evaluate your intervention. preventing homelessnees in veteran population

Develop a 4-6 page plan that will allow you to evaluate your intervention.

You will also be required to submit your completed practicum hours using CORE ELMS. You must submit a minimum of 20 confirmed hours with each assessment deliverable to receive a grade for the entire assessment.

Introduction

Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.

Once an intervention is planned and implemented it is important to evaluate the degree to which the outcomes of the project were achieved. By evaluating the desired outcomes of an intervention, it is possible to make more informed decisions about opportunities for continuous improvement. It is also possible to identify strategies and approaches that could be useful in improving one’s personal practice in other contexts or care areas.

Preparations

  • Read Guiding Questions: Evaluation Plan Design [DOC]. This document is designed to give you questions to consider and additional guidance to help you successfully complete this assessment.
  • As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
    • What specific piece or pieces of technology did you propose using in your implementation plan?
    • How did the type of technology you chose impact the development of your implementation plan?
    • How will the incorporation of the technology you propose make your implementation plan more successful?

Instructions

Note: The assessments in this course are sequenced in such a way as to help you build specific skills that you will use throughout your program. Complete the assessments in the order in which they are presented.

Your evaluation plan design will be the forth section of your final project submission. The goal for this is to finalize the outcomes that your plan is seeking to achieve and to create a plan to evaluate the degree to which those outcomes would have been achieved if your intervention plan has been implemented. This will allow you to determine the degree to which the plan was successful in addressing the identified need of your target population and setting.

You will also discuss ways in which your role allows you to lead change and drive quality improvement, and to potentially improve the project in the future. In addition, you will reflect on how the project will leave you better prepared for success in other aspects of your current and future career. Provide enough detail so that the faculty member assessing your implementation plan design and discussion will be able to provide substantive feedback that you will be able to incorporate into the final draft of your project.

At minimum, be sure to address the bullet points below, as they correspond to the grading criteria. You may also want to read the scoring guide and the Guiding Questions: Evaluation Plan Design [DOC] document to better understand how each criterion will be assessed. In addition to the bullet points below, provide a brief introduction that refreshes the reader’s memory about your problem statement, your planned intervention, and how you intended to implement your intervention (this should only be a single paragraph).

Reminder: These instructions are an outline. Your heading for this this section should be Evaluation of Plan and not Part 1: Evaluation of Plan.

Part 1: Evaluation of Plan
  • Define the outcomes that are the goal of an intervention plan.
  • Create an evaluation plan to determine the impact of an intervention for a health promotion, quality improvement, prevention, education, or management need.
Part 2: Discussion

Advocacy

  • Analyze the nurse’s role in leading change and driving improvements in the quality and experience of care.
  • Explain how the intervention plan affects nursing and interprofessional collaboration, and how the health care field gains from the plan.

Future Steps

  • Explain how the current project could be improved upon to create a bigger impact in the target population as well as to take advantage of emerging technology and care models to improve outcomes and safety.

Reflection on Leading Change and Improvement

  • Reflect on how the project has impacted your ability to lead change in personal practice and future leadership positions.
  • Reflect on the ways in which the completed intervention, implementation, and evaluation plans can be transferred into your personal practice to drive quality improvement in other contexts.
Address Generally Throughout
  • Integrate resources from diverse sources that illustrate support for all aspects of an evaluation plan for an intervention, as well as for professional discussion about the plan.
  • Communicate evaluation plan and discussion of the project in a professional way that helps the audience to understand how the outcomes will be evaluated, as well as what was learned through the project process.

reply1,2

·
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

When assessing this patient, it's important to ask questions that will help the provider understand the underlying causes and potential treatment options. Given the patient's recent loss and significant life changes, it's crucial to approach the assessment with sensitivity. Here are three questions I'd like to ask, along with their rationales:

1. Have you observed any changes in your sleep pattern, mood, or feelings since your husband passed away?

Rationale: This question allows the patient to provide insight into the nature and duration of her sleep disturbances and changes in her mood or feelings. Understanding the onset and progression of depression symptoms can related to her recent bereavement following her husband's passing.

