Author: admin

C791 Advanced Information Management

Advanced Information Management C791

The Electronic Health Record, also known as EHR is a digital database of both past and current clinical information including everything from demographics to test results and medical conditions (Tan & Payton, 2017). Health information systems have both advantages and disadvantages surrounding their usability, interoperability, scalability and compatibility. They have a direct affect on patient care and documentation and can affect the quality and delivery of nursing care and patient outcomes. Having access to patient records using an EHR allows information to be immediately available to all providers who have access to the EHR – including co-workers in other areas of the same hospital as well as in other hospitals with the same EHR. This can be extremely beneficial to the patient and health care providers alike. Unfortunately, EHRs are very expensive to implement as well as maintain – as they require multiple levels of training as well as periodic upgrades due to changes in healthcare delivery as well as system changes.

ORDER A PLAGIARISM-FREE PAPER HERE

Health Information Systems

A1. There are advantages and disadvantages of the EHR. In the area of usability, young nurses may have only been exposed to EHRs, and in fact most or all of their education may have taken place with electronic textbooks, tests and paper submission. For them, using an EHR may be very easy and they will have an advantage over older nurses, like myself, who learned nursing on pen and paper. All of my nursing schoolwork involved writing papers by hand and testing on paper. Advantages for nurses young and old, however, are the systematic charting methods provided by an EHR. Quick templates for charting  and check-box documentation on the EHR can provide reminders for the nurse to ensure that all problems that the patient is experiencing are addressed. A disadvantage can occur when the n nurse uses only the check-boxes and fails to provide to elaborate on issues occurring which are not addressed in the boxes. Without adding a narrative or written progress note in addition to the check boxes, the nurse may not truly tell the patients’ story, allowing for important details to be omitted. In the area of interoperability, one advantage is that if multiple providers use the same EHR, the patients records may be visible by all providers. For instance, if a patient sees a primary care physician who is aligned with a hospital system, then if the patient is admitted to the hospital he/she is aligned with the notes, diagnoses, lab results and demographics will all be visible by both the office staff and the hospital staff. Additionally, interoperability with lab would ensure that test results would flow into the chart rather than allowing for the chance for human error in entering lab values or times. A disadvantage would be if the patient sees a primary care physician who uses one type of EHR and presents to a hospital with another type of EHR. Most EHRs are only compatible with like EHRs, so the only way to ensure information from a physician office would not be visible by hospital staff or if one hospital system uses one type of EHR and another hospital system uses another type of EHR, there would be no visibility of information if the patient was transferred from one hospital to another. As related to scalability, an advantage would occur if the EHR chosen by a hospital is capable of expanding as healthcare regulations change and as the hospital system grows or expands to include additional service lines. A disadvantage would occur if the EHR chosen had limits on the ability to optimize the use to fit the needs of changing healthcare regulations or if it would not allow for expansion or growth throughout the system. Compatibility of the EHR would be an advantage if the current computer system of the hospital could handle the EHR without purchasing new equipment. When patients’ blood glucose levels are tested, does the information from the glucometer flow directly into the EHR? This would definitely be an advantage. Also it would be advantageous if the EHR had the ability to run on different hardware, as many people have a preference of the system they use. It would be a disadvantage if the EHR only ran on one system, or was only able to function in one area of the hospital. It would be important to ensure that the EHR had platforms for the Emergency Department, Inpatient, Outpatient, Surgery and Testing areas. If it was not capable of crossing over to any area of the hospital the patient might experience during a stay, it would be a disadvantage. C791 Advanced Information Management.

A2. Patient care and documentation can be positively impacted by implementation of an EHR. Using an EHR provides that all patient information is recorded in the exact same manner on each patient and provides continuity of care between shifts. Reminders for labs, medications, tests, and other areas of patient care can be helpful to ensure that the nurses caring for the patient provide all of the care ordered for the patient during their shift.  Additionally, if the patients chart needs to be reviewed for quality indicators or issues, the care is documented in the same manner and in the same area for each patient. If the patient seeks care from another physician or hospital system that uses the same EHR, then their care has the potential to be more appropriate because their history will be available for physicians, nurses and other caregivers with access, resulting in a higher level of care provided.

A3. The quality and delivery of nursing care and patient outcomes can be positively affected with the implementation of the EHR. Quality reviews can take place in real time – while the patient is still a patient- rather than having to wait for paper documentation to be scanned in to a record. Additionally, with paper documentation, there is no way to mine data to measure quality across a unit or a hospital. Data mining is the process of using software to discover or establish relationships (Mastrian & McGonigle, 2017).  If patient data is entered into an EHR, reports can be run to determine what treatments are being used, if they are effective and if proper documentation is happening among many other things. Patient outcomes can be positively affected because chart audits can happen in real time. C791 Advanced Information Management.

Organizational Benefits

B1. The EHR provides the opportunity to improve efficiency and quality of patient care, resulting in better outcomes (Mastrian & McGonigle, 2017). Patients come to healthcare facilities with hopes to get better. They do not plan to get sicker or to have complications, known as Hospital Acquired Conditions or HACs, resulting from treatments that they receive (or do not receive) during their hospitalization. In the facility where I work, approximately 3 years ago, a HAC known as Catheter Associated Urinary Tract Infection or CAUTI rates were high, and we set out on a mission to decrease these rates. We tracked and trended the rates of infection and the number of catheter days for each infection, from our EHR for the previous 3 years, and came up with goals for number of catheter days and diagnoses requiring catheterization vs. catheter use for nurse convenience. Additionally, we looked at where the CAUTIs were occurring (what unit), the age of the patient, what the course of treatment was (did the patient go to surgery or other diagnostic areas) and even drilled down to what nurse(s) and aide(s) cared for the patient. Nurse(s) and tech(s) caring for patients who developed a CAUTI were counseled and education was provided to all newly hired employees. Because of the information we gathered, using the EHR our nurse leadership team created a report to run each day to determine what patients might be at greatest risk for a CAUTI. The EHR allows for reports to be very in depth and include information such as what patients have catheters and how many days the catheter has been in place. Knowing the longer the catheter is in, the higher the risk of infection, we work as an interdisciplinary team to determine if the patient needs to continue with the catheter or if it could be discontinued. This, along with other actions such as implementing the use of TheraWorx cleaning have caused a significant decrease in the amount of CAUTIs. In 2015 and 2016, our hospital had seven CAUTIs during each year. In 2018 we had three CAUTIs and year to date in 2019 we have only had two. This is because of reports run and analyzed from the EHR.  HAC rates are continually measured using data from the HER to improve patient outcomes. Another way that quality improvement data collected can lead to measurable improvement is by using the EHR to review charts of patients who have had a negative outcome during a hospital stay, such as a fall with injury or a medication error. C791 Advanced Information Management. In the case of a fall with injury, our quality department will use the EHR to perform a full chart review. Then, they will use the information from the chart review to determine what co-workers were involved in the event, what medications or treatments the patient was receiving, and what the patient was doing at the time of injury. Every patient receives a fall risk assessment at the time of admit, completed in the HER, resulting in a fall risk score which is visible by the bedside nurse and others providing care to ensure the proper precautions are in place. If the patient experiences a fall, a near miss, or a change in condition, the bedside nurse is prompted to complete a new fall risk assessment in the EHR which will result in a new fall risk score. If the event is what as known as a never event, such as a death as a result of the fall, then this is reportable and the EHR will be useful to both the quality and legal department of the hospital as well as federal or state regulatory agencies or legal counsel who obtain access to the EHR.

B2. There are federal guidelines regarding the privacy of health information for EHRs including the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH)  (Mastrian & McGonigle, 2017). Additionally, anyone using an EHR needs to ensure information is secure and network security is managed (Mastrian & McGonigle, 2017). In the hospital where I work, we have a unit for geriatric psychiatric patients. This is a locked unit with limited access and all patients are considered private. Their names are not visible by all on house census reports or other documents. Only co-workers who have electronic access, granted by their leader, can access the records of these patients. Because it is not practical to assume that everyone a patient on this unit comes into contact with would have this electronic access, a level of security known as “breaking the glass” exists in our EHR. C791 Advanced Information Management. This allows for anyone to access their record, but in order to do so they have to “break the glass” which requires them to state the reason they need to be in the chart and agree to quality review to ensure they have the right and the access is necessary. This insures the patients in this high security area are kept as private as possible. Data back-up is also necessary. A few years ago, a Mercy Hospital in Joplin, Missouri was completely destroyed by a tornado. Many patient records were destroyed and while patients were cared for in other facilities in the area, their information was not accessible due to the other hospitals not having compatible EHRs. This data was eventually recoverable, but not in real time. As a result, each Mercy Hospital now has all of its data backed up to a computer system offsite in a database accessible to anyone at any time. The data isn’t just stored on-site, but continually backed up offsite. These measures assure compliance with HIPAA and HITECH.

B3. Patient privacy is protected in many ways in an EHR. In the hospital where I work, a watchdog system is in place to monitor everyone who views a patient’s chart. If at any time, an employee views a patient chart and there is a match of the last name or home address, an alert is sent to the employee’s leader. It is then the leader’s role to investigate the reason the employee viewed the chart. The EHR system we use is EPIC, and the watchdog system reveals all locations in the chart viewed by the employee. If the employee had a reason to be in the patient’s chart, such as checking in the patient in the Emergency Department, but the only part of the chart viewed by the employee was the check-in screen, then there is no reason for disciplinary action. But if that same employee, responsible for checking in the patient to the Emergency Department went on to view previous visits or lab results, then they have violated HIPAA and are disciplined according to the hospital policy for privacy which aligns with HIPAA. Patient privacy is additionally protected through the process of granting employees access to the EHR. Each employee’s leader is responsible for requesting access which aligns with their training and job duties. Kitchen employees have no reason to be in a patient’s chart, so they are not trained in the EHR and do not have access. Nurses are only given access to patients on the floor(s) or department(s) where they will be working. This assures employees are not given access to patient’s private information when not required for the completion of their duties.

B4. Organizational efficiency and productivity will improved by adopting an EHR, although there have been few studies of EHRs with very little reported data (Mastrian & McGonigle, 2017). One way that efficiency is improved is standardization of charting using the EHR. Pathways can be built for standard physician orders for patients with specific conditions such as Chronic Obstructive Pulmonary Disease or COPD. Head to toe assessments are completed by multiple nurses across multiple shifts, but using the EHR, the assessments are completed the same way every time. The same documentation on each patients provides continuity of care for patients across the continuum of care, in addition to providing the ability to view data complied over a whole hospital stay on one screen in the same place every time. Productivity will be improved because the members of the care team will all be able to document at the bedside while care is being performed. In the case of a patient in cardiac arrest, where multiple members of the care team are providing care simultaneously, EPIC EHR provides a “code narrator” allowing for one point person to document all interventions during the code in real time while the code is happening. In the absence of an EHR, this documentation would be done by hand and might not be the same way every time or might cause the nurse doing the documentation to chart after the end of the event taking up time that could be used to care for other patients or to continue care on that patient if they survive. Additionally, once the documentation is entered into the EHR in real time, there is no need to scan any documents or information into the chart which provides a streamlined method of recordkeeping. If patient information is recorded on paper rather than in an EHR, there could be waste as eventually the paper would be scanned into the chart and then shredded to ensure privacy. C791 Advanced Information Management. Efficiency can also be enhanced in the area of human and capital resources. Using an EHR, each time a procedure is performed on a patient, a medication is given or a supply is used, these are recorded in the EHR and automatically charged to the patient account. This decreases the need for someone to enter charges manually into the system, thereby increasing productivity and decreasing the number of people required for care. In addition to the data listed above, there are many other ways organizational efficiency and productivity will improve with the implementation of an EHR.

Essential Stakeholder Roles for System Implementation

There are multiple layers of leadership required for implementing an EHR within a healthcare system, including but not limited to: Implementation Manager, Physician Champion, Information Technology Lead and SuperUser Lead. The Implementation Manager may be associated with the vendor of the EHR. They are responsible for making sure the project is on schedule, monitoring the work plan, maintaining a list of problems at the hospital or vendor level that need resolution, scheduling events surrounding implementation and may include communicating updates to the implementation team. Their expertise would need to be in both the inner workings and implementation of the specific EHR to be implemented (from a vendors perspective) and also in the structure of the implementation team (from the hospital perspective). This person would need to have excellent communication and organizational skills as the success of the implementation really begins and ends with them. They will also need delegation skills, as there is no way they could be expected to accomplish all facets of their role without support. It is never recommended to implement an EHR without a physician champion. A close relationship between the physician champion and the implementation team is imperative to the success of the EHR. Physicians will need the EHR to function clinically in a way that is beneficial to them as well as the patient. The Physician Champion will serve as a liaison between the implementation team and the facility physicians, so good communication skills are also required. It is essential that physicians “buy in” to the EHR, so it will be necessary for them to have a voice in the development, optimization and implementation of the EHR. The Information Technology Lead is the person that every member of the team can go to for answers related to the operation of the software and hardware of the EHR C791 Advanced Information Management. They deploy the workstations or other hardware needed, install the appropriate software and drivers on computers, tablets, scanners, printers and other hardware. They are also responsible for the operation of the software on the deployed hardware. The IT Lead will need to work with Leads from all departments within the hospital (Nurse and other Clinical Leads, Lab and other Ancillary Service Leads) so good communication skills are necessary. They will also need to understand the EHR and how the software is installed and how the hardware is intended to work once the software is installed. They will need to have a working knowledge of all areas of the EHR and what each department can expect to be required to do to login, use, and troubleshoot issues that arise. The SuperUser Lead  creates a network of Super-Users within the organization to provide continued support during and after implementation of the EHR. These SuperUsers must be recruited and trained by the SuperUser Lead. SuperUsers must be personable and willing to help employees with various skills within the organization. They will need to be able to work with very computer savvy employees as well as those who have very little computer expertise. They will provide IT support during implementation as well as assisting with new employees hired after implementation. They will be chosen based on their knowledge of different facets of the EHR so that they can provide very specific and effective assistance to employees.

Plan for Evaluation

Once an Electronic Health Record has been implemented by a team within a hospital setting, it will be important to continually evaluate the success of the EHR in the different areas of the hospital. National professional organizations have developed position papers regarding the importance of evaluation as well as methods for evaluation. One such organization, Healthcare Information and Management System Society or HIMSS, developed a position paper titled Transforming Nursing Practice Through Technology and Informatics. In this paper, they outline the value of nursing informatics, connecting with the consumer, and implications for time and plan of care (“HIMSS,” June 16, 2011). HIMSS believes that nursing should be key stakeholders in not only the development and design of EHR, but also in the evaluation and optimization of EHR (“HIMSS,” June 16, 2011) . The position statement from HIMSS is in alignment with other professional organizations such as the American Nurses Association (ANA), and the Alliance for Nursing Informatics (ANI) (“HIMSS,” June 16, 2011). Having strong nursing informatics leadership will play a key role in evaluating the success of system implementation. These leaders will orchestrate what information will be provided, how patient care is supported by the gathering and documentation of data and what financial and business implications there are as a result of implementation (“HIMSS,” June 16, 2011). National benchmarks exist in all service areas in the hospital. The EHR should allow each service area to easily compile data to measure their area against national benchmarks as well as their peers. The ease in which data is gathered from the EHR will allow more time for changes in practice guidelines or protocols to provide for safer care for the patient and a better work environment for the employee. Continual evaluation by all service areas as well as discussions between unit service area leadership and nursing informatics leadership regarding possible optimizations to the EHR are imperative to a successful EHR implementation. C791 Advanced Information Management.

 

References

Mastrian, K. G., & McGonigle, D. (2017).
Informatics for Health Professionals
(Custom WGU ed.). [Western Governors University]. Retrieved from https://wgu.vitalsource.com/#/books/9781284155402

Position statement on transforming nursing practice through technology and informatics. (June 16, 2011). Retrieved from https://www.himss.org/sites/himssorg/files/HIMSSorg/handouts/HIMSSNIPositionStatementMonographReport.pdf

Tan, J., & Payton, F. C. (2017).
Adaptive Health Management Information Systems: Concepts, Cases, & Practical Adaptions
(Custom WGU ed.). [Western Governors University]. Retrieved from https://wgu.vitalsource.com/#/books/9781284155396 C791 Advanced Information Management

Differential diagnosis for skin conditions soap note example

SOAP NOTE

Differential Diagnosis for Skin Conditions

 

 

Skin Condition Picture # 2

 

 

Patient Initials: __JB___                     Age: __47___                         Gender: __M___

 

ORDER A PLAGIARISM-FREE PAPER HERE

SUBJECTIVE DATA: 

 

Chief Complaint (CC): 
Red lesions on trunk of body

 

History of Present Illness (HPI): 
Joe Brown is a 47-year-old Caucasian male who presents to practice with complaints of red lesions on the trunk area. The red lesions developed two weeks ago

of his body. The patient has not reported any irritating or soothing factors, and he has not tried any treatment for the lesions. Joe Brown reports the lesion does not affect his daily lifestyle and in not impacting in a negative way. Joe is just worried it could be something more severe. differential diagnosis for skin conditions soap note example

 

Medications: 

Lopressor 25mg twice daily

Lovastatin 40mg at bedtime

Xarelto 20mg daily with dinner

 

 

Allergies: 
Penicillins- rash,

 

Past Medical History (PMH): 

Hypertension diagnosed at 44

Atrial Fibrillation diagnosed at 46

Dyslipidemia diagnosed at 42

 

Past Surgical History: 

Vasectomy (2010)

herniorrhaphy (2008)

 

Sexual/Reproductive History: 
Patient denies any issues reproductively. Patient is currently divorced with 2 children and had a vasectomy in 2010. Patient has no history STDs and all sexual encounters have heterosexual.

