and informaticists? If it is not currently being used to support research, how could it be used in the future?
  5. What types of opportunities are available for nurses, in any scope of practice, that gives them the chance to participate in the design and testing of this system?
  6. How might the technology be enhanced so it better meets the needs of the professionals currently using the system?
  7. Compare what you learn with how your chosen technology is being used in the workplace. Think about your own workplace and consider speaking with other professionals who currently use the system.
     Directions
     Write an paper in which you discuss and apply what you have learned about how your chosen information system is used in the delivery of patient care and how it contributes (or does not contribute) to improved patient care. Include the following categories:
  • Describe your chosen information system used in nursing and how it contributes to evidence-based nursing practices.
  • Describe the types of data that are tracked and how the data are monitored, stored, and trended.
  • Describe how a nurse researcher, nurse leader, and nurse informaticist use information technology to define patient safety within the context of outcomes.
  • Describe how nurses can enhance the technology through participation in design and testing of the system.
  • Additional Requirements
  • Written communication: Ensure written communication is free of errors that detract from the overall message.
  • APA formatting: Format resources and citations according to current APA style and formatting guidelines. Include the following:
    • Title page.
    • Running head (a short title that appears on every page).
    • Title on the first page of text.
    • Level 1 headings for paper sections.
    • In-text parenthetical citations and a reference list.
  • Number of resources: Cite a minimum of four peer-reviewed resources.
  • Length: Submit 4 typed, double-spaced pages.
  • Font and font size: Use Times New Roman, 12 point.

Advanced practice nurses often treat patients with vein and artery disorders such as chronic venous insufficiency (CVI) and deep venous thrombosis (DVT). While the symptoms of both disorders are noticeable, these symptoms are sometimes mistaken for signs of other conditions, making the disorders difficult to diagnose. Nurses must examine all symptoms and rule out other potential disorders before diagnosing and prescribing treatment for patients. In this Assignment, you explore the epidemiology, pathophysiology, and clinical presentation of CVI and DVT.

To Prepare

• Review the section “Diseases of the Veins” (pp. 598-599) in Chapter 23 of the Huether and McCance text. Identify the pathophysiology of chronic venous insufficiency and deep venous thrombosis. Consider the similarities and differences between these disorders.
• Select a patient factor different from the one you selected in this week’s Discussion: genetics, gender, ethnicity, age, or behavior. Think about how the factor you selected might impact the pathophysiology of CVI and DVT. Reflect on how you would diagnose and prescribe treatment of these disorders for a patient based on the factor you selected.
• Review the “Mind Maps—Dementia, Endocarditis, and Gastro-oesophageal Reflux Disease (GERD)” media in the Week 2 Learning Resources. Use the examples in the media as a guide to construct two mind maps—one for chronic venous insufficiency and one for venous thrombosis. Consider the epidemiology and clinical presentation of both chronic venous insufficiency and deep venous thrombosis.

To Complete

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

• Compare the pathophysiology of chronic venous insufficiency and deep venous thrombosis. Describe how venous thrombosis is different from arterial thrombosis.
• Explain how the patient factor you selected might impact the pathophysiology of CVI and DVT. Describe how you would diagnose and prescribe treatment of these disorders for a patient based on the factor you selected.
• Construct two mind maps—one for chronic venous insufficiency and one for deep venous thrombosis. Include the epidemiology, pathophysiology, and clinical presentation, as well as the diagnosis and treatment you explained in your paper.

Soap Note 1 Acute Conditions Due 10/12/2019

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?

Comments:

Total Score: ____________ Instructor: __________________________________