Nursing CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of
last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
General:
Head:
EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.


O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History.
Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)


A

.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.


P.
  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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Assessment-2-4040

Assessment 2

Protected Health Information (PHI): Privacy, Security, and Confidentiality Best Practices

Instructions- Prepare a 2-page interprofessional staff update on HIPAA and appropriate social media use in health care.

Introduction- Health care providers today must develop their skills in mitigating risks to their patients and themselves related to patient information. At the same time, they need to be able distinguish between effective and ineffective uses of social media in health care.

This assessment will require you to develop a staff update for the interprofessional team to encourage team members to protect the privacy, confidentiality, and security of patient information.

Preparation- As you begin to consider the assessment, it would be an excellent choice to complete the Breach of Protected Health Information (PHI) activity. The activity will support your success with the assessment by creating the opportunity for you to test your knowledge of potential privacy, security, and confidentiality violations of protected health information. The activity is not graded and counts towards course engagement.

To successfully prepare to complete this assessment, complete the following:

· Review the infographics on protecting PHI provided in the resources for this assessment, or find other infographics to review. These infographics serve as examples of how to succinctly summarize evidence-based information.

· Analyze these infographics and distill them into five or six principles of what makes them effective. As you design your interprofessional staff update, apply these principles. 
Note: In a staff update, you will not have all the images and graphics that an infographic might contain. Instead, focus your analysis on what makes the messaging effective.

· Select from any of the following options, or a combination of options, the focus of your interprofessional staff update:

· Social media best practices.

· What not to do: social media.

· Social media risks to patient information.

· Steps to take if a breach occurs.

· Conduct independent research on the topic you have selected in addition to reviewing the suggested resources for this assessment. This information will serve as the source(s) of the information contained in your interprofessional staff update. Consult the 

BSN Program Library Research Guide
 for help in identifying scholarly and/or authoritative sources.

Instruction- In this assessment, assume you are a nurse in an acute care, community, school, nursing home, or other health care setting. Before your shift begins, you scroll through Facebook and notice that a coworker has posted a photo of herself and a patient on Facebook. The post states, “I am so happy Jane is feeling better. She is just the best patient I’ve ever had, and I am excited that she is on the road to recovery.”

You have recently completed your annual continuing education requirements at work and realize this is a breach of your organization's social media policy. Your organization requires employees to immediately report such breaches to the privacy officer to ensure the post is removed immediately and that the nurse responsible receives appropriate corrective action.

You follow appropriate organizational protocols and report the breach to the privacy officer. The privacy officer takes swift action to remove the post. Due to the severity of the breach, the organization terminates the nurse.

Based on this incident's severity, your organization has established a task force with two main goals:

· Educate staff on HIPAA and appropriate social media use in health care.

· Prevent confidentiality, security, and privacy breaches.

The task force has been charged with creating a series of interprofessional staff updates on the following topics:

· Social media best practices.

· What not to do: Social media.

· Social media risks to patient information.

· Steps to take if a breach occurs.

You are asked to select one or more of the topics and create the content for a staff update containing a 
maximum of two content pages. 
This assessment is not a traditional essay.
 It is a staff educational update about PHI. Consider creating a flyer, pamphlet, or one PowerPoint slide (not an entire presentation). Remember it should not be more than two pages (excluding a title and a reference page).

The task force has asked team members assigned to the topics to include the following content in their updates in addition to content on their selected topics:

· What is protected health information (PHI)?

· Be sure to include essential HIPAA information.

· What are privacy, security, and confidentiality?

· Define and provide examples of privacy, security, and confidentiality concerns related to the use of technology in health care.

· Explain the importance of interdisciplinary collaboration to safeguard sensitive electronic health information.

· What evidence relating to social media usage and PHI do interprofessional team members need to be aware of? For example:

· What are some examples of nurses being terminated for inappropriate social media use in the United States?

· What types of sanctions have health care organizations imposed on interdisciplinary team members who have violated social media policies?