 

Personal/Social History: 
Patient smoked 1 packs of cigarette/day x 10 years and drinks 2 bottles of beer a week for 26 year. Patient denies ever using recreational drugs. Patient does not exercise regularly but considers himself active due to the nature of his job (construction worker). Patient admits he does not follow a prescribed diet he still consume food high in fat and salt.

 

Immunization History: 
His immunization is up to date. He received his last flu shot and pneumonia vaccines in 2017 differential diagnosis for skin conditions soap note example

 

Significant Family History:

Father- Father is deceased, age 70, complications of type 2 diabetes

Mother- mother is deceased, 64, from hemorrhagic stroke

 

Siblings- two brothers with history of hypertension.

 

Children-2 children alive and well no significant medical issues.

 

Lifestyle: 
He currently works in the construction industry and has worked for in constructions for the past 20 years. He has been married once but currently is divorced and has 2 children with his wife. He lives in a middle-class neighborhood in the suburbs. He enjoys barbequing during his free time. He has a strong support system through his family and friends. Patient get a yearly physical check up but not vision and dental.

 

 

Review of Systems: 
From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).
 
Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).

General: 
Mr. Brown is well-developed, well nourished Caucasian male who is alert and cooperative. He is negative for recent changes in weight, fever, chills or night sweats.

 Respiratory: 
He denies SOB or exposure to tuberculosis.

 Cardiovascular/Peripheral Vascular: 
Mr. Brown denies chest pain, palpitation or irregular rhythm. No history of edema, exercise intolerance and claudication.

 Gastrointestinal: 
negative for heartburn; negative for nausea, vomiting, bowel changes. Bowel movements are solid and negative for frank blood.

  Skin: 
Presence of ruby red papules on trunk, denies pruritus or pain.

Hematologic: 
Mr. Brown denies prolonged bleeding times and easy bruising. No history of anemia.

Allergic/Immunologic: 
Mr. Brown is allergic to penicillin. No asthma or atopy. Patient has never been tested for HIV. Patient denies any recurrent infections.

 

OBJECTIVE DATA:

 

Physical Exam:

Vital signs:
 Temp 97.0; P78 and regular; R 18 and regular BP 138/72 right arm. His weight is currently 190. Height 6’2”. BMI is 25.

 

General: 
Mr. Brown is well-developed, well nourished Caucasian male who is alert and cooperative.

Chest/Lungs: 
Breath sounds clear to auscultation in all lung fields. There is symmetry in chest wall expansion and diaphragmatic excursion.

Breast:
No masses or sign of gynecomastia

Neck:
Presesnce of full range of motion. Absence of carotid bruit and absence of mass.

HEENT:

Heart/Peripheral Vascular: 
Heart regular rate and rhythm. No heart murmur, rub, or gallop. Pulses +2 bilateral radials and +2 bilateral pedals. Absence of peripheral edema.

Abdomen: 
Bowel sounds present x4 quadrants. Soft, non-tender, non-distended abdomen. Absence of organomegaly or masses.

Skin: 
Tiny bright ruby-red, round papules on the trunk of Mr. Joe’s body. Turgor is good, no cyanosis or jaundice.

 

Lab Tests and Results:

CBC- RBC 4.7, PLT 200, HGB 13, HCT 44

Chemistry: triglycerides 455, LDL 198, Total cholesterol 234; otherwise WNL.

 

ASSESSMENT: 

 

Priority Diagnosis: 
Cherry Angioma

 

Differential Diagnoses:

Drug eruption

Pityriasis Rosea

Thrombocytopenic purpura

 

The primary diagnosis selected in this patient is cherry angioma, as the clinical presentation and history best supports this diagnosis.  The patient presented with a non-painful, non-pruritic papular rash limited to the trunk of the body with no other negative symptoms.  A drug eruption could be responsible for a red rash on the patient’s trunk, but the patient denies any use of new medications and the rash is not generalized, pink, and morbilliform, how drug rashes usually are presented (Ball et al., 2015).  Pityriasis Rosea meets some of the criteria, but the rash is not itchy, scaly, or in oval patches, and the patient denies any recent illnesses (Dains, Baumann, & Scheibel, 2016).  Thrombocytopenic purpura is a contender for a priority diagnosis since the patient is on blood thinners and at risk for increased bleeding, but lab results show that platelet and other blood counts are within normal limits, and the rash is not generalized (Ball et al., 2015).

 

References

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.

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.

Ely, J. W., & Stone, M. S. (2010). The generalized rash: Part I. Differential diagnosis. 
American Family Physician
, 81(6), 726-734. Retrieved from http://www.aafp.org/afp/2010/0315/p726.html

 

Comprehensive SOAP

 

 

Patient Initials
:           JS                   
Age
:    58yo               
Gender:
          Male

 

SUBJECTIVE DATA:

 

Chief Complaint (CC):
Skin abnormality appearance of a wide array of firm red bumps on chest and upper stomach (Slide #2) differential diagnosis for skin conditions soap note example

 

History of Present Illness (HPI):
JS is a 58-year-old white male who appears today to address numerous red bumps on his chest that spreads down to his abdomen. He reports there is a gradual onset over the past few months and he did not have this many a few years ago. He is concerned he may have cancer since he asked some friends and they said it could be start of it. He denies any pain to the areas, exudate, bleeding, or change in shape. He denies any fever and no presentation to contact aggravations such as chemicals. States his job can be a little stressful at times but not too significant. No changes in lifestyle. He does not have any personal history of skin growths before other than moles but there is a family history of skin cancer.

 

Medications:

Celexa 20mg daily

Metoprolol 25mg BID

 

Allergies:

Amoxicillin

 

Past Medical History (PMH):

Depression: diagnosed at age 37

Hypertension: diagnosed at 46

 

Past Surgical History (PSH):

Lasik Eye Surgery (Dr. John Stefano, MD), age 47

Cholecystectomy (Dr. Anil Makani, MD), age 54

Appendectomy (Surgeon Unknown), age 16

 

Sexual/Reproductive History:

Heterosexual, he is currently sexually active with one partner.  He uses no barrier

methods and his wife has entered menopause.

 

Personal/Social History:

Never smoked, occasional ETOH use (5 wine coolers per month), denies any use of illicit drugs

 

            Immunization History:

His immunizations are up to date.  He has not received the flu vaccination since last year and the Pneumococcal vaccine has not been administered. differential diagnosis for skin conditions soap note example

 

            Significant Family History:

Mother deceased in February 2018 due to acute lung injury, father is still living; history of hypertension, skin cancer and prostate enlargement, two siblings who are without any medical issues. He has two sons and two daughters ages 34, 31, 21, and 18. All healthy and living nearby.

 

            Lifestyle:

He is currently employed selling life insurance from his home office. He is married to his wife of 28 years and lives in his own home with her. He is currently sexually active. He has four children and four grandchildren, all live in close proximity. He is active to some degree.  He takes walks with his wife 2-3 days a week. He attends chapter meetings monthly for his place of employment.  He visits his father on a daily basis to assist him with any needs that he may have around his home.

 

            Review of Systems:

 

General:

Mr. Shockey is a well-appearing Caucasian male who presents alert. He appears to have good hygiene. Denies fatigue, fever, chills, recent weigh gain or loss, or loss of appetite.  Answers questions appropriately.

 

HEENT:

No vision or hearing impairments; he does not wear glasses other than for reading,
+ history of cataracts.
His last eye exam was approximately one year ago. No recent hearing changes, discharge, ringing in the ears, or ear infections.  He revealed his sense of smell is unblemished. No nasal or sinus issues. Nasal mucosa is pink without rhinorrhea or sinus delicacy. Oral mucosa clean, moist and intact. His last dental exam was 05/2018. Denies any concerns with chewing or swallowing.

 

Neck:

Supple, full scope of movement. No thyromegaly. No carotid bruits. No masses or tracheal deviation noted.

 

Breasts:

N/A

 

Respiratory:

Breath sounds are clear upon auscultation. Diaphragmatic excursion appears symmetrical. Denies any dyspnea on exertion, increased sputum production or cough. Denies ever having positive PPD.

 

Cardiovascular:

No chest pain, palpitations,
+ history of murmur as a child
; no history of arrhythmias, edema, or pain with walking or varicosities.

 

Gastrointestinal:

No nausea, vomiting;
+ for occasional reflux
. No abdominal discomfort, no changes in bowel pattern, denies any diarrhea, or constipation.

 

Genitourinary:

Urinary pattern is normal, denies any inability to urinate, or any form of incontinence, urgency or difficulty starting stream. He is heterosexual and is currently sexually active. No history of STDs.

 

Musculoskeletal:

Denies any bone or joint pain, no arthritis, gout and reports full ROM. No history of fractures or osteoporosis.

 

Psychiatric:

No history of anxiety.
+ history of depression for a number of years
. No sleep disturbances or hallucinations.
+ for hospitalization to a psychiatric ward for symptom control of his depression and has received electrical shock therapy
. He denies suicidal/homicidal ideation.

 

Neurological:

No syncopal episodes,
+ for dizziness when taking Celexa
. No tingling or numbness, no headaches.
+ for change in thinking patterns and memory after his electrical shock therapy about 8 years ago
. No tremors or abnormal movements; no history of gait issues or problems with coordination; he has been without falls and denies any type of seizure activity. differential diagnosis for skin conditions soap note example

 

Integumentary/Hematologic/Lymphatic: 

+ for multiple 1-2 mm firm, elevated papules
, appearing bright red, diffuse over his chest and upper abdomen, non-blanchable. No rashes, itching, or bruising. Denies any bleeding disorders, excessive bruising or blood transfusions.

 

Endocrine:

No endocrine issues or hormonal disorder.

 

Allergic/Immunologic:

+ history of generalized
hives as a child after ingestion of amoxicillin.

 

            OBJECTIVE DATA:

 

                        Physical Exam:

 

Vital signs: B/P 122/78, right arm, sitting, adult regular cuff; P 74 and regular; T 97.6 orally; RR 19; non-labored; Wt: 193 lbs; Ht: 6’1; BMI 25.5

 

General:

A&O x3, NAD, does not appear uncomfortable

 

HEENT:

PERRLA, Extra Ocular Muscle Intact, Ear canals patent.  Nasal mucosa

pink, normal turbinates.  No septal deviations.  Oral mucosa pink and moist.  Pharynx is nonerythematous and without exudate.  Teeth in good repair.

 

Neck:

Carotids no bruit, jugular vein distention or t-megally, Full ROM

 

Chest/Lungs:

Clear to auscultation AP&L, Symmetric chest wall, respirations non-

labored.

 

Heart/Peripheral Vascular:

RRR without murmur, rub, or gallop; S1 S2; +2 peripheral pulses bilaterally, no edema

 

Abdomen:

benign, normal bowel sounds in all 4 quadrants, no rebound tenderness, no masses.

 

Genital/Rectal:

Deferred at this time.

 

Musculoskeletal:

Symmetric muscle development; muscle strengths 5/5 all groups

 

Neurological:

CN II – XII intact, DTR’s intact, speech clear and in good tone.

 

Skin/Lymph Nodes
: multiple 1-2 mm firm, elevated papule, color appears bright red, diffuse over the chest and upper abdomen, non-blanchable.

 

ASSESSMENT:

 

                        Diagnostics:

None required

 

                        Differential Diagnosis (DDx):

 

Glomeruloid hemangioma-Small, firm, red-to-violaceous, vault formed papules, papulonodules, subcutaneous pale blue compressible tumors, wine-red sessile or pedunculated papules, or injuries with cerebriform morphology. They extend in estimate, estimating couple of millimeters to couple of centimeters in distance across, and are found essentially on the storage compartment and proximal appendages and is portrayed by lone or numerous blue-red papules (Gupta, et al., 2013).

Petechiae is red to purple injuries showing up on the mucous films and skin. Injuries can be macular and discernable (American Academy of dermatology, n.d.). Petechiae is little sores estimating under 0.5 cm (Ball et al., 2015). differential diagnosis for skin conditions soap note example

Cherry angioma-Cutaneous vascular expansion which shows as single or different spots and happens transcendently on the upper trunk and arms. They regularly show up as round-to-oval, splendid, red, arch formed papules and pinpoint macules measuring up to a few millimeters in distance across. The histopathologic discoveries of a cherry angioma are steady with a genuine slim hemangioma, which is shaped by various, recently created vessels with thin lumens and unmistakable endothelial cells organized in a lobular manner in the papillary dermis. The etiology of cherry angiomas isn’t outstanding. In any case, since cherry angiomas tend to increment in number as the patient’s age expands, 75% of grown-ups more than 75 years old were seen in an ongoing report, the maturing process may assume a part in the pathogenesis of cherry angiomas (Sanz, et al., 2017).

 

Diagnosis/Client Problems:

 

Cherry Angioma – Cutaneous vascular expansion which shows as single or different spots and happens transcendently on the upper trunk and arms. They regularly show up as round-to-oval, splendid, red, arch formed papules and pinpoint macules measuring up to a few millimeters in distance across (Sanz, et al., 2017). Glomeruloid hemangioma is vascular multiplication and shows up all of a sudden on the storage compartment, furthest points, head, and neck area in this way it is discounted (Gupta, et al., 2013). Red to purple, hyperkeratotic and combining papules, happens most regularly on the lower locale of the trunk, hindquarters, and thighs and is normally connected with Lyosomal storage diseases. This was not observed at all and therefore is precluded.

 

Plan:
Findings were presented to Mr. Shockey. In the event that treatment is wanted for corrective appearance, disturbance or bleeding; may allude to dermatology for electrocautery or laser treatment (Kim, 2009). Patient refuses as of now but may consider if any issues arise.

 

 

 

 

References

 

American Academy of Dermatology. (n.d.). Petechiae, purpura, and vasculitis.

Retrieved from file:///C:/Users/User/Downloads/Petechiae–Purpura-and-Vasculitis.pdf

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.

Gupta, J., Kandhari, R., Ramesh, V., & Singh, A. (2013). Glomeruloid

hemangioma in normal individuals.
Indian Journal of Dermatology
, 58(2), 160. doi:10.4103/0019-5154.108088

Kim, J., Park, H., & Ahn, S. K. (2009). Cherry Angiomas on the Scalp.
Case

Reports In Dermatology,
1(1), 82-86. Retrieved from Walden Library database

Sanz, V., Martorell, A., Alegria-Landa, V., Diaz, F. J., Torrelo, A., Alfaro-Rubio,

A., & Kutzner, H. (2017). Cherry hemanginomas and lipomas with peculiar distribution.
Journal of the American Academy of Dermatology
. 76(6). DOI: https://doi.org/10.1016/j.jaad.2017.04.280 differential diagnosis for skin conditions soap note example

Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

Practice Change and Quality Improvement Models

Most of the changes taking place in the healthcare services are related to the factors dealing with patient safety, evidence-based practices, and quality. The various models which are entirely factual and related to quality have aided the nurses in conceptualizing their understanding, and to a greater extent enhanced the issuing of appropriate health services. In consideration of this DNP project which primarily deals with the high fall rate of long-term care residents, the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model and the six sigma model are identified as the appropriate models which can be used in this DNP project. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model.

ORDER A PLAGIARISM-FREE PAPER HERE

Application of (JHNEBP) and the Six Sigma Model

In the view of a change being evident in the practicum and the efforts of the project, the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model, according to Dang and Dearholt (2017), is compelling in the process of problem-solving and decision making. Its design is placed in the scope of meeting the needs of the practicing nurses and has a three-step process, practice question, evidence, and translation (PET) which ensures latest research finding. Once this model is applied effectively, there is the quick and appropriate incorporation of best practices into patients care (Dang & Dearholt, 2017). Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model. The six sigma model, on the other hand, provides guidance on the part relating to quality. Here, this model directs the spotlight on statistical data, as such, its primary aim being to eliminate the defects which may eventually cause harm to the patients in question (McGonigal, 2017). Information is collected and critically analyzed to ensure a standardized platform is established. Its implementation not only offers services which can be termed as nearly perfect but also a reduction in costs incurred by healthcare organizations is evident (McGonigal, 2017).

 
Examples of Application

In consideration of the (JHNEBP) model being linked to three step process, practice question, evidence, and translation (PET) which ensures latest research finding, the methods such as definition of the questioning scope, conducting the research, and creating a plan of action are the primary examples enumerated in the application of the change model (Dang & Dearholt, 2017). Critical cross-referencing of data, which also involves the offering of updates based on the data gathered is considered an example when dealing with the six sigma model (McGonigal, 2017). Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

Conclusion

The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model and the six sigma model, once applied expertly will ensure quick and appropriate incorporation of best practices into patients care and also reduce the cost incurred by the health care organizations (McGonigal, 2017).

 

References

Dang, D., & Dearholt, S. L. (2017). Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines. Sigma Theta Tau.

McGonigal, M. (2017). Implementing a 4C Approach to Quality Improvement. 
Critical care nursing quarterly
, 
40
(1), 3-7.

 

The Johns Hopkins Nursing EBP Model

Evidence-based practice (EBP) is now a core competency for all

health care professionals (IOM, 2003). This requires leaders in both

academia and service to align their educational and practice environments to promote practice based on evidence, to cultivate a spirit

of continuous inquiry, and to translate the highest quality evidence

into practice. Selecting a model for EBP fosters end-user adoption of

evidence and embeds this practice into the fabric of the organization.

The objectives for this chapter are to:

■ Describe The Johns Hopkins Nursing Evidence-based Practice

Model

■ Introduce bedside nurses and nurse leaders to the PET process

(Practice Question, Evidence, and Translation), a tool to guide

nurses through the steps in applying EBP Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

3

The Johns Hopkins Nursing

Evidence-Based Practice

Model and Process Overview

Sandra L. Dearholt, MS, RN

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

34 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

The Johns Hopkins Nursing Evidence-Based Practice

Model

The Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP; see Figure

3.1) depicts three essential cornerstones that are the foundation for professional

nursing: practice, education, and research.