2. Could you describe your emotions and have you ever experienced thoughts of self-harm or suicide?

Rationale: This question aims to comprehend a person's emotional state and evaluate the presence of suicidal thoughts or self-harm ideation. It's important to ask such questions without delay in treatment. Since the patient has a history of major depressive disorder (MDD), and her depression has worsened, it's crucial to explore her emotional state.

3. How have you been coping with the loss of your husband, and have you sought support or counseling to help you through this difficult time?

Rationale: Inquiring about coping strategies and support systems is essential for assessing the patient's resilience and identifying potential sources of assistance. Grief counseling or therapy can be invaluable in helping individuals navigate the complex emotions associated with loss. Additionally, it's important to assess whether the patient has been utilizing any resources to manage her depression.

·
Identify people in the patient's life you would need to speak to or get feedback from to further assess the patient's situation. Include specific questions you might ask these people and why.

To gain a more comprehensive understanding of the patient's situation and evaluate her social support network, I would identify individuals in the patient's life, such as family members or close friends. Engaging in conversations with these individuals can be beneficial because they may have insights into the patient's emotional well-being and daily functioning. I would ask Questions like: “Could you please share any observations regarding alterations you may have noticed in the patient's behavior, mood, or sleep patterns following her husband's passing?” Family members and close friends are often the first to detect significant shifts in a person's behavior and emotional state. Their observations can offer valuable insights into the patient's emotional condition and the way the loss of her husband has affected her daily life.

·
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

In evaluating a 75-year-old patient with a chief complaint of insomnia and depression, diabetes (DM), and hypertension (HTN), a thorough assessment should include both physical exams and diagnostic tests: A physical examination should include checking blood pressure, heart rate, heart sounds, peripheral pulses, respiratory rate, and temperature. It should also involve assessing the patient's overall appearance and evaluating their general health.  In addition, assessing mental status, cognitive function, and neurological signs can help identify any neurological issues that may be contributing to sleep disturbances. Consider arranging a sleep study, also known as polysomnography (PSG). This medical test monitors various physiological functions while a person sleeps.

Diagnostic Tests include the following Blood Tests: Complete Blood Count (CBC) will check for anemia or other blood-related issues that can affect sleep and overall health; a Comprehensive Metabolic Panel (CMP), assess kidney and liver function, electrolytes, and glucose levels; The HbA1c (Glycated Hemoglobin) test can monitor her long-term blood glucose control, can provide valuable insights into her diabetes management. The results of these exams and tests will inform a comprehensive treatment plan tailored to the patient's specific needs.

·
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

When assessing a patient with insomnia, along with chronic medical conditions like diabetes and hypertension, this patient likely has Major Depressive Disorder (MDD). She had no history of MDD before her husband's passing, and the current worsening of her depression may be attributed to his death. Although anxiety can cause insomnia problems, MDD with Bereavement seems most likely. However, we need to ensure there aren't other underlying causes, such as sleep problems or medical issues. To do that, we should conduct thorough assessments and laboratory tests. She needs to seek help from both her regular doctor and a mental health professional to find the right treatment and support.

·
List two pharmacologic agents and their dosing that would be appropriate for the patient's antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

When selecting pharmacologic agents for this 75-year-old patient, the choice of antidepressant therapy should consider pharmacokinetics and pharmacodynamics. Reduced kidney and liver function in elderly individuals can potentially affect both pharmacokinetics and pharmacodynamics.

SSRIs, such as sertraline (Zoloft) and escitalopram (Lexapro), are two preferred for elderly patients. They are generally well-tolerated and have a lower risk of certain side effects, such as sedation or anticholinergic effects, which can be problematic for older adults. Sertraline (Zoloft) 150mg once daily or Escitalopram (Lexapro) 20 mg daily would be appropriate for this patient.

