Assignment 3:

Practicum Journal and Time Log

“A vital part of the reflective process is to plan for changes in your behavior.”

— Somerville & Keeling, 2004.

Being a reflective practitioner enables NPs to identify weaknesses and target professional development in order to address these weaknesses. In turn, this increases the NPs’ ability to provide the best care to patients and their families. Reflection also affords the NP time to consider communication and their efforts toward creating a culture of mutual support with colleagues, a characteristic that is essential to successful NP practice (Somerville & Keeling, 2004).

Each week you will complete a Journal Entry and Time Log that prompts you to reflect on your Practicum Experiences and how they relate to your Professional Goals and Self-Assessment of Clinical Skills. This week you will begin documenting your Practicum Experiences in your Practicum Journal.

Somerville, D., Keeling, J. (2004). A practical approach to promote reflective practice within nursing. Nursing Times, 100(12), 42–45. Retrieved from http://www.nursingtimes.net/Journals/2012/11/30/v/l/x/040323A-practical-approach-to-promote-reflective-practice-within-nursing.pdf

To prepare

For this course’s Practicum Experience, address the following in your Practicum Journal:

From your perspective, explain the role of nurse practitioners in clinical settings

Develop goals and objectives for the Practicum Experience in this course

Create a proposed timeline of practicum activities based on your practicum requirements.

As a professional nurse, you are expected to apply your expertise to patient care. On occasion, you will also be expected to share that expertise.

With evolving technology and continuous changes to regulations designed to keep up these changes, there is usually a need to share information and expertise to inform colleagues, leadership, patients, and other stakeholders.

In this Assignment, you will study a recent nursing informatics-related healthcare policy, and you will share the relevant details via a fact sheet designed to inform and educate.

To Prepare:

• Review the Resources on healthcare policy and regulatory/legislative topics related to health and nursing informatics.
• Consider the role of the nurse informaticist in relation to a healthcare organization’s compliance with various policies and regulations, such as the Medicare Access and CHIP Reauthorization Act (MACRA).
• Research and select one health or nursing informatics policy (within the past 5 years) or regulation for further study.

The Assignment: (1 page)

Create a 1-page fact sheet that your healthcare organization could hypothetically use to explain the health or nursing informatics policy/regulation you selected. Your fact sheet should address the following:

• Briefly and generally explain the policy or regulation you selected.
• Address the impact of the policy or regulation you selected on system implementation.
• Address the impact of the policy or regulation you selected on clinical care, patient/provider interactions, and workflow.
• Highlight organizational policies and procedures that are/will be in place at your healthcare organization to address the policy or regulation you selected. Be specific.

need 1 reply comment to each post with a credible sources, citation and years above 2013 in APA format.

Post 1

CHIEF COMPLAINT: Shortness of Breath and cough

Subjective:  Pt presents with complaints of shortness of breath and productive cough.  Pt relates he is coughing up thick green sputum with occasional bloody sputum. Pt relates that he has increased shortness of breath with walking.  Patient relates that he is also short of breath at rest. Pt also relates that he has had some chills and sweats and felt like he may have a fever.  He states that he has taken Tylenol for those symptoms.

Objective: Temperature 100.9, Respiratory rate 20, Heart rate 82, Blood pressure right arm 128/70, Oxygen saturation 89% on room air, Weight 210 pounds, EKG shows normal sinus rhythm, Chest radiograph

Assessment:  Skin is warm and moist. Thorax is symmetrical with diminished breath sounds with rales and expiratory wheezes throughout, negative for rhonchi. Wet productive cough noted during exam. Heart is regular sinus rhythm with rate of 82. Good S1, S2; negative S3 or S4 and negative for murmur. Abdomen protuberant with normoactive bowel sounds auscultated in all four quadrants. No pedal edema noted. 2+ dorsalis pedis pulses bilaterally. Neurologic: Patient is awake, alert and oriented to person, place and time. Chest radiograph shows infiltrate in the right middle lobe.