• Practice, the basic component of all nursing activity (Porter-O’Grady,

1984), reflects the translation of what nurses know into what they do. It

is the who, what, when, where, why, and how that addresses the range of

nursing activities that define the care a patient receives (American Nurses

Association [ANA], 2010). It is an integral component of health care

organizations.

• Education reflects the acquisition of nursing knowledge and skills

necessary to build expertise and maintain competency.

• Research generates new knowledge for the profession and enables the

development of practices based on scientific evidence. Nurses not only

“rely on this evidence to guide their policies and practices, but also

as a way of quantifying the nurses’ impact on the health outcomes of

healthcare consumers” (American Nurses Association, 2010, p. 22).

Figure 3.1 The Johns Hopkins Nursing Evidence-Based Practice Model

RESEARCH

• Experimental

• Quasi-experimental

• Non-experimental

• Qualitative

NON-RESEARCH

• Clinical Practice Guidelines

• Expert Opinion

• Organizational Experience

• Clinical Expertise

• Consumer Preferences

Internal

Factors

External

Factors

Culture

Environment

Equipment/Supplies

Staffing

Standards

Accreditation

Legislation

Quality Measures

Regulations

Standards

PRACTICE

EDUCATION

RESEARCH ©The Johns Hopkins Hospital/The Johns Hopkins University

Johns Hopkins Nursing Evidence-Based Practice Model

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 35

Nursing Practice Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

Nurses are bound by, and held to, standards established by professional nursing organizations. For example, the American Nurses Association (2010) has

identified six standards of nursing practice (scope) that are based on the nursing process (see Table 3.1) and ten standards of professional performance (see

Table 3.2). In addition to the ANA, professional specialty nursing organizations

establish standards of care for specific patient populations. Collectively, these

standards define scope of practice, set expectations for evaluating performance,

and guide the care provided to patients and families. Because these standards

provide broad expectations for practice, all settings where health care is delivered

must translate these expectations into organization-specific policies, protocols,

and procedures. As part of this process, nurses need to question the basis of their

practice and use an evidence-based approach to validate or change current practice based on the evidence. Conventionally, nurses have based their practice on

policies, protocols, and procedures often unsubstantiated by evidence (Melnyk,

Finout-Overholt, Stillwell, & Williamson, 2009). The use of an evidence-based

approach, however, is now the standard set by professional nursing organizations

and is an essential component of the Magnet Model for organizations aspiring to

Magnet recognition (Reigle et al., 2008).

The Magnet Model (see Figure 3.2) has five key components: (a) transformational leadership; (b) structural empowerment; (c) exemplary professional

practice; (d) new knowledge, innovations, and improvements; and (e) empirical

outcomes. To provide transformational leadership, nursing leaders need to have

vision, influence, clinical knowledge, and expertise (Wolf, Triolo & Ponte, 2008).

They need to create the vision and the environment that supports EBP activities, such as continuous questioning of nursing practice, translation of existing

knowledge, and development of new knowledge. Through structural empowerment nursing leaders promote professional staff involvement and autonomy in identifying best practices and using the EBP process to change practice. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model. Magnet

organizations demonstrate exemplary professional practice such as maintaining

strong professional practice models; partnering with patients, families, and interprofessional team members; and focusing on systems that promote patient and

staff safety. New knowledge, innovations, and improvements challenge Magnet

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

36 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

organizations to design new models of care, apply existing and new evidence

to practice, and make visible contributions to the science of nursing (American

Nurses Credentialing Center [ANCC], 2011). Additionally, organizations are required to have a heightened focus on empirical outcomes to evaluate quality. The

EBP process supports the use of data sources such as quality improvement results, financial analysis, and program evaluations when answering EBP questions.

Table 3.1 American Nurses Association Standards of Practice

1. Assessment: The collection of comprehensive data pertinent to the health care

consumer’s health and/or situation. Data collection should be systematic and

ongoing. As applicable, evidence-based assessment tools or instruments should be

used, for example, evidence-based fall assessment tools, pain rating scales, or wound

assessment tools.

2. Diagnosis: The analysis of assessment data to determine the diagnoses or issues.

3. Outcomes identification: The identification of expected outcomes for a plan

individualized to the health care consumer or the situation. Associated risks, benefits,

costs, current scientific evidence, expected trajectory of the condition, and clinical

expertise should be considered when formulating expected outcomes.

4. Planning: The development of a plan that prescribes strategies and alternatives to

attain expected outcomes. The plan integrates current scientific evidence, trends, and

research.

5. Implementation: Implementation of the identified plan, which includes partnering

with the person, family, significant other, and caregivers as appropriate to implement

the plan in a safe, realistic, and timely manner. Utilizes evidence-based interventions

and treatments specific to the diagnosis or problem.

a. Coordination of Care: Coordinates/organizes and documents the plan of care.

b. Health Teaching and Health Promotion: Employing strategies to promote health

and a healthy environment.

c. Consultation: Graduate-level prepared specialty nurse or advanced practice

registered nurse provides consultation to influence the identified plan, enhance

the abilities of others, and effect change.

d. Prescriptive Authority and Treatment: Advanced practice registered nurse

prescribes evidence-based treatments, therapies, and procedures considering

the health care consumer’s comprehensive health care needs.

6. Evaluation: Progress towards attainment of outcomes. Includes conducting a

systematic, ongoing, and criterion-based evaluation of the outcomes in relation to the

structures and processes prescribed by the plan of care and the indicated timeline.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 37

Table 3.2 American Nurses Association Standards of Professional Performance

1. Ethics: The delivery of care in a manner that preserves and protects health care

consumer autonomy, dignity, rights, values, and beliefs.

2. Education: Attaining knowledge and competency that reflects current nursing

practice. Participation in ongoing educational activities. Commitment to lifelong

learning through self-reflection and inquiry to address learning and personal growth

needs.

3. Evidence-Based Practice and Research: The integration of evidence and research

findings into practice by utilizing current evidence-based knowledge, including

research findings, to guide practice.

4. Quality of Practice: Contributing to quality nursing practice through quality

improvement activities, documenting the nursing process in a responsible,

accountable, and ethical manner, and using creativity and innovation to enhance

nursing care.

5. Communication: Communicating effectively in a variety of formats in all areas of

practice.

6. Leadership: Providing leadership in the professional practice setting and the

profession.

7. Collaboration: Collaboration with health care consumer, family, and others in the

conduct of nursing practice.

8. Professional Practice Evaluation: Evaluation of one’s nursing practice in relation

to professional practice standards and guidelines, relevant statutes, rules, and

regulations.

9. Resource Utilization: Utilizes appropriate resources to plan and provide nursing

services that are safe, effective, and financially responsible.

10. Environmental Health: Practicing in a safe and environmentally safe and healthy

manner. Utilizes scientific evidence to determine if a product or treatment is an

environmental threat.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

38 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

Figure 3.2 American Nurses Credentialing Center Magnet Model Components

(© 2008 American Nurses Credentialing Center. All rights reserved. Reproduced with the permission of the

American Nurses Credentialing Center.)

An organization’s ability to create opportunities for nurses, as part of an interprofessional team, to develop EBP questions, evaluate evidence, promote critical thinking, make practice changes, and promote professional development has

a major impact on achieving Magnet status. Anecdotal evidence suggests nursing

staff who participate in the EBP process feel a greater sense of empowerment and

satisfaction as a result of contributing to changes in nursing practice based on

evidence. Change may also be more readily accepted within the organization and

by other disciplines when it is based on evidence that has been evaluated through

an interprofessional EBP process.

Nursing Education

Nursing education begins with basic education (generally an associate or a bachelor’s degree) in which fundamental nursing skills and knowledge, natural and

behavioral sciences, professional values, behaviors, and attitudes are learned. Advanced education (a master’s or doctorate degree) expands knowledge based on

theory, refines practice, and often leads to specialization in a particular practice

Global Issues in Nursing & Health Care

Empirical

Outcomes

Structural

Empowerment

Exemplary

Professional

Practice

New Knowledge,

Innovations, &

Improvements

Transformational

Leadership

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 39

area. Advanced nursing education incorporates an increased emphasis on the application of research and other types of evidence to influence or change nursing

practice and care delivery systems.

Ongoing education, such as conferences, seminars, workshops, and inservices,

are required to remain current with new knowledge, technologies, and skills or to

establish ongoing clinical competencies. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model. Because the field of health care is becoming increasingly more complex and technical, no one individual can know everything about how best to provide safe and effective care, and no one degree can

provide the necessary knowledge needed to span an entire career. It is, therefore,

an essential expectation that nurses participate in lifelong learning and continued

competency (IOM, 2011). Lifelong learning is not only individual learning, but

also interprofessional, collaborative, and team-oriented learning. For example, using simulation and web training to educate nursing and medical students together

on roles and responsibilities, effective communication, conflict resolution, and

shared decision-making is expected to result in collaborative graduates ready to

work effectively in patient-centered teams. Further, the use of interprofessional

education is thought to foster collaboration in implementing policies, improving

services, and preparing teams to solve problems that exceed the capacity of any

one professional (IOM, 2011).

Nursing Research

Nursing research uses qualitative and quantitative systematic methods and an

EBP approach directed toward the study and improvement of patient care, care

systems, and therapeutic outcomes. Although it is commonly accepted that best

practices are based on decisions validated by sound, scientific evidence, in fact,

the rate at which current research is translated into nursing practice is often slow.

Many nurses are influenced to some extent by what is known as knowledge creep,

in which they gradually see the need to change practice based on limited research

and word of mouth (Pape & Richards, 2010). Creating structures and support

for nurses to use evidence in their clinical practice will help narrow this evidencepractice gap (Oman, Duran, & Fink, 2008). Nursing leaders need to support and

encourage proficiency in and use of nursing research to generate new knowledge,

inform practice, and promote quality patient outcomes. To accomplish this, the

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

40 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

organization needs to build a strong infrastructure through the development of

mentors, skills-building programs, financial support, computer access, and availability of research consultative services.

The JHNEBP Model—The Core

At the core of the Johns Hopkins Nursing EBP model is evidence. The sources

of evidence include both research and non-research data which inform practice,

education, and research. Research produces the strongest type of evidence to

inform decisions about nursing practice. However, because research evidence answers a specific question under specific conditions, outcomes may not always be

readily transferable to another clinical setting or patient population. Before translating research evidence into practice, nurses need to carefully consider the type

of research, consistency of findings, quantity of supporting studies, quality of the

studies, relevance of the findings to the clinical practice setting, and the benefits

and risks of implementing the findings.

In many cases, research relevant to a particular nursing practice question

may be limited. Consequently, nurses need to examine and evaluate other sources

of non-research evidence, such as clinical guidelines, literature reviews, recommendations from national and local professional organizations, regulations,

quality improvement data, and program evaluations. These, along with expert

opinion, clinician judgment, and patient preferences, are sources of non-research

evidence. Patient interviews, focus groups, and patient satisfaction surveys are all

examples of preference-related evidence. Patients are taking a more active role in

making decisions for their health care; therefore, clinicians need to discover what

patients want, help them find accurate information, and support them in making

these decisions (Krahn & Naglie, 2008). A patient’s values, beliefs, and preferences will also influence the patient’s desire to comply with treatments, despite

the best evidence.

Internal and External Factors

The JHNEBP Model is an open system with interrelated components. As an open

system, practice, education, and research are influenced not only by evidence, but

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 41

also by external and internal factors. External factors can include accreditation

bodies, legislation, quality measures, regulations, and standards. Accreditation

bodies (e.g., The Joint Commission, Commission on Accreditation of Rehabilitation Facilities) require an organization to achieve and maintain high standards of

practice and quality. Legislative and regulatory bodies (local, state, and federal)

enact laws and regulations designed to protect the public and promote access to

safe, quality health care services. Failure to follow these laws and regulations has

adverse effects on an organization, most often financial. Examples of regulatory

agencies include the Centers for Medicare and Medicaid Services, Food and Drug

Administration, and state boards of nursing. State boards of nursing regulate

nursing practice and enforce Nurse Practice Acts, which serves to protect the

public. Quality measures (outcome and performance data) and professional standards serve as yardsticks for evaluating current practice and identifying areas for

improvement or change. The American Nurses Credentialing Center, through its

Magnet Recognition Program®, developed criteria to assess the quality of nursing

and nursing excellence in organizations. Additionally, many external stakeholders such as health care networks, special interest groups/organizations, vendors,

patients and families, the community, and third-party payors exert influence on

health care organizations. Despite the diversity among these external factors, one

common trend is the expectation that organizations base their health care practices and standards on sound evidence.

Internal factors can include organizational culture, values, and beliefs;

practice environment (e.g., leadership, resource allocation, patient services,

organizational mission and priorities, availability of technology, library support);

equipment and supplies; staffing; and organizational standards. Enacting EBP

within an organization requires

■ A culture that believes EBP will lead to optimal patient outcomes

■ Strong leadership support at all levels with the necessary resource allocation (human, technological, and financial) to sustain the process

■ Clear expectations that incorporate EBP into standards and job descriptions

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

42 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

Knowledge and evaluation of the patient population, the health care

organization, and the internal and external factors are essential for successful

implementation and sustainability of EBP within an organization.

The JHNEBP Process: Practice Question, Evidence, and

Translation

The 18-step JHNEBP process (Appendix D) occurs in 3 phases and can be simply

described as Practice question, Evidence, and Translation (PET) (see Figure 3.3).

The process begins with the identification of a practice problem, issue, or concern. This step is critically important because how the problem is posed drives

the remaining steps in the process. Based on the problem statement, the practice

question is developed and refined, and a search for evidence is conducted. The evidence is then appraised and synthesized. Based on this synthesis, a determination

is made as to whether or not the evidence supports a change or improvement in

practice. If the data supports a change, evidence translation begins and the practice change is planned, implemented, and evaluated. The final step in translation

is dissemination of results to patients and families, staff, hospital stakeholders,

and, if appropriate, the local and national community.

Figure 3.3 The JHNEBP PET Process: Practice Question, Evidence, and Translation

(© The Johns Hopkins Hospital/The Johns Hopkins University)

Practice

Question Evidence Translation

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 43

Practice Question

The first phase of the process (steps 1–5) includes forming a team and developing

an answerable EBP question. An interprofessional team examines a practice concern, develops and refines an EBP question, and determines its scope. The Project

Management Guide (see Appendix A) should be referred to frequently throughout the process to direct the team’s work and gauge progress. The tool identifies

the following steps.

Step 1: Recruit Interprofessional Team

The first step in the EBP process is to form an interprofessional team to examine

a specific practice concern. It is important to recruit members for which the question holds relevance. When members are interested and invested in addressing

a specific practice concern, they are generally more effective as a team. Bedside

clinicians (or frontline staff) are key members because they likely have firsthand

knowledge of the problem, its context, and impact. Other relevant stakeholders

may include team members such as clinical specialists (nursing or pharmacy),

members of committees or ancillary departments, physicians, dieticians, pharmacists, patients, and families. These may provide discipline-specific expertise

or insights to create the most comprehensive view of the problem and, thus, the

most relevant practice question. Keeping the group size to 6–8 members makes it

easier to schedule meetings and helps to maximize participation.

Step 2: Develop and Refine the EBP Question

The next step is to develop and refine the clinical, educational, or administrative

EBP question. It is essential that the team take the necessary time to carefully

determine the actual problem (see Chapter 4). They need to identify the gap between the current state and the desired future state—in other words, between

what the team sees and experiences and what they want to see and experience.

The team should state the question in different ways and get feedback from

nonmembers to see if any agreement on the actual problem exists and if the question accurately reflects the problem. The time devoted to challenging assumptions

about the problem, looking at it from multiple angles and obtaining feedback

is always time well spent. Incorrectly identifying the problem results in wasted

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

44 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

effort searching and appraising evidence that, in the end, does not provide the

knowledge that allows the team to achieve the desired outcomes.

Additionally, keeping the question narrowly focused makes the search for evidence specific and manageable. For example, the question “What is the best way

to stop the transmission of methicillin-resistant staphylococcus aureus (MRSA)?”

is extremely broad and could encompass many interventions and all practice settings. In contrast, a more focused question is, “What are the best environmental

strategies for preventing the spread of MRSA in adult critical-care units?” This

narrows the question to environmental interventions, such as room cleaning;

limits the age group to adults; and limits the practice setting to critical care. The

PET process uses the PICO mnemonic (Sackett, Straus, Richardson, Rosenberg,

& Haynes, 2000) to describe the four elements of a focused clinical question:

(a) patient, population, or problem, (b) intervention, (c) comparison with other

treatments, and (d) measurable outcomes (see Table 3.3).

Table 3.3 Application of PICO Elements

Patient, population, or

problem

Team members determine the specific patient,

population, or problem related to the patient/population

under examination. Examples include age, sex,

ethnicity, condition, disease, and setting.

Intervention Team members identify the specific intervention

or approach to be examined. Examples include

interventions, education, self-care, and best practices.

Comparison with other

interventions, if applicable

Team members identify what they are comparing the

intervention to, for example, current practice or another

intervention.

Outcomes Team members identify expected outcomes based on

the implementation of the intervention. The outcomes

must include metrics that will be used to determine the

effectiveness if a change in practice is implemented.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 45

The Question Development Tool (see Appendix B) guides the team in defining the practice problem, examining current practice, identifying how and why

the problem was selected, limiting the scope of the problem, and narrowing the

EBP question using the PICO format. The tool also helps the team develop their

search strategy by identifying the sources of evidence to be searched and possible

search terms. It is important to recognize that the EBP team can go back and further refine the EBP question as more information becomes known as a result of

the evidence search and review. Refer to Chapter 4 for more details regarding the

development and refining of an EBP practice question.

