Practice nurse 11

Nurse 11: Criterion:

Applies the nursing process to systems or processes at the unit/team/work group level to improve care as a community care nurse case manager. Demonstrates leadership by involving others in improving care.

Nurse 111 Criterion:

Provides leadership in the application of the nursing process to client care, organizational processes, and /or systems, improving outcomes at the program or service level. 

Self Assessment

Ethics – Nurse 11

NOTE: Enter your documentation of achievement for the current grade first and then document any additional achievement that relates to the next higher grade. Make sure to address the following questions: 91) What was done? (2) For whom was it done(Population)? (3) What was the outcome?

Nurse 11 Criterion:

Supports and enhances client self-determination. Serves as a resource for clients and staff in addressing ethical issues.

Nurse 111 Criterion:

Provides leadership in identifying and addressing ethical issues that impact clients and staff, including initiating and participating in ethics consultation.

Self Assessment:

Resource Utilization – Nurse 11:

NOTE: Enter your documentation of achievement for the current grade first and then document any additional achievement that relates to the next higher grade. Make sure to address the following questions: 91) What was done? (2) For whom was it done(Population)? (3) What was the outcome?

Nurse 11 Criterion:

Identifies and assesses resource utilization and safety issues, taking appropriate action.

Nurse 111 Criterion:

Manages program resources (Financial, human, material, or informational) to facilitate safe, effective, and efficient care.

Self -Assessment

                                           Professional Development

Performance – Nurse 11

NOTE: Enter your documentation of achievement for the current grade first and then document any additional achievement that relates to the next higher grade. Make sure to address the following questions: (1) What was done? (2) For whom was it done(Population)? (3) What was the outcome?

Nurse 11 Criterion:

Evaluate the practice of self and others using professional standards, relevant statutes, and regulations. Takes action to improve performance.

Nurse 111 Criterion:

Uses professional standards of care and practice to evaluate programs and /or service activities.

Self-Assessment. 

                                                                          Education/ Career Development – Nurse 11

Enter your documentation of achievement for the current grade first and then document any additional achievement that relates to the next higher grade. Make sure to address the following questions: 91) What was done? (2) For whom was it done(Population)? (3) What was the outcome?: 

Nurse 11 Criterion:

Acquires knowledge and skills to maintain expertise in area of practice. Participates in educational activities to improve clinical knowledge and enhance role performance

Nurse 111 Criterion:

Implements an educational plan to meet changing program or service needs for self and others. Maintains knowledge of current techniques, trends, and professional issues.

Self Assessment

Collegiality-nurse 11

NOTE: Enter your documentation of achievement for the current grade first and then document any additional achievement that relates to the next higher grade. Make sure to address the following questions: 91) What was done? (2) For whom was it done(Population)? (3) What was the outcome?

Nurse 11 Criterion:

Educates colleagues and/or students and serves as a preceptor and /or mentor

Nurse 111 Criterion:

Coaches colleagues in team building. Makes sustained contributions to health care by sharing expertise within and /or outside the medical facility.

Self Assessment:

Collaboration-nurse 11

NOTE: Enter your documentation of achievement for the current grade first and then document any additional achievement that relates to the next higher grade. Make sure to address the following questions: 91) What was done? (2) For whom was it done(Population)? (3) What was the outcome?

Nurse 11 Criterion:

Uses group process to identify, analyze, and resolve care problems.

Nurse 111 Criterion:

Uses the group process to identify, analyze, and resolve care problems.

Self Assessment:

Quality of Care – Nurse 11

NOTE: Enter your documentation of achievement for the current grade first and then document any additional achievement that relates to the next higher grade. Make sure to address the following questions: 91) What was done? (2) For whom was it done(Population)? (3) What was the outcome?

Nurse 11 Criterion:

Initiates/participates in quality improvement activities that result in approved outcomes.

Nurse 111 Criterion:

Initiates interdisciplinary projects to improve organizational performance.

Self Assessment:

Please read carefully the instructions, you need to use the template, the discussion for this week and the professor feedback.

if you have any questions please contact me.

PLEASE RESPOND TO THE FOLLOWING CLASSMATE'S POST IN 50 WORDS OR MORE:

In your work setting, which future trend(s) are likely to have the largest effect on patient care and related information systems?

In my work environment, the introduction of Artificial Intelligence (AI) and technologies of machine learning are likely to have the greatest impact on patient care and information systems. These technologies have the ability to process large amounts of data both from EHRs, wearable devices and genomic data to provide insights that aid in clinical decision-making, personalized treatment and prediction of outcomes (Shilo et al., 2020). AI-based tools can help to diagnose diseases more accurately and efficiently, provide treatment recommendations, and detect patterns that influence public health.

Additionally, telehealth and remote monitoring technologies are rapidly gaining popularity, changing the way healthcare is provided. These technologies make it possible to monitor the health status of patients in real time, reduce the number of visits, and bring health care closer to people, especially those living in remote areas. The introduction of these technologies into information systems requires strong data management and security but improves patient care by making it more personalized, efficient, and accessible (Shilo et al. 2020).

References

Shilo, S., Rossman, H., & Segal, E. (2020). Axes of a revolution: challenges and promises of big data in healthcare. Nature medicine, 26(1), 29-38.

 PLEASE RESPOND TO THE FOLLOWING CLASSMATE'S POST IN 50 WORDS OR MORE: 

 

Option 1

1. What other questions should the nurse ask about the cough?

How long have you had this cough?  Was it gradual or sudden?  How often do you cough? Is there any blood in the phegm?  How long has the phlegm been green? Is the phlegm thick, thin, or frothy?  Does the phlegm have an unusual odor?  Is the coughing associated with any chest pain or ear pain?  Do you have any problems catching your breath after coughing?  Is there anything in particular that causes the cough?  Does activity make it better or worse? Are you using any treatments to lessen the symptoms of the cough? If so, prescription or over the counter?   If so, are they working? 

