For this 4-5 pages assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health

For this 4-5 pages assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Esther, an elderly patient who is complaining of abdominal discomfort. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment.

Submission Parameters:

For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s).

1. Introduction (including purpose statement)
2. Focus of the assessment
   1. Describe the focus of this particular assessment on the patient complaining of abdominal discomfort.
3. Subjective Component
   1. Describe the ROS, PMH, and other relevant data in this section.
4. Objective Component
   1. Describe the physical examination findings including techniques of examination
5. Documented evidence to support clinical reasoning
   1. Describe the list of differential diagnoses
6. Plan of care
   1. Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment.
7. Conclusion
8. References (use primary and/or reliable electronic sources)

 

In regards to APA format, please use the following as a guide:

• Include a cover page and running head (this is not part of the 4-5 pages limit)
• Include transitions in your paper (i.e. headings or subheadings)
• Use in-text references throughout the paper
• Use double space, 12 point Times New Roman fonta
• Apply appropriate spelling, grammar, and organization
• Include a reference list (this is not part of the 4-5 pages limit)
• Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)

 

Competency	20	18	16	0	Points Earned
Focus of the Assessment is identified with Special Considerations including Documented Focused Health History	Documentation clearly shows student has completed a focused assessment with identified special considerations including a well-documented focused health history.	Documentation supports the student has completed the focused assessment with minimal identification of special concerns. The focused health history is documented.	Documentation supports the student has completed the focused assessment without identification of special concerns. The focused health history is documented and lacks depth and specificity of weekly topic.	Documentation supports the student attempted to complete the focused assessment without identification of special concerns. The focused health history is briefly documented and lacks depth and specificity of weekly topic.	/20
	20	18	16	0
Documented Physical Examination Findings including Techniques of Examination	Documentation clearly shows student has completed the physical examination and accurately describes the techniques of examination for the week.	Documentation supports the student has completed the physical examination and describes the techniques of examination for the week.	Documentation supports student completed some of the physical examination for the focused assessment of the week. Documentation is accurate but lacks depth.	No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability of tasks completed in this week.	/20
	20	18	16	0
Documented Evidence to Support Clinical Reasoning with External Course Resources	Discourse clearly shows the student has studied the topic and has given thought to the focused assessed topic and documentation for the week.	Discourse supports the student has studied the topic and has given thought to the focused assessment topic and documentation for the week.	Discourse supports student studied some of the topic for the focused assessment topic this week. Discourse is accurate but lacks depth.	No evidence that that student has read or studied the topic. Discourse lacks depth. May be presented in a rambling manner. Content is inaccurate &/or is unclear.	/20
	20	18	16	0
Individualized Plan of Care Based Upon Clinical Findings	Accurately presents an individualized plan of care based upon clinical findings.	Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted.	Presents a plan of care that is not individualized based upon the clinical findings.	A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings.	/20
	5	4	3	0
Developmentally and Culturally Specific	Accurately documents a developmentally and culturally specific assessment and plan of care for the selected patient.	Documents a developmentally and culturally specific assessment and plan of care.	Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient.	A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings.	/5
	5	4	3	0
Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice	Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the focused physical assessment.	Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation.	Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the focused physical assessment or inaccuracies are evidenced in the written assessment.	Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the focused physical assessment.	/5
	10	9	8	0
Grammar, Spelling, and Punctuation APA Format	APA Format, grammar, punctuation and spelling is accurate with errors.	APA Format, grammar, punctuation and spelling is accurate with less than two types of errors.	APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors.	APA Format, grammar, punctuation and spelling is accurate with more than five types of errors.	/10
COMMENTS:				TOTAL:	/100

 

EBP Change Process Form Assignment

  EBP Change Process form

ACE Star Model of Knowledge Transformation

Follow Nurse Daniel as your process mentor in the weekly Illustration section of the lesson. Please do not use any of the Nurse Daniel information for your own topic, nursing intervention, or change project.  Nurse Daniel serves as an example only to illustrate the change process.

 

Star Point 1:  Discovery (Identify topic and practice issue)

Identify the topic and the nursing practice issue related to this topic. (This MUST involve a nursing practice issue.)

 

 

Briefly describe your rationale for your topic selection. Include the scope of the issue/problem.

 

 

Star Point 2:  Summary (Evidence to support need for a change)

Describe the practice problem in your own words and formulate your PICOT question.

 

 

List the systematic review chosen from the CCN Library databases. Type the complete APA reference for the systematic review selected.

 

 

 

 

List and briefly describe other sources used for data and information. List any other optional scholarly source used as a supplement to the systematic review in APA format.

 

 

Briefly summarize the main findings (in your own words) from the systematic review and the strength of the evidence.

 

 

 

Outline one or two evidence-based solutions you will consider for the trial project.

 

 

 

Star Point 3:  Translation (Action Plan)

Identify care standards, practice guidelines, or protocols that may be in place to support your intervention planning (These may come from your organization or from the other sources listed in your Summary section in Star Point 2).

 

 

List your stakeholders (by title and not names; include yourself) and describe their roles and responsibilities in the change process (no more than 5).