Priority diagnosis includes 1. Pneumonia 2. Myocardial Infarction 3. Pulmonary embolism   4. Congestive Heart Failure 5. Asthma

1. Pneumonia: The patient presents with productive cough and shortness of breath with exertion.  Patient has elevated temperature and low oxygen saturations along with diminished breath sounds, rales and expiratory wheezes which are all consistent symptoms with community acquired pneumonia. (Lynn, 2017).  Chest radiograph shows right middle lobe infiltrate which is also consistent with pneumonia. (Kaysin and Viera, 2016).

2. Myocardial Infarction: The patient presents with shortness of breath and low oxygen saturations.  Pt states that his shortness of breath is worse with exertion but is present at rest also.  Dyspnea is a frequent associated symptom with MI. (Lawesson, Thylen, Ericsson, Swahn, Isaksson and Angerud, 2018). The patient did have an EKG completed that revealed a normal sinus rhythm at a rate of 80 with no obvious signs of ectopy.  Evaluation of troponin level would assist in ruling out MI as a diagnosis for this patient. (Berliner, Schneider, Welte and Bauersachs, 2016).

3. Pulmonary Embolism: Dyspnea is the primary symptom for patients with PE. (Garcia-Sanz, Pena-Alvarez, Lopez-Landeiro, Bermo-Dominguez, Fonturbel and Gonzalex-Barcala, 2014). Onset of dyspnea with PE is typically sudden and further history for this patient related to onset of symptoms.  Evaluation of any extremity pain and swelling, D-dimer or chest angiography would also assist in determining if this was a more likely diagnosis. (Berliner, Schneider, Welte and Bauersachs, 2016).

4. Congestive Heart Failure: Dyspnea is also a common symptom with congestive heart failure.  Fatigue, diminished exercise tolerance and fluid retention are also common symptoms of CHF. (Berliner, Schneider, Welte and Bauersachs, 2016). The patient has rales noted upon auscultation which could be consistent with congestive heart failure however coupled with the remainder of the exam including productive cough with thick green sputum and fever, CHF would not be the primary diagnosis. Further evaluation of extremities of abdomen and extremities for signs of fluid retention would be indicated as well as labs such as BNP.

5. Asthma: The patient has expiratory wheezes and shortness of breath which are both consistent with asthma; however the patient also has fever and productive cough which are not consistent asthma symptoms. (Huether and McCance, 2017).

Plan: Not indicated

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V. & Reinhold, J. A.  (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The Differential Diagnosis of Dyspnea. Deutsches Aerzteblatt International, 113(49), 834. doi:10.3238/arztebl.2016.0834

Debasis, D., & David C., H. (2009). Chest X-ray manifestations of pneumonia. Surgery Oxford, (10), 453. doi:10.1016/j.mpsur.2009.08.006

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

García-Sanz, M., Pena-Álvarez, C., López-Landeiro, P., Bermo-Domínguez, A., Fontúrbel, T., & González-Barcala, F. (2014). Original article: Symptoms, location and prognosis of pulmonary embolism. Revista Portuguesa De Pneumologia, 20194-199. doi:10.1016/j.rppneu.2013.09.006

Post  2

S:

Chief Complaint: “I am having chest pain at this time”

History of Present Illness: Pleasant, Caucasian male experiencing an acute onset of sharp, constant chest pain when taking a deep breath.  Denies any alleviating factors. Yesterday his wife noticed his RT leg was edematous with erythema, denies any injury. Recently he returned from a vacation with an 8-hour plane ride. The patient was not asked if his pain radiated or if he had nausea or dizziness.

Past Medical History: Denies taking any medications. Allergies, surgeries, past medical conditions “not provided.” History of cancer or deep vein thrombosis not provided.

Social History: Married

Review of symptoms:

General: Feels short of breath when taking a deep breath, also having sharp lower RT rib pain.

Cardiovascular: Experiencing tachycardia. Peripheral edema started yesterday in RT lower leg.

Pulmonary: Reports having sharp pain when taking a deep breath with no relief measures noted. Complains of dyspnea with productive hemoptysis cough this morning.

Gastrointestinal: “not provided.”

O:

VS: BP 148/88 RT arm; P 112 and irregular; R 32 and labored; T 97.9 orally; Pulse Ox 90% on RA; His current weight is stable at 210 pounds.