· What have been the financial penalties assessed against health care organizations for inappropriate social media use?

· What evidence-based strategies have health care organizations employed to prevent or reduce confidentiality, privacy, and security breaches, particularly related to social media usage?

Notes

· Your staff update is limited to two double-spaced content pages. Be selective about the content you choose to include in your update so you can meet the page length requirement. Include 
need-to-know information. Omit 
nice-to-know information.

· Many times people do not read staff updates, do not read them carefully, or do not read them to the end. Ensure your staff update piques staff members' interest, highlights key points, and is easy to read. Avoid overcrowding the update with too much content.

· Also, supply a separate reference page that includes two or three peer-reviewed and one or two non-peer-reviewed resources (for a total of 3–5 resources) to support the staff update content.

·
Additional Requirements-
Written communication: Ensure the staff update is free from errors that detract from the overall message.

·
Submission length: Maximum of two double-spaced content pages.

·
Font and font size: Use Times New Roman, 12-point.

·
Citations and references: Provide a separate reference page that includes 2–3 current, peer-reviewed and 1–2 current, non-peer-reviewed in-text citations and references (total of 3–5 resources) that support the staff update's content. Current 
means no older than 5 years.

·
APA format: Be sure your citations and references adhere to APA format. Consult the 

Evidence and APA
 page for an APA refresher.

Context- Health professionals today are increasingly accountable for the use of protected health information (PHI). Various government and regulatory agencies promote and support privacy and security through a variety of activities. Examples include:

· Meaningful use of electronic health records (EHR).

· Provision of EHR incentive programs through Medicare and Medicaid.

· Enforcement of the Health Insurance Portability and Accountability Act (HIPAA) rules.

· Release of educational resources and tools to help providers and hospitals address privacy, security, and confidentiality risks in their practices.

Technological advances, such as the use of social media platforms and applications for patient progress tracking and communication, have provided more access to health information and improved communication between care providers and patients.

At the same time, advances such as these have resulted in more risk for protecting PHI. Nurses typically receive annual training on protecting patient information in their everyday practice. This training usually emphasizes privacy, security, and confidentiality best practices such as:

· Keeping passwords secure.

· Logging out of public computers.

· Sharing patient information only with those directly providing care or who have been granted permission to receive this information.

Today, one of the major risks associated with privacy and confidentiality of patient identity and data relates to social media. Many nurses and other health care providers place themselves at risk when they use social media or other electronic communication systems inappropriately. For example, a Texas nurse was recently terminated for posting patient vaccination information on Facebook. In another case, a New York nurse was terminated for posting an insensitive emergency department photo on her Instagram account.

Competencies Measured- By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

· Competency 1: Describe nurses' and the interdisciplinary team's role in informatics with a focus on electronic health information and patient care technology to support decision making.

· Describe the security, privacy, and confidentially laws related to protecting sensitive electronic health information that govern the interdisciplinary team.

· Explain the importance of interdisciplinary collaboration to safeguard sensitive electronic health information.

· Competency 2: Implement evidence-based strategies to effectively manage protected health information.

· Identify evidence-based approaches to mitigate risks to patients and health care staff related to sensitive electronic health information.

· Develop a professional, effective staff update that educates interprofessional team members about protecting the security, privacy, and confidentiality of patient data, particularly as it pertains to social media usage.

· Competency 5: Apply professional, scholarly communication to facilitate use of health information and patient care technologies.

· Follow APA style and formatting guidelines for citations and references.

· Create a clear, concise, well-organized, and professional staff update that is generally free from errors in grammar, punctuation, and spelling.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

Protected Health Information (PHI): Privacy, Security, and Confidentiality Best Practices Scoring Guide

CRITERIA

Describe the security, privacy, and confidentially laws related to protecting sensitive electronic health information that govern the interdisciplinary team.

Explain the importance of interdisciplinary collaboration to safeguard sensitive electronic health information.

Identify evidence-based approaches to mitigate risks to patients and health care staff related to sensitive electronic health information.