1. Develop a problem list from the objective and subjective data.

Green phlegm could indicate infection.  Runny nose and sore throat could indicate a virus or sinus infection.  Hypertension.  Ronchi and wheezing possibility of obstructive lung disease.  TM bulging possible ear infection.  Red sore throat with pustules could indicate infection. Fatigue.

1. What nursing diagnoses can be derived from the problems list?

Ronchi and wheezing: Impaired gas exchange related to rhonchi and wheezing. 

Impaired swallowing related to pain in throat.

Acute pain related to sore throat.

Decreased activity related to fatigue.

1. What should be included in the plan of care?

Assess respiratory rate, oxygen saturation, lung sounds.  Provide patient with pain relief, cough suppressants, breathing treatments, steroids.  Keep patient in a comfortable position with head of bed elevated to minimize shortness of breath. Sputum sample to determine bacteria.   

1. What risk factors are associated with this age group?

Heart disease and hypertension.  Respiratory diseases such as asthma, emphysema, and COPD.  Cancer. Prostate problems.

1. Based on the readings, what is the most likely cause of this patient’s cough?

Based on the readings, wheezing is a common symptom of acute bronchitis. Fatigue, post-nasal drip, and sore throat are also symptoms of bronchitis.

Jarvis, C. (2016). Physical Examination & Health Assessment /: 7th edition. Elsevier.

  

Patient Health History

This assignment should be at least a 6-to-7-page summary in APA format documenting the findings of a comprehensive health history excluding a title and a reference page. The paper should not exceed 15 pages in length. 

The title page and the reference page are required.

For this assignment, you will conduct a health history as part of your future physical assessment assignment.  

Do not complete the assignment on a patient in your care at your place of employment due to HIPAA. The volunteer must be an adult.

The volunteer you will be assessing will be considered “normal” or nearly normal in most situations. 

They are not required to be without illness or disease processes, this is just who is normally available to students to assess. 

However, students will need to ensure even normal findings are addressed according to the assessment guidelines. 

Example: the volunteer does not have an IV, but you will still need to communicate that this is the case in your documentation. 

Avoid oversimplifying your assessment and documentation.

For example, if assessing peripheral pulses, avoid writing “peripheral pulses assessed.” Instead, document “Pedal pulses assessed bilaterally. Both pulses were 2+ with a rate of 78 bpm.”

Create a heading for each criterion listed in the rubric.

· Identifying Data and Source of History

-Maintain client's confidentiality. DO NOT include their name.
-Date health history was conducted
-Date of Birth
-Ethnicity/Race
-Sex/Gender if different from sex assigned at birth
-Primary language
-Marital status
-Living arrangements/who do they with? Do they utilize hospice or home health services? If so, what do they use home health for?
Religious preferences or practices that affect health care?
-Occupation?
-General impression of the patient (for example, are they in acute distress?) Appropriate body language and hygiene? Look stated age?
-General mood?
-Make sure the information was thorough and met the guidelines above.

· Chief Complaint

-The main reason for seeking healthcare and the situational events surrounding it. Describe fully (this will likely be fictional if the volunteer is healthy).
-What does the client expectation does the client have for the health care providers involved in their care? 

-What does the client hope to accomplish? What does health mean to the client? 

-Demonstrate the components of symptom analysis using the “Seven Attributes of a Symptom.”

· Medications

-Limit this to 5 examples
-Prescription medications (dose, route, frequency, reason for prescription/reason for PRN).
-Over-the-counter medications, including herbs (name, dose, frequency, route):

· Allergies

-Allergies and reactions when exposed to allergen?
-How were these reactions treated?

· Current and Past Medical and Surgical History

-What diseases did you have as a child (example: Chicken pox, measles, mumps, etc.)?
-Current chronic medical conditions and its impact on daily living?
-Previous hospitalizations? (Year, reason, impact)?
-Previous accidents or injuries (for example care accident)?
-Up to date on vaccinations?
-Uses any assistive devices?

-Previous surgeries? (Year, reason, impact or result)
-Problems with anesthesia (ask only if this is indicated)? If yes, describe.

· Family History

-Notable diseases, disorders, or disabilities of grandparents?
-Notable diseases, disorders, or disabilities of parents?
-Notable diseases, disorders, or disabilities of siblings?
-Notable diseases, disorders, or disabilities of children?
-Indicate if a family member is not applicable (such as patient does not have children). Indicate if patient or family member adopted or not.

· Personal Social History

-Alcohol use: never used, past user, present user, details
 

For past and present alcohol users only:
-Have you ever felt the need to cut down on your drinking?
-Have you ever felt annoyed by criticism of your drinking?
-Have you ever felt guilty about your drinking?
-Have you ever had the need for an eye-opener to treat a hangover or to steady your nerves?
 

-Tobacco use: never used, past user, present user, details (smoked? Dipped? How frequently, how much (#of cartons, #cigars, #cigarettes, for how many years, etc.)
 

-Recreational drug use: never used, past user, present user, include details
 

-In home or work environment (other smokers, on the job chemicals such as pesticides, etc.)
 

-Exercise patterns
 

-Sleep patterns

Write up/Documentation of assessment.

Appropriate ROS questions in each system area, including documentation of pertinent positives and negatives.

Use correct verbiage in your documentation. For example, instead of saying “wet breath sounds,” say “crackles noted bilaterally in lower lung lobes, upper lobes clear.”

Do not use the term “WNL,” within normal limits, or anything similar. This assignment is not intended to be a “document by exception” approach. Instead, document exactly what you assess even if it is normal.