The patient has been taking Sertraline (Zoloft), her start dose was 100mg daily; increase slowly, no more than a maximum Dose of 200 mg once daily; sertraline increases serotonin levels and can be effective in treating depression. Escitalopram is considered perhaps the best-tolerated SSRI, with the fewest cytochrome P450 (CYP450)-mediated drug interactions. (Stahl, 2021). Escitalopram (Lexapro) 20 mg daily is also the appropriate choice.

·
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?

When prescribing antidepressant therapy, it's important to consider drug contraindications and alterations. For the selected antidepressant, escitalopram (Lexapro), don't use it with MAOIs or within 14 days after stopping an MAOI to prevent serotonin syndrome. This is a contraindication due to the risk of serotonin syndrome, a potentially life-threatening condition characterized by agitation, confusion, rapid heart rate, and other symptoms. Escitalopram is primarily metabolized in the liver; it should be used with caution in patients with severe hepatic impairment or elderly with decreased liver function. In such cases, a lower initial dose and slower titration may be considered, as drug clearance may be reduced.

In all cases, ethical prescribing involves a thorough assessment of the patient's medical history, medication history, and potential contraindications. Dosing adjustments, when necessary, should be made to maximize therapeutic benefits while minimizing risks and adverse effects.

·
Include any “checkpoints” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

In depression treatment, scheduled follow-up appointments are vital for assessing progress, managing side effects, and adjusting treatment. Common intervals are every 4 weeks. At the checkpoint, like follow-up data at weeks 4, 8, 12, etc., make treatment decisions based on the patient's response, side effects, and goals. If there's significant improvement with few side effects, stick with the current dose. If there's limited improvement or major side effects, consider increasing the dose (if not already at the maximum) or trying a different antidepressant. In cases of long-term remission with a low risk of recurrence, think about tapering or discontinuing the medication.

At Week 4 (four weeks after initiating treatment), it's the time to evaluate the patient's initial response to medication. Inquire about changes in mood, sleep patterns, energy levels, and any side effects.

At Week 8 (eight weeks after starting treatment), it's time to reassess the patient's mood and overall well-being. Keep an eye on side effects, whether they're taking the medication as prescribed, any changes in their medical conditions, and any suicidal ideation.

At Week 12 (12 weeks after starting treatment), continue monitoring the patient's mood and how they're responding to treatment. Check for any signs that their depression might be coming back or getting worse.

Ongoing Follow-up (Regularly, every 3-6 months): Continue to monitor the patient's mental health, medication adherence, and any emerging side effects. Evaluate the need for ongoing treatment.

 


Reference:

Levenson JC, Kay DB, Buysse DJ. The pathophysiology of insomnia. Chest. 2015 Apr;147(4):1179-1192. doi: 10.1378/chest.14-1617. PMID: 25846534; PMCID: PMC4388122.

Stahl, S. M. (2021). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.

Lexapro Labeling-508; Reference ID: 4036381 https://www.fda.gov/media/135185/download

D. Saa Critical Care Wk 4 Discussion

MY NUMBER ASSIGNED WAS 2 WHICH IS: Renal 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:

Interview: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.

c

Criteria

Possible Points

Points Earned

Comments

Title Page:
no running header used,

Title accurately reflects purpose of research, follows APA format, includes your name, course name and number and Dr. Shantelle Smith in the instructor spot

2


Introduction: Identifies
nature & scope of the problem &
significance of conducting the integrated research review
to generate knowledge for nursing practice.

10


Background: Provides
background information,
explains & defines problem, explains
significance &
importance of problem,
defines terms if necessary.

10


Research Problem Statement: Indicates the
gap in knowledge needed for nursing practice &
provides a basis for the study purpose.

10


Research Purpose: Clear concise statement of the specific aim or goal of the study, one sentence.

5


Research Question: Clear, concise interrogative statement, written in present tense, using PICOT format with a nursing focus

5


Research Utilization Model:
Explains the JHNEBP model and how it fits with and can be used for your proposed EBP change.