Step 3: Define the Scope of the EBP Question and Identify Stakeholders

The EBP question may relate to the care of an individual patient, a specific population of patients, or the general patient population within the organization.

Defining the scope of the problem assists the team in identifying the appropriate

individuals and stakeholders who should be involved and kept informed during

the EBP project. A stakeholder can be defined as an individual or organization

that has an interest, personal or professional, in the topic under consideration

(Agency for Healthcare Research and Quality, 2011). Stakeholders may include a

variety of clinical and nonclinical staff, departmental and organizational leaders,

patients and families, insurance payors, or policy makers. Identifying and including appropriate EBP team members and keeping key stakeholders informed can

be instrumental to successful change. The team should consider whether the EBP

question is specific to a unit, service, or department, or if it involves multiple departments. If the latter, a much broader group of individuals need to be recruited

for the EBP team, with representatives from all areas involved. Key leadership in

the affected departments should be kept up-to-date on the team’s progress. If the

problem affects multiple disciplines (e.g., nursing, medicine, pharmacy, respiratory therapy), each discipline should also be included.

Step 4: Determine Responsibility for Project Leadership

Identifying a leader for the EBP project is a key success factor. The leader

facilitates the process and keeps it moving forward. The leader should be

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

46 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

knowledgeable about evidence-based practice and have experience and a proven

track record in leading interprofessional teams. It is also helpful if this individual

knows the organizational structure and strategies for implementing change within the organization.

Step 5: Schedule Team Meetings

Setting up the first EBP team meeting can be a challenge and includes activities

such as:

■ Reserving a room with adequate space conducive to group discussion

■ Asking team members to bring their calendars so that subsequent meetings can be scheduled

■ Ensuring that a team member is assigned to record discussion points and

group decisions

■ Keeping track of important items (e.g., copies of the EBP tools, extra paper, dry erase board, and so on)

■ Providing a place to keep project files

■ Establishing a timeline for the process

Evidence

The second phase (steps 6–10) of the PET process deals with the search for, appraisal of, and synthesis of the best available evidence. Based on these results, the

team makes recommendations regarding practice changes.

Step 6: Conduct Internal and External Search for Evidence

Team members determine the type of evidence to search for (see Chapter 5) and

who is to conduct the search and then bring items back to the committee for

review. Enlisting the help of a health information specialist (librarian) is critical.

Such help saves time and ensures a comprehensive and relevant search. In addition to library resources, other sources of evidence include: Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

■ Clinical practice guidelines

■ Quality improvement data

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 47

■ Position statements from professional organizations

■ Opinions of internal and external experts

■ Regulatory, safety, or risk management data

■ Community standards

■ Patient and staff surveys and satisfaction data

Step 7: Appraise the Level and Quality of Each Piece of Evidence

In this step, research and non-research evidence is appraised for level and quality.

The Research Evidence Appraisal Tool (see Appendix E) and the Non-Research

Evidence Appraisal Tool (see Appendix F) assist the team in this activity. Each

tool includes a set of questions to determine the type, level, and quality of evidence. The PET process uses a five-level scale to determine the level of the evidence, with level I evidence as the highest and level V as the lowest (see Appendix

C). Based on the questions provided on the tools, the quality of each piece of evidence is rated as high, good, or low-major flaws. The team reviews each piece of

evidence and determines both the level and quality. Evidence with a quality rating

of low-major flaws is discarded and not used in the process. The Individual Evidence Summary Tool (see Appendix G) tracks the team’s appraisal of each piece

of evidence, including the author, date, evidence type, sample, sample size, setting,

and study findings, that helps to answer the EBP question, limitations, level, and

quality. Chapters 6 and 7 provide a detailed discussion of evidence appraisal.

Step 8: Summarize the Individual Evidence

The team numerically sums the pieces (sources) of evidence that answer the

practice question for each level (I–V) and records the totals on the Synthesis and

Recommendations Tool (see Appendix H). The relevant findings that answer

the EBP question for each level are then written in summary form next to the

appropriate level.

Step 9: Synthesize Overall Strength and Quality of Evidence

Next, the team determines the overall quality for each level (I–V) and records

it on the Synthesis and Recommendations Tool (see Appendix H). Through

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

48 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

synthesis, the team makes a determination as to the overall strength and quality of the collected body of evidence, taking into consideration the: (a) level, (b)

quantity, (c) consistency of findings across all pieces of evidence, and (d) applicability to the population and setting. The team can use the quality criteria for

individual evidence appraisal as a guide for determining overall quality. Making

decisions about the overall strength and quality is both an objective and subjective process. The EBP team should devote the necessary time to thoughtfully

evaluate the body of evidence and come to agreement on the overall strength and

quality. Refer to Chapters 6 and 7 and Appendix I for more information on evidence synthesis.

Step 10: Develop Recommendations for Change Based on Evidence Synthesis

Based on the overall appraisal and synthesis of the evidence, the team considers

possible pathways to translate evidence into practice. A team has four common

pathways to consider when developing a recommendation (Poe & White, 2010):

■ Evidence may be compelling, with consistent results that support a

practice change

■ Evidence may be good, with consistent results that support a practice

change

■ Evidence may be good, but with conflicting results that may or may not

support a practice change

■ Evidence may be nonexistent or insufficient to support a practice change

Based on the selected translation pathway, the team then determines whether

to make the recommended change or investigate further (see Table 3.4). The

team lists its recommendations on the Synthesis and Recommendations Tool.

The risks and benefits of making the change should be carefully considered.

Initiating a change as a pilot study (with small sample size) to determine possible

unanticipated adverse effects is strongly recommended.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 49

Table 3.4 Translation Pathways for EBP Projects Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

Evidence

Compelling,

consistent

Good,

consistent

Good, but

conflicting

Insufficient/

absent

Make

recommended

change?

Yes Consider pilot

of change

No No

Need for further

investigation?

No Yes,

particularly

for broad

application

Yes, consider

periodic

review for new

evidence or

development

of research

study

Yes, consider

periodic

review for new

evidence or

development of

research study

Risk-benefit

analysis

Benefit clearly

outweighs risk

Benefit may

outweigh risk

Benefit may

or may not

outweigh risk

Insufficient

information

to make

determination

Reprinted from Poe and White, 2010

Translation

In the third phase (steps 11–18) of the process, the EBP team determines if the

changes to practice are feasible, appropriate, and a good fit given the target setting. If they are, the team creates an action plan, implements and evaluates the

change, and communicates the results to appropriate individuals both internal

and external to the organization.

Step 11: Determine Fit, Feasibility, and Appropriateness of Recommendation for

Translation Pathway

The team communicates and obtains feedback from appropriate organizational

leaders, bedside clinicians, and all other stakeholders affected by the practice

recommendations to determine if the change is feasible, appropriate, and a

good fit for the specific practice setting. They examine the risks and benefits of

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

50 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

implementing the recommendations. They must also consider the resources available and the organization’s readiness for change (Poe & White, 2010). Even with

strong, high-quality evidence, EBP teams may find it difficult to implement practice changes in some cases. For example, an EBP team examined the best strategy

for ensuring appropriate enteral tube placement after initial tube insertion. The

evidence indicated that x-ray was the only 100% accurate method for identifying

tube location. The EBP team recommended that a post-insertion x-ray be added

to the enteral tube protocol. Despite presenting the evidence to clinical leadership

and other organizational stakeholders, the recommendation was not accepted

within the organization. Concerns were raised about the additional costs and adverse effects that may be incurred by patients (appropriateness). Other concerns

related to delays in workflow and the availability of staff to perform the additional X-rays (feasibility). Risk management data showed a lack of documented

incidents related to inappropriate enteral tube placement. As a result, after weighing the risks and benefits, the organization decided that making this change was

not a good fit at that time.

Step 12: Create Action Plan

If the recommendations are a good fit for the organization, the team develops a

plan to implement the recommended practice change. The plan may include:

■ Development of (or change to) a protocol, guideline, critical pathway,

system or process related to the EBP question

■ Development of a detailed timeline assigning team members to the tasks

needed to implement the change (including the evaluation process and

reporting of results)

■ Solicitation of feedback from organizational leaders, bedside clinicians,

and other stakeholders

Essentially, the team must consider the who, what, when, where, how, and

why when developing an action plan for the proposed change.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 51

Step 13: Secure Support and Resources to Implement Action Plan

The team needs to give careful consideration to the human, material, or financial

resources needed to implement the action plan. Obtaining support and working

closely with departmental and organizational leaders can help to ensure the successful implementation of the EBP action plan.

Step14: Implement Action Plan

When the team implements the action plan, they need to ensure that all affected

staff and stakeholders receive verbal and written communication, as well as education about the practice change, implementation plan, and evaluation process.

EBP team members should be available to answer any questions and troubleshoot problems that may arise during implementation.

Step 15: Evaluate Outcomes

Using the outcomes identified on the Question Development Tool (see Appendix

B), the team evaluates the degree to which the outcomes were met. Although, of

course, the team desires positive outcomes, unexpected outcomes often provide

opportunities for learning, and the team should examine why these occurred.

This examination may indicate the need to alter the practice change or the implementation process, followed by re-evaluation. The evaluation should also be

incorporated into the organization’s quality improvement process when ongoing

measurement, evaluation, and reporting are indicated.

Step 16: Report Outcomes to Stakeholders

The team reports the results to appropriate organizational leaders, bedside

clinicians, and all other stakeholders. Sharing the results, both favorable and unfavorable, helps disseminate new knowledge and generate additional practice or

research questions. Valuable feedback obtained from stakeholders can overcome

barriers to implementation or help develop strategies to improve unfavorable

results.

Step 17: Identify Next Steps

EBP team members review the process and findings and consider if any lessons

have emerged that should be shared or if additional steps need to be taken.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

52 Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Second Edition

These lessons or steps may include a new question that has emerged from the

process, the need to do more research on the topic, additional training that may

be required, suggestions for new tools, the writing of an article on the process

or outcome, or the preparation of an oral or a poster presentation at a professional conference. The team may identify other problems that have no evidence

base and, therefore, require the development of a research protocol. For example,

when the recommendation to perform a chest X-ray to validate initial enteral

tube placement was not accepted (see the scenario discussed in step 11), the EBP

team decided to design a research study to look at the use of colormetric carbon

dioxide detectors to determine tube location.

Step 18: Disseminate Findings

This final step of the process is one that is often overlooked and requires strong

organizational support. The results of the EBP project, at a minimum, need to be

communicated to the organization. Depending on the scope of the EBP question

and the outcome, consideration should be given to communicating findings external to the organization in appropriate professional journals or through presentations at professional conferences.

Summary

This chapter introduces the JHNEBP Model and the steps of the PET process.

Nursing staff with varied educational preparation have successfully used this

process with mentorship and organizational support. They have found it very

rewarding both in understanding the basis for their current nursing interventions

and incorporating changes into their practice based on evidence (Newhouse,

Dearholt, Poe, Pugh, & White, 2005).

References

Agency for Healthcare Research and Quality. (2011). Engaging stakeholders to identify and

prioritize future research needs. Retrieved from http://www.effectivehealthcare.ahrq.gov/index.

cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=698

American Nurses Association. (2010). Nursing: Scope and standards of practice. Washington, DC:

Author.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview 53

American Nurses Credentialing Center. (2011). Announcing the model for ANCC’s magnet

recognition program. Retrieved from http://www.nursecredentialing.org/Magnet/

ProgramOverview/New-Magnet-Model.aspx

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC:

The National Academics Press.

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington,

DC: The National Academics Press.

Krahn, M., & Naglie, G. (2008). The next step in guideline development, incorporating patient

preferences. Journal of the American Medical Association, 300(4), 436-438.

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2009). Igniting a spirit

of inquiry: An essential foundation for evidence-based practice. American Journal of Nursing,

109(11), 49-52.

Newhouse, R., Dearholt, S., Poe, S., Pugh, L., & White, L. (2005). Evidence-based practice. Journal

of Nursing Administration, 35(1), 35-40.

Oman, K. S., Duran, C., & Fink, R. (2008). Evidence-based policy and procedure. Journal of

Nursing Administration, 38(1), 47-51.

Pape, T. M., & Richards, B. (2010). Stop “knowledge creep.” Nursing Management, 41(2), 8-11.

Poe, S. S., & White, K. M. (2010). Johns Hopkins nursing evidence-based practice: Implementation

and translation. Indianapolis, IN: Sigma Theta Tau International.

Porter-O’Grady, T. (1984). Shared governance for nursing: A creative approach to professional

accountability. Rockville, Maryland: Aspen Systems Corporation.

Reigle, B. S., Stevens, K. R., Belcher, J. V., Huth, M. M., McGuire, E., Mals, D., & Volz, T. (2008).

Evidence-based practice and the road to Magnet status. Journal of Nursing Administration, 38

(2), 97-102.

Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidencebased medicine: How to practice and teach EBM. Edinburgh: Churchill.

Wolf, G., Triolo, P., & Ponte, P. R. (2008). Magnet recognition program: The next generation.

Journal of Nursing Administration, 38(4), 200-204.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved.

Dearholt, S. L. D. D. (2012). Johns Hopkins Nursing Evidence-Based Practice. Indianapolis: Sigma Theta Tau International. Retrieved from

http://ebookcentral.proquest.com/lib/davuport-ebooks/detail.action?docID=3383920

Created from davuport-ebooks on 2017-03-13 09:55:13. Copyright © 2012. Sigma Theta Tau International. All rights reserved. Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) and the six sigma model

NURS 6050 Assignment: Agenda Comparison Grid and Fact Sheet or Talking Points Brief

Assignment: Agenda Comparison Grid and Fact Sheet or Talking Points Brief

It may seem to you that healthcare has been a national topic of debate among political leaders for as long as you can remember.

ORDER A PLAGIARISM-FREE PAPER HERE

Healthcare has been a policy item and a topic of debate not only in recent times but as far back as the administration of the second U.S. president, John Adams. In 1798, Adams signed legislation requiring that 20 cents per month of a sailor’s paycheck be set aside for covering their medical bills. This represented the first major piece of U.S. healthcare legislation, and the topic of healthcare has been woven into presidential agendas and political debate ever since. NURS 6050 Assignment: Agenda Comparison Grid and Fact Sheet or Talking Points Brief

As a healthcare professional, you may be called upon to provide expertise, guidance and/or opinions on healthcare matters as they are debated for inclusion into new policy. You may also be involved in planning new organizational policy and responses to changes in legislation. For all of these reasons you should be prepared to speak to national healthcare issues making the news.

In this Assignment, you will analyze recent presidential healthcare agendas. You also will prepare a fact sheet to communicate the importance of a healthcare issue and the impact on this issue of recent or proposed policy.

The Assignment: (1- to 2-page Comparison Grid, 1-Page Analysis, and 1-page Fact Sheet)

Part 1: Agenda Comparison Grid

Use the Agenda Comparison Grid Template found in the Learning Resources and complete the Part 1: Agenda Comparison Grid based on the current/sitting U.S. president and the two previous presidential administrations and their agendas related to the public health concern you selected. Be sure to address the following:

· Identify and provide a brief description of the population health concern you selected and the factors that contribute to it. NURS 6050 Assignment: Agenda Comparison Grid and Fact Sheet or Talking Points Brief

· Describe the administrative agenda focus related to the issue you selected.

· Identify the allocations of financial and other resources that the current and two previous presidents dedicated to this issue.

· Explain how each of the presidential administrations approached the issue.

(A draft of Part 1: Agenda Comparison Grid should be posted to the Module 1 Discussion Board by Day 3 of Week 1.)

Part 2: Agenda Comparison Grid Analysis

Using the information you recorded in Part 1: Agenda Comparison Grid on the template, complete the Part 2: Agenda Comparison Grid Analysis portion of the template, by addressing the following:

· Which administrative agency would most likely be responsible for helping you address the healthcare issue you selected?

· How do you think your selected healthcare issue might get on the agenda for the current and two previous presidents? How does it stay there?

· Who would you choose to be the entrepreneur/ champion/sponsor of the healthcare issue you selected for the current and two previous presidents? NURS 6050 Assignment: Agenda Comparison Grid and Fact Sheet or Talking Points Brief

Part 3: Fact Sheet or Talking Points Brief (THIS PART IS NEEDED)

Based on the feedback that you received from your colleagues in the Discussion, revise Part 1: Agenda Comparison Grid and Part 2: Agenda Comparison Grid Analysis.

Then, using the information recorded on the template in Parts 1 and 2, develop a 1-page Fact Sheet or Talking Points Brief that you could use to communicate with a policymaker/legislator or a member of their staff for this healthcare issue. You can use Microsoft Word or PowerPoint to create your Fact Sheet or Talking Point Brief. Be sure to address the following:

· Summarize why this healthcare issue is important and should be included in the agenda for legislation.

· Justify the role of the nurse in agenda setting for healthcare issues. NURS 6050 Assignment: Agenda Comparison Grid and Fact Sheet or Talking Points Brief

Building a Health History

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

ORDER A PLAGIARISM-FREE PAPER HERE

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following new patients:

·        76-year-old Black/African-American male with disabilities living in an urban setting

·        Adolescent Hispanic/Latino boy living in a middle-class suburb

·        55-year-old Asian female living in a high-density poverty housing complex

·        Pre-school aged white female living in a rural community Building a Health History

·        16-year-old white pregnant teenager living in an inner-city neighborhood

To prepare:

With the information presented in Chapter 1 in mind, consider the following:

·        How would your communication and interview techniques for building a health history differ with each patient?

·        How might you target your questions for building a health history based on the patient’s age, gender, ethnicity, or environment?

·        What risk assessment instruments would be appropriate to use with each patient?

·        What questions would you ask each patient to assess his or her health risks?

·        Select 
one
 patient from the list above on which to focus for this Discussion.