 

 

What specifically is your nursing role in the change process? Other nursing roles?

 

 

List your stakeholders by position titles (charge nurse, pharmacist, etc.).–Why are the members chosen (stakeholders) important to your project?

 

 

 

What type of cost analysis will be needed prior to a trial?  Who needs to be involved with this?

 

 

 

Star Point 4: (Implementation)

Describe the process for gaining permission to plan and begin a trial.  Is there a specific group, committee, or nurse leader involved?

 

 

 

Describe the plan for educating the staff about the change process trial and how they will be impacted or asked to participate.

 

 

 

Outline the implementation timeline for the change process (start time/end time, what steps are to occur along the timeline).

 

 

 

 

List the measurable outcomes based on the PICOT.  How will these be measured?

 

 

What forms, if any, might be used for recording purposes during the pilot change process. Describe.

 

What resources are available to staff (include yourself) during the change pilot?

 

Will there be meetings of certain stakeholders throughout the trial?  If so, who and when will they meet?

 

 

 

 

Star Point 5: (Evaluation)

How will you report the outcomes of the trial?

 

 

What would be the next steps for the use of the change process information?

 

 

 

 

 

Nursing Situation to PICOT Paper

Has to be APA format Has to include all things listed on the rubric This is a specific type of nursing research paper; i have attached the rubric and an example paper below along with some other documents that will be helpful for understanding the topic. This paper moves you from a nursing situation to a PICOT question and finally reading some evidence. Research and evidence-based practice starts with questions. These questions can be identified through nursing situations. For this assignment, you will identify and describe a nursing situation in which you have
recognized a problem in your nursing practice. The problem must be something that you see consistently, such as central line infections. Next, develop one PICOT question (see p. 30, Box 2.1 templates for a PICOT Question). The types of PICOT questions include intervention, prognoses/prediction, diagnosis or diagnostic test, etiology, and meaning. Next you find an EBP publication and provide a short summary. Here is my picot question I have already formatted: In preoperative anaemic adults undergoing non‐cardiac surgery (P), how does erythropoietin
therapy combined with an iron supplement before surgery (I) compared to a placebo ( C ) affect needing a blood transfusion (O) within the immediate recovery period (T). Also I will upload the document where I explain the nursing diagnosis that I have created. Here is the research article my paper will be based around: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012451.pub2/full
Please read the attached guidelines: Note: The Example Introduction is not the complete paper. It is only the introduction. As in all writing, the introduction started on a topic that shifted to psychological distress in the example final paper. The body of the paper includes appraisal of one published evidence article. Please read the Nursing Situation to PICOT Guidelines document carefully (see attachment). The FAQs provides an
outline for the paper (see attachment).

Renal Trauma Assignment

Module 02 Case Study – Renal Trauma

Purpose

To use critical thinking and data collection to recognize and report complications that may impact the morbidity and mortality of clients who have sustained a traumatic insult to the urinary tract while functioning within the LPN scope of practice

Competency

Select appropriate nursing interventions for clients with disorders of the urinary system

Instructions

Read the scenario below and answer the questions. When you see a

that means a clue.

The Story

It is Friday the 13^th and a full moon. You are an LPN that normally works on a medical-surgical unit but your unit is overstaffed and the emergency department is short staffed. The nursing supervisor asks for a volunteer to go down to be an extra pair of hands. You volunteer as tribute. When you get to the ER you are asked to do vitals on a client in the trauma room. The client is a 24-year-old male who was stabbed multiple times to the abdomen.

The wounds appear superficial and the client has been stable thus far. He will be going to CAT scan as soon as they can fit him in. You approach the client who appears  slightly pale with cool, clammy but is alert and talkative. The vital signs are:   97.3 (PO) P= 115 BP= 95/54 Resp rate= 24 Pain= 6/10. You notice the client voided 100 mL   tea-colored urine in his urinal.

One hour later the client becomes unconscious. His pulse is now 144 and blood pressure is 70/50. The client is taken to the OR and has a nephrectomy for a very damaged and bleeding right kidney.

Answer the following questions:

1. What were the clues in the data collection that should have alerted you and the staff that there might be a problem? (5-10 sentences)
2. Why is the urine “tea colored?” (one sentence)
3. What are some other interventions that could have been done? (2-5 sentences)
4. Was the LPN in this scenario working within the scope of practice for an LPN? Why or why not? (5-10 sentences)
5. How did the environment of care (busy ER) contribute to the client’s deterioration? (5-10 sentences)

Format

• Standard American English (correct grammar, punctuation, etc.)
• Logical, original and insightful
• Professional organization, style, and mechanics in APA format
• Submit document through Grammarly to correct errors before submission

Resources

APA Online Guide

Nursing Theory

-Research and select one counseling theory and one nursing theory that will best guide your practice in psychotherapy
-Explain reasons you selected these theories, support your approach with evidence-based literature
-Develop at least two goals and at least two objectives for the practicum experience
-Develop a timeframe of practicum activities based on the course requirements and your goals
-Explain any ethical and/or legal implications related to counseling clients
-Support your response with evidence-based literature