8


Search Criteria and Results: Includes Data Research Table correctly cited in APA and search terms and results. Includes Literature Review Tables correctly attached and labeled as an Appendix and referenced in this section. General description of types of articles and level of evidence based on the Melnyk rating pyramid.

5


References: Formatted and cited correctly, obtained from Mav Library, includes DOI# or website if no DOI available

10

APA Format

free of spelling and grammatical errors

10

Total Points Earned____________ (out of 75)

This is the first assignment to introduce your PICO(T), scope and nature of the problem, background information of the problem, details regarding your research review, and the Johns Hopkins EBP approach you have taken for your research. This is a “building assignment” as part 1, then next week, part 2 will add to the Final Research Paper Assignment. You do not need to worry about self-plagiarism when continuing to part 2 and so on. If you have taken this course prior to this semester, you may not use any of your previous work from that time.

Assignment Part 1 – 75 possible points. See Assignment Part 1 Rubric and Example paper.

Instructions: Follow APA 7th ed. format and follow Assignment Part 1 Rubric (refer to example paper part 1, which also includes some part 2 components, so please pay attention to the rubric)

1. Use APA 7th ed. Manual or recommend APA template sites listed in content section to set up paper (Chapter 2, APA manual 7th ed.)

2. Write in 12pt font Times New Roman

3. This is formal writing assignment: DO NOT write in first person this means do not use: I statements. Instead, say “the writer or the author” or avoid those altogether by just referring to the components of the paper without the use of these.

4. Include a Title page (Do not use Assignment 1… as your title) The title should not be your entire PICOT but should allow the reader to understand what your Research is about *see example papers in the course You do not need to use a running head for your paper but include page # appropriately placed per APA (refer to Chapter 2 and Section 2.3, 2.4. Figure 2.2).

Example title: Comparison of Pressure Reduction Boots Versus Repositioning to Reduce Pressure Ulcers in the Elderly

5. Write about your topic in paragraph format using headings and subheadings. Use the rubric headings for the headings in each section of your assignment except “Introduction” the heading for the introduction. In 7th ed. APA this is the restatement of your paper title (see APA 7th ed. Section 2.7). I should see bold headings for the following: Background, Research Problem Statement, Research Purpose, Research Question, Research Utilization Model, Search Criteria and Results, and References

6. Here are the categories for your paper as listed on the rubric:

a. Introduction: Identifies nature & scope of the problem & significance of conducting the integrated research review to generate knowledge for nursing practice. I like to write this after I’ve completed the rest of the paper. It’s a synthesis of what you’ve written and what the reader will learn from the paper.

b. Background: Provides background information, explains & defines problem, explains significance & importance of problem, defines terms if necessary. This is the history of the PICOT. What happened prior to 2018 in relation to your PICOT? This is where you can cite “old and non-current” evidence. Go back as far as you need to. You should have literature support in this section.

c. Research Problem Statement: Indicates the gap in knowledge needed for nursing practice & provides a basis for the study purpose. This is the current state of the problem. Why did you choose this PICOT? Don’t use personal or work experiences unless you can support them in the literature. An example would be that there is a need for your PICOT based on the literature that states further research is needed in this area. Back up with literature support in this section.

d. Research Purpose: Clear concise statement of the specific aim or goal of the study, one sentence. This is only one sentence. What do you hope to accomplish in your research of your PICOT question? Typically, we don’t have one sentence paragraphs/section, but it is approved in this instance.

e. Research Question: Clear, concise interrogative statement, written in present tense, using PICOT format with a nursing focus. All you need to do is include your finalized PICOT question. Again, this is a one sentence section, but it is all I’m requiring.

f. Research Utilization Model: Explains the JHNEBP model and application to your PICOT for your proposed EBP change. Include your week 3 assignment in paragraph format. Make sure it flows with your paper. (This section is from your week 3 assignment. Please utilize feedback from me or if you achieved 100%, only revise to flow with the rest of your paper. Make sure to add the references to your Research Review Part 1 reference page.