Develop a professional, effective staff update that educates interprofessional team members about protecting the security, privacy, and confidentiality of patient data, particularly as it pertains to social media usage.

Follow APA style and formatting guidelines for citations and references.

Create a clear, concise, well-organized, and professional staff update that is generally free from errors in grammar, punctuation, and spelling.



improved team communications

improved team communications, patient and family centered care, and disparities and inequities in care, into your practice

Nursing chapter2 assignment

FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION,

  

· State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

·

Critical Care Wk 4

 

MY NUMBER ASSIGNED WAS 1 WHICH IS: Pre-Renal & Post Failure
 

Each student will be assigned a number randomly.  Whatever your number is, select the corresponding topic below, then post a minimum of 5 bullet points about the topic.
 

Your bullet points should address key components of the topic, such as what, how, who, & why.  This information should not be basic things you learned in Med/Surg, but rather advanced critical care based.
 

Think about this as a group effort to create a study guide. Use ONLY your textbook, but do not cut & paste from the book.
 

Then create, find, or borrow a test style question about your topic & post at the bottom of your bullet points. The format needs to be multiple choice or select all that apply. Think NCLEX style.
 

PART 2:

 

Part 2:

You will take a few minutes and ask 2 people about their personal coping mechanisms for dealing with the stress of working in healthcare during this unique time of Covid. Stress can be physical, emotional, spiritual, or any combination of triggers. Ask a diverse variety of people, don’t forget those in other departments at different points of hierarchy. For example, ask your unit manager, environmental services, volunteers, patients, fellow nurses, etc. Write 2-3 paragraphs on your findings and impressions while respecting the person’s identity.

USING POLICY CHANGE AS A TOOL TO ADDRESS INEQUITIES

HOW BEST TO USE POLICY TO PROMOTE OPPORTUNITIES

PRESCRIBING FOR CHILDREN AND ADOLESCENTS

  • Bipolar Disorder or Major Depressive Disorder   
  •         
  • Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your assigned disorder in children and adolescents.
  • Explain the risk assessment you would use to inform your treatment decision making. What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?
  • Explain whether clinical practice guidelines exist for this disorder and, if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.
  • Support your reasoning with at least three scholarly resources, one each on the FDA-approved drug, the off-label, and a non-medication intervention for the disorder. Attach the PDFs of your sources.

Discussion 5

According to ANA, no single staffing model—patient acuity, budget-based, or nurse-patient ratio—is best for all settings and situations. Most organizations use a combination of methods and tailor the overall staffing approach to their specific needs. 

Respond to at least 1 of the following prompts:

1. What staffing model is implemented at the facility where you work?  What would you recommend for modifying the staffing model where you work, what is you recommendation based on and how would you implement the change?  (Support your thoughts/ideas with academic literature OR required readings) 

2. There are in existence nursing-sensitive indicators affected by staffing.  Can you suggest another nursing-sensitive indicator not being measured that might affect staffing?  What would be the indicator and how would you measure the indicator?  (Support your thoughts/ideas with academic literature OR required readings) 

3. Understanding others’ roles provides insight into who can best perform a particular task and how it could be redesigned to be more efficient and effective. How would delegation have a positive effect on staffing?  (Support your thoughts/ideas with academic literature OR required readings) .  Please look at the Florida Nurse Practice Act to verify what roles the RN MUST perform by law. 

PLEASE FOLLOW INSTRUCTIONS

wk 1 disc 1

 

After completing the cultural assessment evaluation for self-reflection, share the results with your classmates. How did you rate based on the scoring system?  Is there any room for improvement? There is nothing to be shy about if your score was not optimal. 

  • In your own words, how do you define culture? 
  • What strategies do you plan to implement to enhance your cultural understanding? 
  • Do you have any thoughts on the social determinants of health?

I HAVE ATTACHED THE ASSESSMENT EVAL FORM I COMPLETED WITH THE SCORE, PLEASE USE THAT TO ANSWER THE POST ABOVE.