General: Well-nourished, a well developed Caucasian male who is alert and cooperative. He is a good historian and answers questions appropriately. Patient sitting upright at the side of the cot appears anxious with labored breathing. Guarding noted in the anterior, distal RT rib area.

Cardiovascular: Skin is pallor, cool and diaphoretic. Heart rate is tachycardic. S1 and S2 irregular with no S3, S4, or murmur auscultated. RT calf with erythema, 2+ edema, warmth, and tender with palpation. LT leg with no edema, tenderness, or erythema noted. Bilateral 2+ dorsalis pedis pulse. Telemetry showing a sinus arrhythmia.

Gastrointestinal: Protuberant abdomen with active bowels x 4 quadrants.

Pulmonary: LT Lung clear to auscultation, RT middle and lower lobes with diminished breath sounds. No rales, rhonchi, or wheezing auscultated. Respirations labored. Respiratory excursion symmetrical.

Diagnostic results: CXR, ECG, venous doppler studies and ultrasound for DVT, V/Q scan, CT of the chest, labs- sputum culture, cardiac enzymes. Telemetry.

A:

Differential Diagnosis:

1.) Pulmonary Embolism

2.) Pneumonia

3.) Lung Cancer

4.) Myocardial Infarction

5.) Cardiac Arrythmia

P: “not required”

Evidence and Justification of Differential Diagnosis and Diagnostic Tests

Gruettner J. et al. (2015) report the Wells risk score assesses the history of a previous

DVT or PE in a patient. Assessment of tachycardia, recent surgeries or immobilization,

observation of DVT signs, an alternative diagnosis less likely than pulmonary embolism,

hemoptysis, and cancer are gathered.  Each area is assigned a score and the calculated total score

interprets the probability of having a pulmonary embolism. The patient calculated score

indicated a pulmonary embolism even though the history of cancer was unknown.

The diagnostic test of a CT angiography was found to be successful in the diagnosis of a

pulmonary embolism with Gruettner J. et al. (2015) research. The D-dimer, ABG, EKG, and

computed tomography showed little value in the diagnosis (Gruettner J. et al., 2015).

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016) indicate pneumonia causes the

Nursing Theory Analysis Paper

Overview/Description:

The purpose of this assignment is to describe, evaluate and discuss application of a nursing grand or mid-range theory. This assignment also provides the learner an opportunity to connect theory and research to nursing phenomena. Learners will develop an 8-10 page paper (excluding the title page and references) using APA style to address the elements listed below.

Theory/Author Name and Background

1. Select a Grand or Mid-Range Theory that is appropriate to your practice setting.
2. Describe the theorist’s background in detail and discuss how their experiences have impacted the theory development.
3. Examine crucial references for the original and/or current work of the theorist and other authors writing about the selected theory.
4. Identify the phenomenon of concern or problems addressed by the theory.

Theory Description

1. Explain whether the theory uses deductive, inductive or retroductive reasoning. Provide evidence to support your conclusion.
2. Describe the major concepts of the theory. How are they defined? (theoretically and/or operationally) Is the author consistent in the use of the concepts and other terms in the theory?
3. Interpret how the concepts are defined. Implicitly or explicitly?
4. Examine the relationships (propositions) among the major concepts.

Evaluation

1. Identify explicit and implicit assumptions (values/beliefs) underlying the theory. On what assumptions does the theory build?
2. Examine if the theory has a description of the four concepts of the nursing metaparadigm. If so, how are they explained in the theory? If the metapardigm is not explained, what elements do you see as relevant to the theory and why?
3. Discuss the clarity of the theory. Did it have lucidness and consistency?

Application

1. Examine how the theory would guide nursing actions.
2. Describe specifically how you can use this theory in your area of nursing (Practice, Education, Informatics or Administration).

Download the Theory Critique Template.

APA Style/Format

NURSING THEORY ANALYSIS PAPER3the theory, it is through the close nurse-patient ties created that nurses get vital information that enables them to take better care of their patients (Parker & Smith, 2010). It through the healthy inter-personal relation between a nurse and the patient that helps the nurse create a therapeutic environment vital in patients’ recovery