g. Search Criteria and Results: You should have a paragraph that describes your data search including a general description of types of articles and levels of evidence based on Melnyk’s pyramid, insert the week 4 completed data search table in APA format (how you insert a table into a paper, APA 7th edition manual has instructions in Chapter 7, table 7.1), and you will also reference your week 4 literature review table in this section. The literature review table should be correctly inserted at the end of the paper, per APA formatting, labeled as an Appendix and referenced in this “search criteria and results” section in the paper as a way to guide the reader to look at the appendix. So, the data search table is inserted directly into the Search Criteria and Results section, but the Literature Review Table is inserted as an Appendix at the end of the paper. I will be grading and returning feedback by Tuesday end of day so you have ample time to revise if necessary.

h. References: formatted and cited correctly, all with the exception of 1-2 should be obtained from Mav Library or other reliable source (no .coms, blogs, etc. should be used), includes DOI# or website if no DOI available. To format an APA reference page, please see APA 7th edition manual, chapters 9-10.

Case Study 3

 

Answer the questions in both scenarios in your own words. Answer these questions as if you were talking to a peer, unless otherwise indicated.

Shock Case Studies

Scenario #1

K.L., a 25-yr-old Korean American, was not wearing his seat belt when he was the driver involved in a motor vehicle crash. The windshield was broken and K.L. was found 10 ft from his car. He was face down, conscious, and moaning. His wife and daughter were found in the car with their seat belts on. They sustained minor injuries and were very frightened and upset. All passengers were taken to the emergency department (ED). The following information pertains to K.L.

Subjective Data

  • States, “I can’t breathe”
  • Cries out when abdomen is palpated

Objective Data

Physical Examination:

  • Cardiovascular: BP 80/56 mm Hg; apical pulse 138 but no palpable radial or pedal pulses; carotid pulse present but weak
  • Respiratory: respiratory rate 35 breaths/minute; labored breathing with shallow respirations; asymmetric chestwall movement; absence of breath sounds on left side
  • Trachea deviated slightly to the right
  • Abdomen: slightly distended and left upper quadrant painful on palpation
  • Musculoskeletal: open compound fracture of the lower left leg

Diagnostic Studies

  • Chest x-ray: Hemothorax and six rib fractures on left side
  • Hematocrit: 28%

Interprofessional Care in the ED

  • Intraosseous access in right proximal tibia placed prehospital
  • Left chest tube placed, draining bright red blood
  • Fluid resuscitation started with crystalloids
  • High-flow O2via non-rebreather mask

Emergency Surgical Procedures

  • Splenectomy
  • Repair of torn intercostal artery
  • Repair of compound fracture

Discussion Questions

  1. What types of shock is K.L. experiencing? What clinical manifestations did he display that support your answer?
  2. What were the causes of K.L.’s shock states? What are other causes of these types of shock?
  3. Priority Decision: What are the priority nursing responsibilities for K.L.?
  4. Priority Decision: What ongoing nursing assessment parameters are essential for this patient?
  5. What are his potential complications?
  6. Patient-Centered Care: K.L.’s parents arrive. English is their second language. They are very anxious and asking about their son. What can you do to provide culturally competent family-centered care?
  7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses?
  8. Teamwork and Collaboration: Identify the tasks that could be delegated to unlicensed assistive personnel (UAP).
  9. Evidence-Based Practice: You are orienting a new graduate RN. He asks you why crystalloids are used instead of colloids for fluid resuscitation. What is your response?
  10. Examine therapeutic nursing interventions associated end-of-life decision-making.

 The following is information that will assist you in answering the question associated with scenario #2

Septic shock is

“A life-threatening organ dysfunction caused by a dysregulated host response to infection” (McCance & Huether, 2019, p. 1550).

The infectious process starts with an infectious agent entering the bloodstream and causing bacteremia either directly from the site of infection or indirectly by releasing toxic substances into the bloodstream. Some of the most common causes of septic shock are gram-negative or gram-positive bacteria, viruses, and fungi. The most common sites of infection are the lungs, bloodstream, intravascular catheters, intra-abdominal, urinary tract, and surgical wounds (McCance & Huether, 2019).