·        Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration. Building a Health History.

·        Select 
one
 of the risk assessment instruments presented in Chapter 1 or Chapter 26 of the course text, or another tool with which you are familiar, related to your selected patient.

·        Develop 
at least five
 targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

Post a 1 page paper APA format
 1.
a description of the interview and communication techniques you would use with your selected patient.

2.
Explain why you would use these techniques.

3
Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient.

4
Provide at least five targeted questions you would ask the patient. Building a Health History

Readings

·        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.

o   Chapter 1, “The History and Interviewing Process” (pp. 1–21)

This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

o   Chapter 26, “Recording Information” (pp. 616–631)

This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

·        Sullivan, D. D. (2012). 
Guide to clinical documentation
 (2nd ed.). Philadelphia, PA: F. A. Davis.

o   Chapter 1, “Medicolegal Principles of Documentation” (pp. 1–12 and abbreviations, pp. 18)

o   Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–36) Building a Health History

·        Deeks, A., Lombard, C., Michelmore, J., & Teede, H. (2009). The effects of gender and age on health related behaviors. 
BMC Public Health
,
 
9
, 213–220.

Retrieved from the Walden Library databases.

This article describes a study that sought to determine the effects of gender and age on health-related behaviors. In the study, the authors also investigated the effects of screening practices, health beliefs, and perceived future health needs.

·        Delpierre, C., Lauwers-Cances, V., Datta, G. D., Berkman, L., & Lang, T. (2009). Impact of social position on the effect of cardiovascular risk factors on self-rated health. 
American Journal of Public Health
, 
99
(7), 1278–1284.

Retrieved from the Walden Library databases.

This study assessed the influence of education level on the association between self-rated health and cardiovascular risk factors. The authors explain their methods and results, and they provide recommendations for similar studies in different countries and cultures.

·        Lee, D. W., Neumann, P. J., & Rizzo, J. A. (2010). Understanding the medical and nonmedical value of diagnostic testing. 
Value in Health
, 
13
(2), 310–314.

Retrieved from the Walden Library databases.

The authors of this article detail their attempts to develop a framework for defining the potential value of diagnostic testing. The authors also discuss the implications of their framework for health care delivery systems.

·        University of Michigan Medical School. (2003). 
Geriatric functional assessment
.

Retrieved from 
http://www.med.umich.edu/lrc/coursepages/m1/HGD/GeriatricFunctionalAssess.pdf

This article provides an exercise that emphasizes accurate functional status assessments and effective communication with older patients. The authors recommend tools and techniques to be used when caring for older patients.

Note about Uploading Media:

Please refer to the 
Kaltura Media Uploader
 page located in the course navigation menu.. The documents on this page provide guidance on how to upload media for your Health Assessment Videos assignments for this course.

Optional Resources

·        LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). 
DeGowin’s diagnostic examination
(9th ed.). New York, NY: McGraw- Hill Medical. Building a Health History

o   Chapter 2, “History Taking and the Medical Record” (pp. 15–33)

Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal

Abstract

A research proposal will be conducted to determine if implementing a heart failure program within the hospital will reduce 30-day readmission rates. Medicare is cutting reimbursements to the hospital for readmissions that occur within 30 days.  Implementing an intervention to reduce readmissions using the Iowa model of evidence based practice to promote quality care will be done.  A literature review determined that many organizations implemented a strategy to reduce 30 day readmissions and were successful.  A pilot study will be implemented within the organization to see if enrollment in a heart failure program reduces 30-day readmission rates.  A retrospective analysis will be compared to the pilot study to determine the outcome. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal
 

ORDER A PLAGIARISM-FREE PAPER HERE

Research Proposal

The purpose of this paper is to conduct a research proposal using the Iowa Model of Evidence Based Practice to Promote Quality Care.  My research question is “Do heart failure patients that participate in heart failure programs see a reduced rate of 30-day readmissions?”  Pending the results of the research question, the change will take place at an organizational level.  The Iowa Model of Evidence Based Practice to Promote Quality Care is the change model that will be used to implement this research question.  “The Iowa Model has been revised to focus on implementation of evidence based practice at the organizational level” (Schaffer, Sandau, & Diedrick, 2012, p. 1202).  According to White and Spruce (2015), “Nurses find the Iowa Model intuitively understandable and it has been used in numerous academic settings and health care organizations” (p. 52).  There are multiple steps in the Iowa Model that a team must address to fully implement their research question.  This paper will propose a research to be conducted to determine if finding an intervention to prevent heart failure 30-day readmissions provides higher quality of care and decreased costs for the hospital as an organization.

Statement of the Problem

President Obama passed the Affordable Care Act in March 2010.  “This act penalizes hospitals with a high rate of patient readmission within 30 days of discharge with heart failure as the diagnosis” (Hobbs, Escutia, Harrison, Moore, & Sarpong, 2016, p. 145).  “Estimated costs of these 30-day readmissions in Medicare beneficiaries are in excess of $1 billion each year” (Banoff, Milner, Rimar, Greer, & Canavan, 2016, p. 172).  What can be done to help reduce the rates of readmissions?  “Heart failure is the most frequent reason for rehospitalization among cardiac patients; the current readmission rate for patients with heart failure is 40%” (Hobbs, Escutia, Harrison, Moore, & Sarpong, 2016, p. 145).  For Medicare patients alone, the 30-day readmission rate ranges between 22%-25%.  By 2030, it is estimated that heart failure will annually cost health care $70 billion (Hobbs et al., 2016).  If a hospital has a heart failure readmission rate above the national average, Medicare reduces reimbursement by 1% but it will gradually increase to reducing reimbursement by 3%.  This may appear to be a small percentage but annually heart failure readmissions can cost Medicare about $2 billion (Centrella-Nigro et al., 2016).  If the hospital is able to reduce the readmission rates of heart failure by implementing an intervention such as higher quality post discharge education or a heart failure program, then they can save money by reducing the rate of readmissions.   A heart failure program would be able to offer a range of services that would help the heart failure population avoid preventable readmissions by ensuring health care continuity and promoting the safe transfer of patients from hospital to home.  “One of the most effective methods to reduce costs caused by readmission is for healthcare providers to contact patients after discharge by telephone” (Hobbs, Escutia, Harrison, Moore, & Sarpong, 2016, p. 146).  A study was done that showed a lower rate of readmissions within 30 days just by telephoning the patient post discharge (Hobbs et al., 2016).  This telephone call to the patient could reiterate heart failure discharge education, evaluation of signs and symptoms, medication compliance, diet, weight control and support reassurance (Hobbs et al., 2016).   A nurse in the cardiology clinic or in the cardiac rehabilitation center can place the phone call to the patient.  Every day, the nurse can receive a computerized print out of recent heart failure discharges and then place phone calls out to the patients to see if they have any questions since discharge or if they are experiencing any symptoms.  The heart failure program would start at time of discharge by having the Pharmacist or medication technician review the discharge medication reconciliation to ensure that the patient is on the correct heart failure medications as determined by the guidelines of the Heart Failure Society of America.  Hospitals that implemented a higher quality discharge education with heart failure patients showed a reduced 30-day readmission rate.  A study done using heart failure discharge resources showed a 30-readmission rate of 5% when compared to 13% when using usual discharge protocol (House, Stephens, Whiteman, Swanson-Biearman, & Printz, 2016).  Another study that implemented core measures upon discharge showed an improvement in 30-day heart failure readmission rates by 2% (Gunadi et al., 2015).  Implementing a heart failure program that uses healthcare providers to contact the patients early on post discharge prior to any hospital follow up will help reduce heart failure readmissions and should be implemented.  This will financially affect the hospital if an intervention isn’t put into place.  Since the topic is financial data driven and a process improvement, it is considered to be a problem-focused trigger (White & Spruce, 2015).  This is important information to know on why a possible heart failure program would be a great intervention to reduce heart failure 30-day readmissions.  Not implementing an intervention to reduce the number of heart failure patients can affect the organization as a whole and associated with a cost factor so it would be considered a higher priority. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal

Forming a Team

An organization is composed of hundreds and sometimes thousands of employees.  Finding the right members for a research team is important because the research team is responsible for finding the best solution for that specific research proposal.  The members should have some type of relevance to the research.  “The composition of the team should be directed by the chosen topic and include all interested stakeholders” (Doody & Doody, 2011, p.662).  Since this research is focused on heart failure readmissions, possible team members would be the following: cardiologist, cardiac rehabilitation nurses, cardiac rehabilitation aide, pharmacist, telemetry nurse manager, cardiac step down nurses, dietitian, primary care physician, and/or social workers.  All these team members have direct contact with heart failure patients prior to admission, during admission, or post discharge.  Having a wide range of specialty areas will give the research different points of view.  “It is important to remember that including representatives for all personnel involved is the most successful approach to implementing evidence based practice because change is more successful when initiated by the personnel affected, rather than imposed by management personnel” (White & Spruce, 2015, p.55). Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal

Evidence Retrieval

Gathering evidence and research is the next step in the Iowa Model.  “The most important portion of this step is to form a good question (using the PICOT method) and then conduct a literature search for actual research studies that pertain to the question at hand” (Brown, 2014, p. 157-158).  A medical librarian can assist in the search, as well as using electronic databases like Medline, Cochrane, and/or Cinahl.  Clinical practice guidelines can also be used to search for the best available evidence.  The American Heart Association may have guidelines related to heart failure practice standards that should be implemented into the intervention as well.

Literature Review

            Methodology.

An electronic literature search was done using various databases to find pertinent journal articles, case studies, and/or reports that shed light on preventing heart failure readmission.  Proquest and CINAHL databases were used to search English, full-text, United States sources.  Key terms used to guide the search were heart failure, heart failure readmission rates, preventing heart failure readmissions, and heart failure programs.  The search provided over 10,000 journal articles.  Titles and abstracts were first reviewed to determine the significance to the topic being searched.  Articles that were published between 2010-2016 were included in search criteria.  The search didn’t produce much research pertaining to heart failure programs itself so the search was widened to include any type of professional interventions with heart failure patients done to reduce heart failure readmissions using the key words heart failure readmission prevention strategies.  The final sources were chosen based on if they discussed implementation of some of intervention that helped reduced heart failure readmission rates.

Grading the Evidence

All studies will have to be critiqued to ensure that the study is scientifically sound.  “Quantitative data is based on the process of deduction, hypothesis testing and objective methods in order to control phenomena with its focus on theory testing and prediction” (Doody & Doody, 2011, p. 662).  The research team will have to grade each article on its strength, weaknesses, sample size, region research was conducted, reliability, & validity, and risk-benefit ratio.  The team can decide for themselves how they want to go about grading the evidence (teams, singles, or together). With this particular research proposal, there aren’t many risks to the patients because chart review and implementation of an intervention that will possibly benefit their health will be conducted which will not cause harm to the patient. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal

Discussion.

A total of six sources were collected for the literature review that discussed reducing heart failure readmission and different strategies used and implemented within that study.  The literature review came up with many different strategies and techniques that are used to help prevent heart failure readmissions.  Two sources are systematic reviews (Hines et al., 2010; Hobbs et al., 2016) that examined multiple interventions that were done at various sites to prevent heart failure hospital readmissions.  One source is a national cross-sectional study that examined 594 hospitals that reported implementing key practices to reduce readmission rates (McClintock, Mose, & Smith, 2014). The fourth is a case study (Gunadi et al., 2015) that examined a pharmacy led intervention to reduce the heart failure readmission rate.  A quality improvement design (Kreifels & Tracy, 2016) was used to implement a heart failure management program to reduce heart failure readmission and the final source is a multi-site descriptive retrospective study (Centrella-Nigro et al., 2016) that examined six Magnet-designated hospitals and their methods implemented at reducing heart failure readmissions.

Multi-disciplinary intervention.

A multi-disciplinary approach was used in multiple sources (Hines et al., 2010; Hobbs et al., 2016; McClintock et al., 2014) that focused on telephone follow up calls, timely follow up appointments, and/or transitioning the patient from discharge to home and ensuring that home health care needs were addressed prior to discharge.  Hines et al. (2010) “Ideal transition to the home environment for patient with heart failure reduced 30-day readmission rates from 15% to 6%.  This consisted of identifying the patient’s needs and communicating and educating the family and patient on the patient’s care plan and making sure that the patient had a hospital follow up appointment made prior to being discharged.  According to McClintock et al. (2014) hospital readmissions were decreased by “14%-87% by incorporating outpatient interventions such as case management, tele-monitoring, home health, or heart failure clinics” (p. 431).  Patients in this study “Reported receiving education about salt restriction and exercise and adhering to the low-salt diet for a mean of 4.9 days and exercising for a mean off 2.2 of 7 days” (McClintock et al., 2014, p. 431) so it’s “critical to have a follow up appointment within days after hospital discharge”.  Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal .However, given this data McClintock et al. (2014) didn’t report any statistical data that would confirm their findings that an early follow up reduces hospital readmission rates for heart failure patients.  Hobbs et al. (2016) evaluated reviews of heart failure patients by telephone follow up calls with five of their sources and all found a decrease in hospital readmissions.  A small sample study was done in a rural Midwest location that utilized a heart failure management program (Kreifels & Tracy, 2016).  The program followed the American Heart Association and Institute for Health Care Improvement guidelines for heart failure management and nurses gave educational sessions to patients, explained the heart failure program, and scheduled hospital follow up within 72 hours to 7 days of discharge (Kreifels & Tracy, 2016).  There were no heart failure readmissions during the 12-week implementation of this program.

Pharmacy led intervention.

A pharmacy led intervention was done to see if there was improvement in heart failure readmission rates by revising a patient’s medication list and assuring that the patient was being discharged on the correct medications.  Gunadi et al. (2015) did a case study by having a pharmacist and two medication reconciliation technicians review a patient’s medications within 48 hours of admission and then again at discharge to assure “medication appropriateness and dosing, therapeutic duplications, omissions, and drug-drug interactions” (p. 1150).  Each patient was given a readmission complexity score that was based off of the following criteria: previous hospital readmission in past 6 months, ED visit within last 30 days, serum creatinine consistently above 1.5mg/dL, glucose consistently above 200mg/dL, change in functional status, presence of co-morbidities, and use of 7 or more medications (Gunadi et al., 2015). Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal. One point was given for each criteria met and the pharmacist would prioritize their patients based off the patients with the highest score.  The study showed a decrease in readmission rates from 17% to 15% but the hospital also increased their core measures compliance.  There was no statistical analysis done to determine validity or reliability.

Retrospective analysis.

A retrospective analysis was done to determine if physiologic, demographic, and/or psychosocial factors were associated with 30-day readmission rates for heart failure patients by examining electronic charts (Hobbs et al., 2016).  Thirty-seven different variables were examined against 30-day hospital readmission rates among six hospitals.  “Kendall’s Tau-b correlational statistic was used to compare the data” (Hobbs et al., 2016, p165).   This study resulted in that determining demographic, physiologic, and psychologic factors weren’t beneficial in determining which interventions are best to prevent heart failure readmissions.

Conclusion of literature review.

Limitations in this particular study were that not all resources used showed validity or reliability in their findings. Further research can determine if one specific intervention has a greater impact on reducing heart failure readmission rates.  More research can be reviewed when using a larger team.

Implementing the Evidence

This is the step where the team will have to decide if they are going to implement the change into practice.  Doody and Doody (2014) stated “The following criteria should be considered when determining whether research can be implemented into practice: (a) consistent findings exist from numerous studies to support the change, (b) the type and quality of the studies, (c) the clinical relevance of the findings, (d) the number of studies with similar sample characteristics, (e) the feasibility of the findings in practice, and (f) the risk-benefit ratio” (p.158).  If the majority of the criteria is met, then the team should plan to implement the change using a pilot practice.  The team will develop standards for their research question that will be used when implementing their pilot practice.  The studies that were reviewed for this proposal were consistent in the aspect that implementing some form of intervention for heart failure patients upon admission and/or discharge did prove to have a reduction in 30-day readmissions.  Not all resources reviewed were high quality because the majority of studies did not provide validity and reliability factors regarding their research.  The evidence provided by these studies is relevant for our research proposal because it’s guiding the team with various strategies that could possibly be implemented as an intervention to reduce heart failure readmissions.  All studies had similar sample characteristics because all the studies reviewed used heart failure admission/discharge patients as their participants.