Normal Physiology

In normal physiology, when a pathogen invades the body, the body will react with local and systemic responses.

  • Our first line of defense is the body’s natural physical, mechanical, and biochemical barriers such as the epithelial cells and surfaces of the skin. These defenses prevent microorganisms from getting into tissues and also have the ability to remove infectious microorganisms. The surfaces of the skin and mucous membranes of the body also contain normal microbiomes (“normal flora”) that also protects the body by releasing chemicals to prevent pathogens from being colonized (McCance & Huether, 2019).
  • The body’s second line of defense is the inflammatory response. Inflammation causes a vascular response that makes vessel walls become leaky and more permeable and makes white blood cells adhere to vessel walls and migrate out into the tissues. Symptoms usually produced by inflammation are the heat, redness, edema and pain. The goal of inflammation is to prevent and limit infection and interact with components of the adaptive immune system as well as prepare the body for healing (McCance & Huether, 2019). 

There are three important plasma protein systems involved to provide an active barrier against invading pathogens in the inflammatory response.

  • One is a complement system which destroys pathogens directly and work with other components of the immune responses by three pathways: (1) classic, (2) lectin and (3) alternative. The main functions of these are to induce rapid mast cell degranulation, attract white blood cells to pathogens, and “tag” pathogens for destruction (McCance & Huether, 2019).
  • Second is the clotting or coagulation system which forms blood clots that include a meshwork of protein strands at the injured or inflamed site to stop bleeding, trap pathogens to prevent the spread of infection, and provide a framework for repair and healing (McCance & Huether, 2019).
  • The last important inflammatory response is from the kinin system which activates and assists inflammatory cells by the release of mainly bradykinin which causes dilation of blood vessels, pain, smooth muscle contraction, increase vascular permeability and leukocyte chemotaxis (McCance & Huether, 2019). 

There are also many biochemical mediators of the innate immune system that secrete cytokines responsible for activating other cells such as interleukins, chemokines, interferons, and other molecules. These chemicals are important to the vascular changes that occur during the inflammatory process (McCance & Huether, 2019).

Along with the cellular mediators are the cellular components such as platelets, phagocytes (neutrophils, eosinophils, monocytes, macrophages, and dendritic cells), natural killer cells, and lymphocytes. The components respond to the site of the injury together to limit the tissue injury, kill pathogens, remove the debris, and prepare for healing and tissue repair (McCance & Huether, 2019). 

Septic shock begins when the pathogen enters the bloodstream. This stimulates the release toxic substances called the triggering molecules, which triggers the body to activate the proinflammatory responses and release proinflammatory cells such as leukocytes, macrophages, monocytes and platelets as well as proinflammatory mediators such as cytokines (interleukins, tumor necrosis factor alpha and other mediators). Cytokines along with the vasoactive peptides cause vasodilation causing hypotension, relative hypovolemia, and decreased in oxygen delivery to the tissues. The release of proinflammatory cytokines also activate plasma protein systems of the complement, coagulation and kinin systems (McCance & Huether, 2019).

Dysfunction of epithelial cells cause further capillary leaking and microvascular thrombus, tissue hypoxia and apoptosis. Due to tissue hypoxia, the body will start breaking down carbohydrates to make ATP or energy for the body. As more anaerobic cells are being used for energy, the more lactic acid is produced. Without correction, the accumulation will lead to metabolic acidosis causing further damage to the tissues (McCance & Huether, 2019).  

As the responses of proinflammatory and anti-inflammatory mediators intensify the body experiences persistent low arterial pressure, low tissue perfusion, low systemic vascular resistance which will profoundly affect the circulatory, cellular, and metabolic systems. These responses will lead to multiple organ dysfunction syndrome (MODS) due to dysfunction of the kidneys, liver, intestines, lungs, and brain as a result of tissue hypoxia and lack of tissue perfusion (McCance & Huether, 2019). 

Tools

Septic shock is measured by the SOFA score and assessing different systems in relation to the severity of the organ failure. The quick SOFA criteria include a respiratory rate equal or greater than 22 per minutes, altered mentation and systolic blood pressure less than 100 mmHg. The standard SOFA scoring includes respiration, coagulation of platelets, bilirubin level of the liver, mean arterial pressure, Glasgow coma scale score, creatinine level, and urine output.

Clinical manifestations

Clinical manifestations of septic shock usually include fever, chills, sweating, warm progressing to cool skin, respiratory distress, altered mentation, decreased urine output, hypotension, elevated liver enzymes, and decreased platelet counts (McCance & Huether, 2019). 

Scenario #2

Mr. S. S. is a 56-year-old, white male with a right diabetic foot ulcer. He was at his podiatrist’s office for a wound check and was referred to the emergency department (ED) due to increasing purulent drainage and necrotic tissue in the wound. Mr. S.S. noticed the drainage getting worse over the last week and has experienced fevers up to 102 degrees F for two days. He also complains of diaphoresis, fatigue, abdominal pain, and general malaise. He states he just does not feel like himself.  

Past Medical History:

Allergic to Penicillin and shellfish

Uncontrolled Type 2 Diabetes Mellitus 

Hyperlipidemia

Hypertension [baseline 140/90]

Obesity [BMI=32]

Cholecystectomy, age 32 years

Left Above the Knee Amputation (AKA), age 54 years

Pertinent Family History:

Mother- Hyperlipidemia, Hypertension, CABG x2 vessels

Father- Prostate Cancer, age 63 years

Pertinent Social History:

Active Smoker (2 packs/day)

History of Alcoholism

Previous history of homelessness

Emergency Department

In the ED, assessment reveals moderate foul odor, purulent drainage from right foot ulcer, and capillary refill of four seconds on upper and lower extremities. Patient is alert and oriented but short-term memory appears to be impaired and the patient is asking abnormal questions. Two peripheral IVs and an indwelling foley catheter are placed, a 1000mL bolus of IVF is initiated, wound and blood cultures are obtained, and the patient is started on broad spectrum antibiotics. An x-ray of his right foot demonstrates soft tissue inflammation and concern for osteomyelitis, so an MRI was completed of his foot. The patient is transferred to MICU for further management. 

ED Vitals:

Temperature: 101.6 degrees F

Heart Rate: 117 bpm

Respiration Rate: 24 breaths/min

Blood Pressure: 92/45 mm Hg (MAP 61)

Blood glucose: 315 mg/dL

SpO2: 91% on 2L NC

ED Labs:

WBC: 26,000

Lactate: 6.0 mmol/L

C-reactive Protein: 11mg/L

Creatinine: 1.4 mg/dL

pH: 7.32

Medical Intensive Care Unit

Upon admission to MICU, Mr. S.S. is lethargic and flushed. Further assessment demonstrates bounding pulses and right lower extremity edema. His heart rate increased and blood pressure dropped despite the liter bolus. The patient is started on vasopressors to maintain his blood pressure and intubated to protect his airway.

Pertinent Vitals:

Temperature: 101.4 degrees

Heart Rate: 154 bpm

Respiration Rate: 30 breaths/min

Blood Pressure: 72/34 (MAP 47)

SpO2: 86% on 2L NC

  1. All of the options below are the most common causes of septic shock except for: 
    1. Gram-negative bacteria
    2. Gram-positive bacteria
    3. Viruses
    4. Cancer
  2. Which of the following criteria would you expect to see from a patient with septic shock?
    1. Elevated lactate level
    2. 30 ml/hr of urine output
    3. Respiration of 18 rate per minute
    4. Patient is alert and oriented 
  3. Which of the following are measurable components of the quick SOFA? Select all that apply.
    1. Respiration rate
    2. Temperature
    3. Heart rate
    4. Systolic blood pressure 
    5. Mentation
  4. The patient wants to know more about sepsis asking if he or any of his family members would be at higher risk for sepsis. You tell the patient that most vulnerable patients for this problem would be: (Select all that apply)
    1. Children younger than one
    2. Patients who have received recommended vaccinations
    3. Adults 65 years old and older
    4. People with weakened immune systems
    5. People with chronic diseases
    6. People have been traveled outside of the United States
  5. Discuss why septic shock is one of the leading causes of death in the intensive care units.
  6. Examine therapeutic nursing interventions associated end-of-life decision-making.