Pilot Practice

In this step, the study question will be implemented into a pilot practice.  It shouldn’t involve the entire organization but for the sake of this specific research question on heart failure it will end up involving the organization because it isn’t possible to just implement the study in one unit or one department.  To see a change, the team will have to conduct an organizational pilot practice.  “The Iowa Model’s Implementation Guide suggests the following implementation strategies: create awareness, build knowledge and commitment, promote action and adoption, and pursue integration and sustained use” (White & Spruce, 2015, p. 55).  It’s important to gain acceptance across the entire organization. “This can be done through in-service education, audit, and feedback provided by team members.  The evidence needs to be diffused and should focus on its strengths and perceived benefits” (Doody & Doody, 2011, p. 663).  Patients that are going to be admitted with heart failure can be placed on one specific unit (cardiac step down or telemetry).  The pilot study can use the pharmacist on that unit to review medications on admission and on discharge to ensure that all heart failure patients are on the correct medications.  The primary care provider can ensure that the correct diagnostics lab work and tests have been ordered and if they are unsure than a cardiologist should be consulted.  A social worker should also evaluate the patient’s homecare needs upon discharge to see if home assistance or supplies will be needed after discharge. An example would be that a patient needs assistance with their mediations because they are noncompliant or needs transportation to their hospital follow up appointment.   Upon discharge, the unit secretary can all the patient’s primary care provider and/or the patient’s established cardiologist to make a hospital follow up appointment for the patient within seven days of discharge. The discharge nurse will also supply educational heart failure handouts and educate the patient and family member on heart failure symptoms to watch for, importance of medication compliance, special diet, daily weights, smoking cessation, and when to call the doctor or report to the emergency department.  Each day, the cardiac rehabilitation nurse will receive a computerized print out that will give the previous day’s heart failure patient discharge list.  This list can be generated by narrowing the patients that were discharged by their ICD 10 code for heart failure.  The cardiac rehabilitation nurse can make a phone call out to the patient to see how they are feeling since they’ve been discharge.  If the patient has any questions this is the time when the nurse will be able to assist them.  If the nurse is questioning the patient’s symptoms or doesn’t know the best solution for the patient’s problem she can contact the patient’s primary physician or their cardiologist and see what they recommend. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal

Ethical Consideration

Risks 

“The principle of minimizing risks and balancing risks and benefits is one of the most important components of the protection of research subjects and is included in all the major international research ethics guidelines” (Gufenas, 2006).  There won’t be any risks to patients directly because the research won’t directly affect patients.  The patient’s right to self-determination won’t come into effect because the patient isn’t actively participating in the study.  There will be a suggestion for participation in the heart failure program but it’s completely voluntary and will be part of the physician’s orders for better health care.  One could say that it’s a type of coercion because the role a physician plays over a patient.  The physician will order the heart failure program for the patient upon discharge just like a physician would order physical therapy or other rehabilitation.  No coercion is used.  There is a possibility that some of the participants may be of a vulnerable population.  Pregnant women, persons with cognitive impairment, and persons confined to institutions are all possible participants.  According to Grove, Gray, & Burns (2015), “The use of persons with diminished autonomy as research subjects is more acceptable if the following are true: (1) the research is therapeutic—that is, the subjects might benefit from the experimental process; (2) researchers are willing to use vulnerable and nonvulnerable people as subjects; (3) the risk is minimized in the study; and (4) the consent process is strictly followed to ensure the rights of the prospective subjects”.  In this specific research, the retrospective review of charts will be done (this will not harm or violate any patient rights) and also current medical record review Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal.  Patients will have the right to participate in the heart failure program and it will be ordered by their physician but strictly voluntary.  There won’t be any risk of permanent damage, unusual levels of discomfort, or even temporary discomfort.

HIPAA Concerns

This research will be done within a health care organization.  All researchers that are participating in the research will be bound by HIPAA regulations within the hospital setting.  Initially deidentification measures were going to be used which but researchers will need the admission and discharge dates which eliminates this option.  “De-identification is a helpful concept, but de-identifying is difficult, because HIPAA requires the elimination of 18 separate elements that could be used to identify the individual-including name, address, social security number, birth date, admission and discharge dates, and zip code” (Lebowitz, 2005).  However, upon every admission the hospital does have the patient sign a consent and authorization to disclose health information with the hospital setting.  Since the researchers will be within the hospital setting a HIPAA should not be violated.  HIPAA will also not be violated with the results of the research because patient’s identification won’t ever be disclosed.  The only disclosure from this research will be the relationship of heart failure readmissions without enrollment in a heart failure program and heart failure readmissions with enrollment in a heart failure program. Patient identity will never be disclosed. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal.

Informed Consent Components

“Informed consent is a process that protects human subjects and allows for voluntary, autonomous authorization by individuals who participate in clinical research” (Judkins-Cohn, Kielwasser-Withrow, Owen, & Ward, 2014, p.36).  The patients aren’t actively participating in this research and their identity will never be disclosed so informed consent won’t be needed.  The research is strictly a chart review that is examining data reports generated from those chart reviews. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal According to Kaczorowski, Sellors, Lemelin, & Hogg (2001), informed consent is not needed for chart reviews.

Evaluation

Once the research has been implemented and is in action there has to be constant evaluation.  Staff members should feel comfortable on giving their feedback on the pilot practice.  “The team members should be watching for deviation in practice or a decrease in the patient outcomes” (Brown, 2014, p. 158-159.)  Team members should compare baseline data with data after the implementation took effect to see if there is a significant change and to see if evidence contributed to positive patient outcomes (Spruce & White, 2015).  Barriers in the use of the implementation will have to be addressed to ensure that all staff feel confident with the change.  Since this research is looking at a 30-day readmission rate it may have the sleep effect; “benefits may only become apparent after a considerable period of time” (Doody & Doody, 2011, p. 664).  Various interventions were done with heart failure patients post hospital discharge.  Heart failure programs weren’t identified specifically but incorporating an intervention with heart failure patients between admission, discharge, or outpatient proved to show success rates in reducing 30-day heart failure readmission rates. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal.  When the intervention is in place, any heart failure patient that is admitted to be tagged to determine if they are a 30-day readmission.  If they are a 30-day readmission, then their chart will be reviewed to determine what failed.  Maybe the patient never answered when their discharge follow-up call was placed and the nurse never was able to assess the situation, the patient didn’t make their hospital follow up appointment with their doctor, or all discharge needs weren’t met.  The patient will also be interviewed in a non-interrogation way during the admission process to find out more of their health history to see if their readmission could have been prevented and then the team can brainstorm solutions on how to fix that problem for the future.  The intervention can be ongoing with critiques and alterations made by the research team to that best meet patient and healthcare needs.  Employees can be made aware of this new process by way of email, reiterated in departmental meetings, and also a competency to determine they understand why it’s being implemented.  It’s important that all staff is made aware of these changes because staff float from unit to unit and there needs to be a consistency of care in case nurses are floated to the pilot unit.

Conclusion

A heart failure discharge intervention does need to be implemented to help reduce 30-day readmissions.  From the studies that were reviewed there are different strategies that can be implemented within an organization to reduce the readmission rate.  The research team will use the Iowa model to implement this change.  The Iowa Model of Evidence-Based Practice to Promote Quality Care is a great change model to implement a change within an organization.  “The model considers input from the entire organizational system, including patient, providers, and organizational infrastructure, and involves nurses in each of the steps and also allows a practice change before final implementation” (Schaeffer et al., 2012, p. 1202).  There is a sequence of steps that make it easy for all team members to follow.  The Iowa Model will be able to help the organization implement clinical practice guidelines.  With the help of the entire research team, employees being made aware of the change and reasons behind the change, a successful intervention can take place.

 

References

Banoff, K. M., Milner, K., Rimar, J., Greer, A. E., & Canavan, M. (2016, July-August). Assessment of a novel tool for identifying hospitalized patients with heart failure at risk for 30-day readmission, high cost, and longer length of stay.
Nursing Economic
$,
34
(4), 172-181. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal

Brown, C. (2014, April). The iowa model of evidence-based practice to promote quality care: An illustrated example in oncology nursing.
Clinical Journal of Oncology Nursing
,
18
(2), 157-159.

Centrella-Nigro, A., Bognar, L., Burke, K., Faber, K., Flynn, V., Laforgia, M., & Wiklinski, B. (2016, May-June). The readmitted patient with heart failure.
Medsurg Nursing
,
25
, 163-167.

Doody, C. M., & Doody, O. (20
11
). Introducing evidence into nursing practice: using the iowa model.
British Journal of Nursing
, 11, 661-664.

Grove, S. K., Gray, J. R., & Burns, N. (2015).
Understanding nursing research: Building an evidenced-based practice
(6 ed.). St. Louis, MO: Elsevier Saunders.

Gefenas, E. (2006). The concept of risk and responsible conduct of research.
Science and Engineering Ethics
,
12
, 75-83.

Gunadi, S., Upfield, S., Pham, N., Yea, J., Schmiedeberg, M. B., & Stahmer, G. D. (2015, July 1). Development of a collaborative transitions-of-care program for heart failure patients.
American Society of Health-System Pharmacists, Inc
,
72
, 1147-1152.

Hines, P. A., Yu, K., & Randall, M. (2010, March-April). Preventing heart failure readmissions: Is your organization prepared?
Nursing Economics
,
28
, 74-86.

Hobbs, J. K., Escutia, D., Harrison, H., Moore, A., & Sarpong, E. (2016, May-June). Reducing hospital readmission rates in patients with heart failure.
Medsurg Nursing
,
25
, 145-152.

Judkins-Cohn, T. M., Kielwasser-Withrow, K., Owen, M., & Ward, J. (2014). Ethical principles of informed consent: Exploring nurses’ dual role of care provider and researcher.
The Journal of Continuing Education in Nursing
,
45
, 35-42.

Kaczorowski, J., Sellors, J., Lemelin, J., & Hogg, W. (2001, August 21). The ethics of anonymous chart reviews/The authors respond.
Canadian Medical Association Journal
,
165
, 399-401.

Kreifels, E., & Tracy, M. (2016). Chronic heart failure management in rural primary care.
Journal of Doctoral Nursing Practice
,
9
, 20-28.

Lebowitz, P. (2005, June 2005). Protecting privacy and encouraging research.
Pharmaceutical Executive, suppl. Successful Clinical Trials Management
,
10
, 12-15.

McClintock, S., Mose, R., & Smith, L. F. (2014, June). Strategies for reducing the hospital readmission rates of heart failure patients.
The Journal for Nurse Practitioners
,
10
, 430-433.

Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2012, July). Evidence-based practice models for organizational change: Overview and practical applications.
Journal of Advanced Nursing
, 69, 1197-1209.

White, S., & Spruce, L. (2015). Perioperative nursing leaders implement clinical practice guidelines using the iowa model of evidence-based practice.
AORN Journal
, 50-56. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal

Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project

Evidence-Based Practice Model Selection

Evidence-based practice (EBP) is a process of taking knowledge and converting it into the delivery of care (Schaffer, Sandau, & Diedrick, 2013).  Most nurses know that EBP improves the quality of patient care in a cost-effective manner.  Most nurses want to base their patient care decisions on the best evidence available (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012).  It takes more than this knowledge and desire, however, to implement EBP into clinical nursing practice.  Multiple barriers exist that make the realization of EBP challenging.  These roadblocks include inadequate financial support, limited resources, inadequate computer skills, dissatisfaction with supervisors’ assistance in participating in EBP, absence of an academic degree, and unclear and unrealistic workplace goals (Kajermo et al., 2008; Melnyk et al., 2004).  More recently, Melnyk et al. (2012) identified other barriers such as lack of education, inadequate access to information, and time to implement and use EBP.  In 2001, the Institute of Medicine estimated that translating research evidence into clinical practice takes over 17 years.  Even 13 years later, the process is lengthy and full of hurdles (Brown, 2014).  Evidence-based practice models are tools that health care organizations can use to overcome the challenges. Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project

ORDER A PLAGIARISM-FREE PAPER HERE

Evidence-Based Practice Model Selected

Multiple theoretical models have been developed to help turn research discoveries into clinical practice and assist organizations to implement evidence-based practice into their routines. In organizational settings, leadership must decide which evidence-based changes to make and how to do it.  These models present a methodical approach and break the complex process into smaller steps.  Using these models enhances the chance of success, promotes complete implementation, improves resource allocation, and provides a mechanism to evaluate outcomes (Schaffer, Sandau, & Diedrick, 2013).

The Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2002) is one such conceptual model that has been used in numerous academic and organizational settings to facilitate the implementation of EBP (Gawlinski & Rutledge, 2008).  Multiple facilities have documented its success and value.  The Iowa Model utilizes an algorithm with decision points and feedback loops (Schaffer, Sandau, & Diedrick, 2013).  Within the algorithm is a feedback mechanism that helps question current practices and determine if evidence exists that can improve those practices.  The model can focus efforts based on either observed problems or new knowledge (White & Spruce, 2015). Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project

After reviewing other EBP models, the Iowa Model was chosen as the best way to explore new triage methods that could improve patient flow through the emergency department.  Many reasons support this decision.  First, the Iowa Model works well with organizational change (White & Spruce, 2015).  Second, it focuses on an interdisciplinary approach.  The Iowa Model uses input from a team that represents the system in question and collaborates to implement EBP (Schaffer, Sandau, & Diedrick, 2013).  Emergency department processes involve multiple disciplines that work closely together- physicians, nurses, ancillary departments, and administration.  A model that depends on the collaboration of many is a logical choice.  Third, Gawlinski and Rutledge (2008) describe the Iowa model as being intuitively understandable or, in other words, user-friendly.  Finally, the Iowa model is attractive because it allows a trial run of the proposed change before final implementation (White & Spruce, 2015).

The Iowa Model and Improving Emergency Department Patient Flow

Applying the Iowa Model will facilitate the implementation of an evidence-based triage system in the emergency department.  The algorithm in the model has three decision points.  The first decision point is to determine whether the topic is a priority for the organization.  Some topics are triggered by knowledge while some are triggered by problems.  Implementing a new, evidence-based triage model is a priority for the organization, which has been brought to light because of the emergency department crowding issue.  Therefore, the next step is to form an interdisciplinary team (Titler et al., 2002; White & Spruce, 2015).

The team should consist of all interested stakeholders, representatives of every discipline that is directly involved in the EBP implementation (Titler et al., 2002).  It is well documented that change is more successful when initiated by frontline practitioners rather when management imposes it on them (Doody & Doody, 2011).  For the emergency department, the team will include direct patient care nurses, the nurse manager, the nurse educator, a physician, a nurse practitioner, nurses’ aide, and a patient registrar.

According to the Iowa Model, the team is first tasked with searching for evidence (Titler et al., 2002).  They should brainstorm together and determine key words for database searches regarding triage models.  This literature search should include research evidence and existing evidence-based guidelines.  For emergency medicine, there are multiple professional organizations and governmental agencies that have studied triage models.  After evidence has been gathered, the team needs to critique and synthesize the evidence.  If members of the team are not experienced with literature searches and assessing the strength of evidence, they should enlist the help of someone in their organization who is (Titler et al., 2002).  Ideally, the team will find pre-appraised research, systematic reviews, and even guidelines that have already been developed for triage systems.  Existing guidelines will help the team identify gaps in knowledge (White & Spruce, 2015).  This work brings the team to the next decision. Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project

The second decision point in the algorithm is whether there is enough evidence to guide evidence-based practice.  If the team believes there is a sufficient amount of quality research evidence on triage models, they can move on to piloting an evidence-based change.  If they do not have a solid research base, they may decide to proceed using other types of evidence, such as case studies, expert opinion, scientific principles, or theory.  Alternatively, the team may choose to conduct the research that is lacking (Titler et al., 2002).

If the team proceeds with the development of a new triage model, the next phase is to pilot the change in practice.  There are six steps to follow at this stage.  First, the desired outcomes should be determined (Titler et al., 2002).  Modifying triage is an attempt to improve patient flow through the emergency department; therefore, potential outcomes to measure might be length of stay, time it takes until a patient sees a physician, or number of patients who leave without a physician assessment.  The second step is to obtain baseline data; measure the outcomes before implementing change (Titler et al., 2002).

The third step is to develop the written guidelines that establish the new process and protocols for triage.  The fourth step involves testing the new process on a sample of patients.  In the emergency department, the team could decide to test the new triage process for two weeks, or they could use the new process on alternate days for a month.  Regardless, this step involves training all of the personnel involved and communicating the expectations well.  The fifth step is to evaluate the new process by comparing the outcome measures to the baseline data obtained in step two.  This establishes if the new process affected patient flow positively.  Finally, the last step includes modifying the guidelines based on the outcomes.  It is possible that the team needs to tweak the process based on an unexpected factor or a specific need of this particular emergency department that was not foreseen (Titler et al., 2002).

Conclusion

In today’s health care environment, it has never been more important to practice evidence-based care.  Nurse leaders have a responsibility to ensure that high-quality care is delivered in a cost effective way, and EBP leads to improved health care and lower costs.  The Iowa Model of Evidence-Based Practice to Promote Quality Care “serves as a guide for nurses and health care providers to use research findings for improvement of patient care” (Titler et al., 2002, p. 498).  The Iowa Model will be especially useful in directing the implementation of a new triage process to improve emergency department patient flow.

 

References

Brown, C. G. (2014). The Iowa model of evidence-based practice to promote quality        care: An illustrated example in oncology nursing.
Clinical Journal of Oncology Nursing, 18
(2), 157-159. Retrieved from            
http://search.proquest.com/docview/1512448399?accountid=458

Gawlinski, A., & Rutledge, D. (2008). Selecting a model for evidence-based practice   changes: A practical approach.
AACN Advanced Critical Care, 19
, 291-300.       doi:10.1097/01.AACN.0000330380.41766 .63

Doody, C. M., & Doody, O. (2011). Introducing evidence into practice: Using IOWA      model.
British Journal of Nursing, 20
(11), 661-664. Retrieved from            
http://www.researchgate.net/publication/51466031_Introducing_evidence_into_n
            ursing_practice_Using_the_IOWA_model

Institute of Medicine. (2001).
Crossing the quality chasm: A new health system for the       21st century
(pp. 8-25). Washington, DC: National Academies Press. Retrieved        from http://www.nap.edu/read/10027/chapter/1

Kajermo, K. N., Undén, M., Gardulf, A., Eriksson, L. E., Orton, M. L., Arnetz, B. B., & Nordström, G. (2008). Predictors of nurses’ perceptions of barriers to research         utilization.
Journal of Nursing Management, 16
(3), 305-314. Retrieved from    10.1111/j.1365-2834.2007.00770.x Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project

Melnyk, B. M., Fineout-Overholt E., Fischbeck, F. N., Li, H., Small, L., Wilcox, L., &      Kraus, R., (2004). Nurses’ perceived knowledge, beliefs, skills, and needs         regarding evidence-based practice: Implications for accelerating the paradigm   shift.
Worldviews on Evidence-Based Nursing, 1
(3), 185-193. Retrieved from         10.1111/j.1524-475X.2004.04024.x.