SOAP note 2

UTI(Urinary tract infection)

Discussion Post- Literature Review

What is the importance of a literature review and what should you avoid when conducting a literature review?

Submission Instructions:

  • Post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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EVIDENCE-BASED PROJECT, PART 4: RECOMMENDING AN EVIDENCE-BASED PRACTICE CHANGE

EVIDENCE-BASED PROJECT, PART 4: RECOMMENDING AN EVIDENCE-BASED PRACTICE CHANGE

The collection of evidence is an activity that occurs with an endgame in mind. For example, law enforcement professionals collect evidence to support a decision to charge those accused of criminal activity. Similarly, evidence-based healthcare practitioners collect evidence to support decisions in pursuit of specific healthcare outcomes.

In this Assignment, you will identify an issue or opportunity for change within your healthcare organization and propose an idea for a change in practice supported by an EBP approach.

To Prepare:

· Reflect on the four peer-reviewed articles you critically appraised in Module 4, related to your clinical topic of interest and PICOT.

· Reflect on your current healthcare organization and think about potential opportunities for evidence-based change, using your topic of interest and PICOT as the basis for your reflection.

· Consider the best method of disseminating the results of your presentation to an audience. 

The Assignment: (Evidence-Based Project)

Part 4: Recommending an Evidence-Based Practice Change

Create an 8- to 9-slide 
narrated PowerPoint presentation in which you do the following:

· Briefly describe your healthcare organization, including its culture and readiness for change. (You may opt to keep various elements of this anonymous, such as your company name.)

· Describe the current problem or opportunity for change. Include in this description the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general.

· Propose an evidence-based idea for a change in practice using an EBP approach to decision making. Note that you may find further research needs to be conducted if sufficient evidence is not discovered.

· Describe your plan for knowledge transfer of this change, including knowledge creation, dissemination, and organizational adoption and implementation.

· Explain how you would disseminate the results of your project to an audience. Provide a rationale for why you selected this dissemination strategy.

· Describe the measurable outcomes you hope to achieve with the implementation of this evidence-based change.

· Be sure to provide APA citations of the supporting evidence-based peer reviewed articles you selected to support your thinking.

· Add a lessons learned section that includes the following:

· A summary of the critical appraisal of the peer-reviewed articles you previously submitted

· An explanation about what you learned from completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template (1-3 slides)

LEARNING RESOURCES


Required Readings

· Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). 

The connection between evidence-based medicine and shared decision makingLinks to an external site.

Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186

· Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). 

Shared decision making in intensive care units: An American College of Critical Care Medicine and American Thoracic Society policy statementLinks to an external site.

Critical Care Medicine, 44(1), 188–201. doi:10.1097/CCM.0000000000001396

· Opperman, C., Liebig, D., Bowling, J., & Johnson, C. S., & Harper, M. (2016). 

Measuring return on investment for professional development activities: Implications for practiceLinks to an external site.

Journal for Nurses in Professional Development, 32(4), 176–184. doi:10.1097/NND.0000000000000483

· Schroy, P. C., Mylvaganam, S., & Davidson, P. (2014). 

Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision makingLinks to an external site.

Health Expectations, 17(1), 27–35. doi:10.1111/j.1369-7625.2011.00730.xThe Ottawa Hospital Research Institute. (2019). 

Patient decision aidsLinks to an external site.
. Retrieved from https://decisionaid.ohri.ca/