Melnyk, B.M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The state   of evidence-based practice in US nurses: Critical implications for nurse leaders  and educators.
Journal of Nursing Administration, 42
, 410-417. doi:10.1097/    NNA.0b013e3182664e0a

Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2013). Evidence-based practice models    for organizational change: Overview and practical applications.
Journal Of        Advanced Nursing
,
69
(5), 1197-1209. Retrieved from            
http://web.a.ebscohost.com.contentproxy.phoenix.edu/ehost/pdfviewer/pdfviewer
?sid=f237b8c8-f6e7-48d9-a093-4857280ebdf7%40sessionmgr4005&vid             =1&hid=4214

Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., …    Goode, C. J. (2002). The Iowa Model of evidence-based practice to promote  quality care.
Critical Care Nursing Clinics of North America, 13
(4), 497-509.           Retrieved from http://www.researchgate.net/publication/11580356_The_Iowa_             Model_of_Evidence-Based_Practice_to_Promote_Quality_Care

White, S., & Spruce, L. (2015). Perioperative nursing leaders implement clinical practice    guidelines using the Iowa Model of Evidence-Based Practice.
Association of    Operating Room Nurses.AORN Journal, 102
(1), 50-59.             doi:http://dx.doi.org/10.1016/j.aorn.2015.04.001

American College of Emergency Physicians. (2011). Definition of boarded patient,           policy statement.
Clinical & Practice Management.
Retrieved from      
http://www.acep.org/Clinical—Practice-Management/Definition-of-Boarded-
         Patient/

Barish, R. A., Mcgauly, P. L., & Arnold, T. C. (2012). Emergency Room Crowding: A     Marker of Hospital Health.
Transactions of the American Clinical and    Climatological Association
,
123
, 304–311. Retrieved from             http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3540619/

Bellow, A. A., & Gillespie, G. L. (2014). The evolution of ED crowding.
Journal of          Emergency Nursing, 40
(2), 153-160.           doi:http://dx.doi.org/10.1016/j.jen.     2013.01.013

Bernstein, S. L., Aronsky, D., Dusela, R., Epstein, S., Handel, D., Hwang, U., … Asplin,             B. R. (2009). The effect of emergency department crowding on clinically oriented outcomes.
Academic Emergency Medicine, 16
(1), 1-10. Retrieved from     
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2008.00295
            .x/abstract;jsessionid=EDF7E9BEC921E5FD319B74F0500A5287.f03t02

Government Accountability Office. (2009).  Hospital Emergency Departments. Retrieved             from
http://www.gao.gov/new.items/d09347.pdf

Harding, K. E., M.P.H., Taylor, N. F., PhD., & Leggat, S. G., PhD. (2011). Do triage        systems in healthcare improve patient flow? A systematic review of the literature.
            Australian Health Review, 35
(3), 371-83. Retrieved from            http://search.proquest.com/docview/910806287?accountid=458 Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project

Johnson, K. D., Motavalli, M., Gray, D., & Kuehn, C. (2014). Causes and occurrences of  interruptions during ED triage.
Journal of Emergency Nursing, 40
(5), 434-9.             doi:http://dx.doi.org/10.1016/j.jen.2013.06.019

Martin, A., Davidson, C. L., Panik, A., Buckenmyer, C., Delpais, P., & Ortiz, M. (2014). An examination of ESI triage scoring accuracy in relationship to ED nursing attitudes and experience.
Journal of Emergency Nursing, 40
(5), 461-8. doi:http://dx.doi.org/10.1016/j.jen.2013.09.009

Rowe, B. H., Guo, X., Villa-Roel, C., Schull, M., Holroyd, B., Bullard, M., & … Innes,     G. (2011). The role of triage liaison physicians on mitigating overcrowding in         emergency departments: a systematic review.
Academic Emergency Medicine:             Official Journal Of The Society For Academic Emergency Medicine
,
18
(2), 111-     120. doi:10.1111/j.1553-2712.2010.00984.x

Russ, S., Jones, I., Aronsky, D., Dittus, R., & Slovis, C. (2010). Placing physician orders   at triage: The effect on length of stay.
Annals of Emergency Medicine, 56
(1), 27-     33. Retrieved from
http://www.sciencedirect.com.contentproxy
.             phoenix.edu/science/article/pii/S0196064410001198

Stover-Baker, B., Stahlman, B., & Pollack, M. (2012). Triage nurse prediction of hospital  admission
. Journal of Emergency Nursing, 38
(3), 306-310.

White, B. A., Brown, D. F., Sinclair, J., Chang, Y., Carignan, S., McIntyre, J., &   Biddinger, P. D. (2012). Supplemented triage and rapid treatment (START)   improves performance measure in the emergency department.
Journal of        Emergency Medicine, 42
(3), 322-328. Retrieved from
http://www.sciencedirect
.             com.contentproxy.phoenix.edu/science/article/pii/S0736467910002908 Iowa Model of Evidence-Based Practice – NUR 598 Research Utilization Project

NURS 6501: Advanced Pathophysiology Week 1 Discussion: Factors That Influence Disease Sample Essay

Adaptive Response

This paper will be discussing the adaptive responses that lead to diagnoses in three patient scenarios. The first scenario will be discussing Jennifer’s tonsillitis. The second scenario will be on Jack’s allergic contact dermatitis. Finally, the third will be based on Martha’s clinical depression.

Scenario One

Jennifer is a 2-year-old toddler with no significant previous history. The child has a temperature of 102.8F on admit, and her mother states it has been between 101-103.2F for the last three days. Physical examination reveals a visibly ill patient, warm and dry to the touch, slightly reddened tympanic membranes, and healthy BMI. The patient states her throat hurts when she swallows. She also has tender lymph nodes, and 4+ swollen tonsils with diffuse exudates visible on inspection. The patient does not display the signature barking for croup, and physical examination does not show edema of the epiglottis. Tonsillitis is the final diagnosis based on presentations and differential diagnosis.

ORDER A PLAGIARISM-FREE PAPER HERE

Huether and McCance state that tonsillitis is an infection and inflammation of the tonsils. The authors also report that it is usually caused by beta-hemolytic Streptococcus (GABHS) or methicillin-resistant Staphylococcus (MRSA) (2017, p. 717). Adaptive responses to tonsillitis include a painful throat secondary to swollen tonsils, tender lymph nodes in the vicinity of infection, high temperatures, halitosis, and possible stiff neck. It generally affects children who are 2-15 years of age (Mayo Clinic, 2015). NURS 6501: Advanced Pathophysiology Week 1 Discussion: Factors That Influence Disease Sample Essay

Scenario Two

Jack is an adult male in his mid-20s with clinical symptoms of red and irritated hands. The patient reports his hands feeling hot, but not painful. He admits to not wearing protective gloves at his job as a maintenance engineer while using cleaning chemicals. The patient reports no known allergies and no other significant history besides recurrent ear infections when he was much younger. A diagnosis if allergic contact dermatitis is reached due to clinical presentation.

Huether and McCance state that allergic contact dermatitis is a T-cell mediated allergic response in reaction to irritants on the skin. The authors report that the irritant is bound to a carrier protein, leading to the formation of a sensitizing agent, which is then presented to T-cells by the Langerhans cells. Adaptive responses to this condition include erythema, edema, itching, and lesions concentrated in the area of exposure. Risk factors include a genetic susceptibility of several genes that code for filaggrin (an epidermal protein) (2017, p. 1060).

Scenario Three

Martha’s clinical information is very limited. Her only medical history is stated as controlled hypertension. Her main symptoms reported are her “racing heartbeat,” loss of appetite, and trouble sleeping (mentioned twice). The limited information as well as the psychosocial situation of becoming her mother’s caretaker lead to the diagnosis of depression. Adaptive responses to depression include those experienced by Martha (loss of appetite and sleep) as well as feelings of sadness, anger, anxiety, and emptiness. According to the Center for Disease Control and Prevention, patients may also experience back pain, headaches, or decreased acuity in thoughts. Depression can affect anyone of any age (2016). NURS 6501: Advanced Pathophysiology Week 1 Discussion: Factors That Influence Disease Sample Essay

In summary, the adaptive mechanisms were discussed concerning the three clinical scenarios. This included information on tonsillitis, allergic contact dermatitis, and depression.

 

References

Huether, S. E., & McCance, K. L. (2017). 
Understanding pathophysiology 
(6th ed.). St. Louis,

MO: Mosby.

Mayo Clinic. (2015). Tonsillitis. Retrieved from

http://www.mayoclinic.org/diseases-conditions/tonsillitis/basics/symptoms/con-20023538

Center for Disease Control and Prevention. (2016). Depression. Retrieved from

https://www.cdc.gov/mentalhealth/basics/mental-illness/depression.htm NURS 6501: Advanced Pathophysiology Week 1 Discussion: Factors That Influence Disease Sample Essay

NURS 6501: Advanced Pathophysiology Week 1 Discussion: Factors That Influence Disease Sample Essay

NURS 6501:
Advanced Pathophysiology

Week 1 Discussion

Factors That Influence Disease

Patient Scenario

I work in an emergency department in a rural hospital in West Virginia. It is common to treat numerous patients with complaints of chest pain. Most of the patients that I have encountered tend to be male, overweight, have a medical history that includes hypertension, and have obvious poor diet choices. Per the American Heart Association, heart disease is the number one killer in West Virginia in 2010.

ORDER A PLAGIARISM-FREE PAPER HERE

Behavior and Atherosclerosis

There are multiple lifestyle choices that can affect the health of an individual. Choices such as smoking, poor diet choices, and a sedentary lifestyle can all have detrimental effects on a person’s health. These choices place individuals at higher risk for diabetes, hypertension, hypercholesterolemia, and obesity; all of which contribute to atherosclerosis (WebMD, 2017). Males lack LDL-lowering effect of estrogens, smoking leads to injury of endothelial cells, hypertension increases shear stress resulting in damage to the endothelium, and obesity releases factors that can alter the endothelial function and increase the inflammatory state of an individual (Hammer & McPhee, 2014, p. 309). Although genetics can play a major role, prevention remains key and healthy lifestyles remain priority. NURS 6501: Advanced Pathophysiology Week 1 Discussion: Factors That Influence Disease Sample Essay.

 

Pathophysiology

It is vital to have a clear understanding of the disease process and pathophysiology to diagnose and treat different medical conditions successfully, as many conditions have multiple similarities in their presentation or disease processes can have various presentations (Laureate Education, 2012). Atherosclerosis is a chronic inflammatory disease triggered by lipid retention in the arterial wall causing an inflammatory response in the endothelium (Hammer & McPhee, 2014, p. 306). Macrophages are then stimulated that accumulate with lipids causing a fatty streak causing more inflammation and damage; this leads to plaque formation that eventually obstructs blood flow to distal tissues, especially during exercise or stress (Huether & McCance, 2017). However, many plaques are clinically silent until they rupture initiating the clotting cascade leading to rapid thrombus formation that can occlude the affected vessel causing ischemia and infarction (Huether & McCance, 2017). NURS 6501: Advanced Pathophysiology Week 1 Discussion: Factors That Influence Disease Sample Essay

Atherosclerosis is often silent, as symptoms do not typically occur until there is inadequate perfusion of tissue because of obstruction. It also depends on where the vessel obstruction is located. For example, if the vessel involved is one of the coronary arteries, then chest pain and shortness of breath can be the symptomology. If the vessel involved is the carotid artery, then the patient may present with stroke-like symptoms that may resolve, a transient ischemic event. As previously mentioned, although genetics plays an important role in the development of atherosclerosis, lifestyle changes remain as the primary intervention for prevention of this silent killer.

References

American Heart Association. (2010). West Virginia State Fact Sheet. Retrieved from http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_307219.pdf

Hammer, G. D., & McPhee, S. J. (2014).
Pathophysiology of disease: An introduction to clinical medicine
(7th ed.). New York, NY: McGraw-Hill Medical.

Huether, S. E., & McCance, K. L. (2017).
Understanding pathophysiology
(6th ed.). St. Louis, MO: Mosby.

Laureate Education (Producer). (2012).
Introduction of advanced pathophysiology.
Baltimore, MD: Author

WebMD. (2017). What is atherosclerosis? Retrieved from http://www.webmd.com/heart-disease/what-is-atherosclerosis#1 NURS 6501: Advanced Pathophysiology Week 1 Discussion: Factors That Influence Disease Sample Essay

Tina Jones shadow health

Please use the patient information provided below for this paper.

This assignment assesses intended course outcome(s)

#4 Use information found in patients’ health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient’s individual health promotion and disease prevention needs

Students will use the information found in Tina’s history, physical exam, and problem list to formulate an individualized health promotion and disease prevention plan of care. Recommendations should be evidence-based and from credible sources. The readings in module eight contains some suggested sources for obtaining health and screening recommendations for your patient. Tina Jones shadow health.

The plan for addressing the health promotion and disease prevention needs for your patient should include:

Demographics:

–          Age, gender and race of patient

ORDER SHADOW HEALTH ASSESSMENT HELP HERE

WE WILL SCORE ABOVE 95% AND HANDLE THE SOAP NOTE

DON’T STRESS YOURSELF,  JUST CHAT US AT THE RIGHT CORNER BELOW.

–          Education level (health literacy)

 

–           Access to health care

 

Insurance/Financial status

 

–          Is the patient able to afford medications and health diet, and other out-of-pocket expenses?

 

Screening/Risk Assessment

 

–          Identified health concerns based on screening assessments and demographic information

 

Nutrition/Activity

BRIAN FOSTER CHEST PAIN SHADOW HEALTH ASSESSMENT

 

–          What is the patients activity level, is the environment where the patient lives safe for activity

 

–          Nutrition recommendations based on age, race gender and pre-existing medical conditions

 

–          Activity recommendations

 

Social Support

 

–          Support systems, family members, community resources

 

Health Maintenance

 

–          Recommended health screening based on age, race, gender and pre-existing medical conditions

 

Patient Education:

 

–          Identified knowledge deficit areas/patient education needs (medication teaching etc).

 

–          Self-care needs/ Activities of daily living

 

* The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references).

 

Your paper will be evaluated based on the following criteria:

 

Criteria

Level 3

Level 2

Level 1

Demographics

(5%)

Includes age, race and gender of patient

Missing one data item

Missing 2 or more data items

Insurance/Financial status

(10%)

Includes information regarding patient’s insurance status and ability to afford medications and other  out-of-pocket expenses

Missing some information regarding insurance status and ability to pay for medications and other out-of-pocket expenses.

Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses

Screening /risk assessment

(10%)

Identifies health concerns based on screening assessments and demographic information.

Missing some information regarding health concerns, by excluding information from screening assessments and demographics

Health concerns are not identified due to information missing from screening assessments and demographics

Nutrition/activity

(20%)

Completely asses patient’s nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions

Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions

Most of the information regarding the patient’s nutrition and activity levels are missing, recommendations are missing or not based on the patient’s age, race, gender and pre-existing medical conditions

Social support

(10%)

Identifies support systems such as family members and community resources

Missing some information regarding support systems such as family members and/or community resources

Little to no information regarding social support Tina Jones shadow health

Health Maintenance

(20%)

Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions

Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions

Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions

Patient Education

(20%)

Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living

Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living

Lacks identification of knowledge deficit areas/patient education needs. Does not consider self-care needs or activities of daily living.

Organization, spelling and grammar, APA

(5%)

Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA

Organized and easy to read, few spelling or grammar mistakes, few errors in APA

Tina Jones shadow health

Disorganized, difficult to read, many spelling and grammar errors mistakes. Does not use APA

Overall score

Points

(60-100)

Points

(24-59)

Points

( 0-23)

 

 

 

 

 

 

 

Health History

 

Student Documentation

Model Documentation

Identifying Data & Reliability

Ms Jones is xxxx

Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Tina Jones is Alert and xxxx

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.

Reason for Visit

Presents to xxx

“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”

History of Present Illness

The patient is a xxx

Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.

Medications

XXX twice daily XXXX

• Fluticasone propionate, XXX(last use: this morning) • Drospirenone and XXXX (last use: this morning) • XXXX (last use: three months ago) • XXX) • IXXXX (menstrual cramps: last taken 6 weeks ago)

Allergies

XXXX No Known XXX

• XXXX • Denies food and latex allergies • XXXXX. When she is exposed to allergens she states that she has XXXXX, and increased asthma symptoms.

Medical History

Diabetes Type 2 – diagnosed xxx

XXXdiagnosed at age 2 1/2. She uses her XXXwhen she is around cats. Her last aXXXXX in high school. Never intubated. XXXX. She began XXX months ago and initially had some gastrointestinal side effects which have since dissipated. XXXXXXXX. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with XXX. For the past four months (after initiatingXXXX) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested XXX four months ago.

Health Maintenance

Ms Jones has xxx

Last xxx 4 months ago. Last xxx three months ago. Last xxx months ago. xxx2 years ago. xxx: xxx was received within the past year, xxx is not current, and xxx has not been received. She reports that she believes she is up to date on xxx and received the xxxx for xxx. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sx. xx, having belonged to her dad, are in the home, locked in parent’s room.

Family History

-Her Mother is still alive. She has xxx

• Mother: age xxxx• Father: deceased in car accident one year ago at age 58, xxx, and xxx • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a xx, history of xxx, xxx • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of xxxx • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

Has never been pregnant xxx.

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.

Mental Health History

Denies any  problems with xxxx

Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear

 

 

 

 

 

 

Chief Complaint

Finding:

Established chief complaint

Finding:

Reports sore throat

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Is your throat sore?

Finding:

Reports itchy throat

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Is your throat itchy?

Finding:

Reports itchy eyes

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Are your eyes itchy?

Finding:

Reports runny nose

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Do you have a runny nose?

History of Present Illness

Finding:

Asked about onset of symptoms

Finding:

Reports sore throat began “about a week ago”

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.

Example Question:

How long has your throat been sore?

Finding:

Reports runny nose began “about a week ago”

(Available)

Pro Tip: Establishing a timeline for how long Tina’s nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

When did your nose start running?

Finding:

Reports itchy eyes began “about a week ago”

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s eyes have been itching will also aid in treating her itchy eyes.

Example Question:

When did your eyes start itching?

Finding:

Asked about aggravating factors for throat symptoms

Finding:

Reports throat pain is constant

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.

Example Question:

Is the throat pain constant?

Finding:

Reports throat pain is worse in the morning

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.

Example Question:

When does your sore throat feel the worst?

Finding:

Reports some soreness with swallowing

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Does it hurt when you swallow?

Finding:

Asked severity of throat discomfort

Finding:

Describes sore throat as mild to moderate

(Found)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.

Example Question:

Can you rate your sore throat on a scale of 0 to 10?

Finding:

Asked about frequency and duration of runny nose

Finding:

Reports nose is runny “pretty much all day”

(Available)

Pro Tip: Establishing a timeline for how long Tina’s nose has been running will illustrate how long she has been suffering these particular symptoms, when the symptoms are worst, and possible triggers.

Example Question:

How often does your nose run?

Finding:

Asked about character of nasal symptoms

Finding:

Denies itchy nose

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Does your nose itch?

Finding:

Denies sinus pain

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Do you feel any sinus pain?

Finding:

Denies sinus pressure

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Do you feel any sinus pressure?

Finding:

Denies sneezing

(Available)

Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems.

Example Question:

Have you been sneezing?

Finding:

Followed up about character of nasal discharge

Finding:

Reports clear discharge

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

What color is your mucus?

Finding:

Reports thin discharge

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Is the mucus thick?

Finding:

Denies purulent discharge

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Does your mucus have pus in it?

Finding:

Asked about eye symptoms

Finding:

Reports eye itching is constant

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Determining when Tina’s eyes most itch will also aid in treating her itchy eyes.

Example Question:

Do your eyes constantly itch?

Finding:

Reports eye redness

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Are your eyes red?

Finding:

Asked related respiratory symptoms

Finding:

Reports breathing isn’t affected

(Found)

Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns or conditions.

Example Question:

Have you had any changes in your breathing?

Finding:

Denies cough

(Available)

Pro Tip: A shallow history of a patient’s condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Soliciting this information from Tina allows her to explain any recent developments with her asthma.

Example Question:

Do you have a cough?

Finding:

Denies chest tightness

(Available)

Pro Tip: For many patients with asthma, exacerbation often results in chest tightness. Asking Tina if her chest feels tight might point to possible asthma symptoms.

Example Question:

Does your chest feel tight?

Finding:

Asked about related asthma symptoms

Finding:

Denies recent wheezing

(Available)

Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. Asking Tina whether she has been wheezing illustrates how her asthma is presenting.

Example Question:

Have you been wheezing?

Finding:

Denies increase in recent asthma symptoms

(Available)

Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question:

Has your asthma been worse lately?

Finding:

Asked about exposure to allergens

Finding:

Reports no exposure to cats

(Found)

Pro Tip: Tina’s symptoms are consistent with being exposed to allergens. Asking Tina if she’s recently been exposed to allergens could explain what’s triggering her symptoms.

Example Question:

Have you been recently exposed to any allergens?

Finding:

Reports no exposure to mold or mildew

(Available)

Pro Tip: Exposure to mold can result in painful ear, nose, or throat symptoms. Asking Tina if she has mold in her house might indicate a possible trigger that she has been exposed to.

Example Question:

Do you have mold in your house?

Finding:

Reports no exposure to dust

(Available)

Pro Tip: Exposure to dust can result in painful ear, nose, or throat symptoms. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to.

Example Question:

Do you have dust in your house?

Finding:

Reports no known exposure to irritants in work environment

(Available)

Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation.

Example Question:

Are you allergic to anything at work?

Finding:

Reports changing bedding “once a week”

(Available)

Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. By asking Tina if she regularly changes her bedding, you’re soliciting information about environmental factors that might exacerbate her condition.

Example Question:

How often do you change your bedding?

Finding:

Asked about perceived cause of symptoms

Finding:

Describes symptoms as similar to allergies

(Found)

Pro Tip: Questions about what factors might have caused certain symptoms can point to a patient’s environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma might indicate her health literacy and understanding of what factors impact her breathing.

Example Question:

Do you know what’s causing your symptoms?

Finding:

Reports that the symptoms don’t seem like a common cold

(Found)

Pro Tip: A patient is an expert on her body. Asking Tina if she thinks she has a cold will give Tina the opportunity to compare her current symptoms with cold symptoms she’s historically had and describe if her current symptoms differ from those she experiences when she has a cold.

Example Question:

Do you think you have a cold?

ORDER SHADOW HEALTH ASSESSMENT HELP HERE

WE WILL SCORE ABOVE 95% AND HANDLE THE SOAP NOTE

DON’T STRESS YOURSELF,  JUST CHAT US AT THE RIGHT CORNER BELOW.

Finding:

Describes similarity to her sister’s hay fever symptoms

(Available)

Pro Tip: A patient is an expert on her body. Asking Tina if she thinks she is having an allergic reaction will give Tina the opportunity to compare her current symptoms with symptoms she’s historically had during an allergic reaction.

Example Question:

Do you think you are having an allergic reaction?

Finding:

Reports no history of cigarette smoking

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she has recently smoked can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.

Example Question:

Have you smoked cigarettes recently?

Finding:

Reports no recent exposure to secondhand smoke

(Available)

Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking whether Tina has been exposed to secondhand smoke might indicate a proximate environmental trigger.

Example Question:

Have you been exposed to secondhand smoke recently?

Medical History

Finding:

Confirmed use of medications

Finding:

Confirmed medications from previous visit (no new medications)

(Found)

Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.

Example Question:

Have you started taking any new medications?

Finding:

Followed up about inhaler use

Finding:

Uses an inhaler to treat asthma symptoms

(Available)

Pro Tip: It’s essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions.

Example Question:

Do you use an inhaler for your asthma?

Finding:

Inhaler is Proventil

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question:

What is the name of the inhaler you are currently using?

Finding:

Last use of inhaler was last week

(Available)

Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

Example Question:

When did you last use your inhaler?

Finding:

Reports typical inhaler use is 2 – 3 times a week

(Available)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.

Example Question:

How often do you use your inhaler?

Finding:

Reports using 2 – 3 puffs of inhaler when used

(Available)

Pro Tip: Inhaler effectiveness can vary over time for a variety of reasons. Asking Tina about the number on inhaler puffs she needs to resolve symptoms can indicate whether her asthma has worsened or point to potential problems like poor inhaler technique.

Example Question:

How many puffs of your inhaler do you use?

Finding:

Prescribed dosage is 2 puffs

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many puffs of her inhaler she’s prescribed will indicate her treatment plan and the degree to which she complies with it.

Example Question:

How many puffs of your inhaler are you supposed to do?

Finding:

Followed up about medications and relieving factors for nose and eye symptoms

Finding:

Reports no treatment for itchy eyes

(Available)

Pro Tip: Tina’s response to a question about managing her itchy eyes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you treated your eyes with anything?

Finding:

Reports no treatment for nasal symptoms

(Available)

Pro Tip: Tina’s response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you done anything for your runny nose?

Finding:

Reports no antihistamine

(Available)

Pro Tip: Tina’s response to a question about taking any antihistamines will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you taken any antihistamines?

Finding:

Reports no decongestant

(Available)

Pro Tip: Tina’s response to a question about taking any decongestants will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you taken any decongestants?

Finding:

Followed up about medications and relieving factors for throat symptoms

Finding:

Reports lozenges as treatment

(Available)

Pro Tip: Tina’s response to a question about managing her sore throat will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you taken anything for your sore throat?

Finding:

Reports lozenges reduce symptoms

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if the lozenges help will illustrate the extent of her pain and how effectively OTC treatments works for her throat.

Example Question:

Do the lozenges help?

Finding:

Reports ingesting lozenges every few hours

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how frequently she has a lozenge will illustrate the extent of her pain and how effectively OTC treatment works for her throat.

Example Question:

How often do you have a lozenge? Tina Jones shadow health

Finding:

Reports drinking water reduces symptoms

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Does drinking water help?

Finding:

Confirmed allergies

Finding:

Reports known allergy to cats

(Available)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger.

Example Question:

Can you confirm that you’re allergic to cats?

Finding:

Reports known allergy to dust

(Available)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger.

Example Question:

Are you allergic to dust?

Finding:

Reports no previous problems with seasonal allergies

(Available)

Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tina’s breathing. Asking Tina whether she has seasonal triggers will indicate, in part, Tina’s health literacy. Tina Jones shadow health

Example Question:

Do you have seasonal allergies?

Review of Systems

Finding:

Asked about general symptoms

Finding:

Denies recent or frequent illnesses

(Available)

Pro Tip: Asking about recent illnesses can give help you determine the cause of a patient’s symptoms.

Example Question:

Have you been sick recently?

Finding:

Denies chills

(Available)

Pro Tip: Chills could be an indication of fever, which could be an indication of infection.

Example Question:

Have you had any chills?

Finding:

Denies fever

(Found)

Pro Tip: Fever could signal that the patient’s symptoms are caused by an infection.

Example Question:

Have you had a fever?

Finding:

Reports low energy level

(Available)

Pro Tip: Low energy or fatigue can be an important symptoms or contributing factor to discover, and can help you rule out certain conditions.

Example Question:

Have you felt fatigued?

Finding:

Denies nausea or vomiting

(Available)

Pro Tip: Nausea or vomiting can indicate an infection.

Example Question:

Have you felt nauseous?

Finding:

Asked about review of systems for head

Finding:

Reports occasional headaches

(Found)

Pro Tip: Sinus problems can result in increased pressure buildup and headaches. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. Tina Jones shadow health

Example Question:

Do you ever get headaches?

Finding:

Denies current headache

(Available)

Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now.

Example Question:

Do you have a headache currently?

Finding:

Denies history of head injury

(Available)

Pro Tip: People who’ve experienced head injuries are at increased risk for sinusitis. Asking Tina whether she’s ever had a head injury solicits health history information that might explain the cause of her symptoms.

Example Question:

Have you ever had a head injury?

Finding:

Denies lightheadedness

(Found)

Pro Tip: Sinus infections can result in inner ear disturbances and thus lightheadedness. Asking Tina if she is lightheaded could point to inner ear disturbances.

Example Question:

Do you ever get lightheaded?

Finding:

Followed up on headaches

Finding:

Headaches occur once a week

(Found)

Pro Tip: Establishing a timeline for how often Tina gets headaches will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How often do you get headaches?

Finding:

Headaches last “a few hours”

(Found)

Pro Tip: Establishing a timeline for how long Tina’s headaches last will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How long do your headaches last?

Finding:

Describes headaches as tight and throbbing

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

How would you describe your headaches?

Finding:

Describes headache location as behind her forehead

(Found)

Pro Tip: Specifying the location of pain can narrow and define where Tina’s pain is occurring. Soliciting this information allows you to more accurately treat her symptoms. Tina Jones shadow health

Example Question:

Where do you feel your headaches?

Finding:

Rates headache pain as a 3 or 4

(Available)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.

Example Question:

How would you rate your headache pain on a scale of 0 to 10?

Finding:

Reports treating headaches with Tylenol

(Found)

Pro Tip: Tina’s response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

How do you treat your headaches?

Finding:

Reading and studying seem to cause headaches

(Found)

Pro Tip: Soliciting information about possible headache triggers will allow Tina to consider what, if any, activities, weather patterns, movements, or sensory input is correlated with her headaches.

Example Question:

What seems to cause your headaches?

Finding:

Asked about review of systems for eyes

Finding:

Reports occasional blurry vision

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Do you have blurry vision?

Finding:

Reports worsening vision

(Found)

Pro Tip: Establishing a timeline for whether Tina’s vision has gotten worse will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

Has your vision gotten worse? Tina Jones shadow health

Finding:

Denies eye pain

(Found)

Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms.

Example Question:

Have you had eye pain?

Finding:

Denies dry eyes

(Available)

Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom.

Example Question:

Have you had dry eyes?

Finding:

Reports last vision exam was in childhood

(Found)

Pro Tip: Asking Tina when her last vision test was will indicate the degree to which she’s seen her vision as something that has needed medical attention.

Example Question:

When was your last vision test?

Finding:

Does not use corrective lenses

(Found)

Pro Tip: Corrective lenses might indicate a recent change in vision. Asking Tina whether she has glasses or contacts solicits information about her vision history.

Example Question:

Do you have glasses or contacts?

Finding:

Followed up on vision problems

Finding:

Describes blurry vision as “fuzzy letters”

(Available)

Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.

Example Question:

Can you describe your blurry vision?

Finding:

Blurry vision occurs when reading for long periods

(Found)

Pro Tip: Establishing a timeline for how frequently Tina gets blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

When do you get blurry vision?

Finding:

Blurry vision occurs after 2+ hours of reading

(Available)

Pro Tip: Establishing a timeline for how long Tina’s vision stays blurry will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How long have you been reading when your vision gets blurry?

Finding:

Reports that blurry vision and headaches often coincide

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Tina Jones shadow health

Example Question:

Do you get headaches when you have blurry vision?

Finding:

Asked about review of systems for ears

Finding:

Denies general ear problems

(Found)

Pro Tip: Soliciting a shallow medical history relevant to Tina’s chief complaint will allow you to assess her condition relative to past concerns.

Example Question:

Have you had ear problems?

Finding:

Denies change in hearing

(Found)

Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing.

Example Question:

Have you had any changes in your hearing?

Finding:

Denies ear pain

(Found)

Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous. Asking Tina if she has ear pain might indicate a possible ear infection.

Example Question:

Have you had ear pain?

Finding:

Denies ear discharge

(Available)

Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer’s ear. Asking whether she’s noticed ear discharge could indicate whether she has a ruptured eardrum.

Example Question:

Have you noticed ear discharge?

Finding:

Reports last hearing test was in childhood

(Available)

Pro Tip: Asking Tina when her last hearing test was will indicate the degree to which she’s seen her hearing as something that has needed medical attention.

Example Question:

When was your last hearing test?

Finding:

Asked about review of systems for nose

Finding:

Denies change in sense of smell

(Available)

Pro Tip: Changes in sense of smell could be a symptom of acute sinusitis. Asking Tina if she’s had any changes in her sense of smell indicates whether she might be suffering from acute sinusitis.

Example Question:

Have you had any changes in your sense of smell?

Finding:

Reports no nasal or sinus surgeries

(Available)

Pro Tip: A history of nasal surgery might indicate that Tina had chronic nasal problems. Asking Tina if she’s ever had nasal surgery solicits information about her medical history. Tina Jones shadow health

Example Question:

Have you ever had a nasal surgery?

Finding:

Denies nosebleeds

(Available)

Pro Tip: Nosebleeds are often caused by sinusitis. Asking Tina if she ever gets nosebleeds solicits information about her medical history.

Example Question:

Do you ever get nosebleeds?

Finding:

Asked about review of systems for mouth and jaw

Finding:

Denies general mouth problems

(Found)

Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.

Example Question:

Have you ever had problems with your mouth?

Finding:

Denies change in sense of taste

(Available)

Pro Tip: Sinusitis can result in decreased smell or taste. Asking if Tina’s sense of taste has changed lately might indicate a sign of sinusitis.

Example Question:

Has your sense of taste changed?

Finding:

Denies dry mouth

(Found)

Pro Tip: Sinusitis can result in dry mouth. Asking if Tina’s recently had dry mouth might indicate a sign of sinusitis.

Example Question:

Have you had dry mouth recently?

Finding:

Denies history of oral surgery

(Available)

Pro Tip: A history of oral surgery might indicate that Tina had former oral problems. Asking Tina if she’s ever had oral surgery solicits information about her medical history.

Example Question:

Have you ever had oral surgery?

Finding:

Denies mouth pain

(Available)

Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had mouth pain might indicate a problem area that has caused infection.

Example Question:

Do you have mouth pain?

Finding:

Denies mouth sores

(Available)

Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection.

Example Question:

Do you have any mouth sores?

Finding:

Denies gum problems

(Found)

Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms.

Example Question:

Do you have any problems with your gums?

Finding:

Denies tongue problems

(Available)

Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms.

Example Question:

Do you have any problems with your tongue?

Finding:

Denies jaw problems

(Available)

Pro Tip: If left untreated, jaw problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. Tina Jones shadow health

Example Question:

Do you have any problems with your jaw?

Finding:

Asked about review of systems for dentation

Finding:

Denies current dental problems

(Available)

Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she has any dental problems might indicate a problem area that has caused infection.

Example Question:

Do you have any current dental problems?

Finding:

Reports visit within the last 2 years

(Available)

Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area.

Example Question:

When did you last see the dentist?

ORDER SHADOW HEALTH ASSESSMENT HELP HERE

WE WILL SCORE ABOVE 95% AND HANDLE THE SOAP NOTE

DON’T STRESS YOURSELF,  JUST CHAT US AT THE RIGHT CORNER BELOW.

Finding:

Reports regular visits in childhood

(Available)

Pro Tip: Seeing a dentist regularly as a child can lay the foundation for good dental hygiene and prevent infection. Asking Tina how often she saw the dentist as a child will suggest her health and dental history.

Example Question:

How often did you see the dentist when you were a child?

Finding:

Reports a few cavities in childhood

(Available)

Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina what dental problems she’s had might indicate a problem area that has caused infection.

Example Question:

What dental problems have you had?

Finding:

Asked about review of systems for neck, throat and glands

Finding:

Denies history of recurrent strep throat

(Available)

Pro Tip: Soliciting a shallow medical history relevant to Tina’s chief complaint will allow you to assess her condition relative to past concerns.

Example Question:

Do you get strep throat often?

Finding:

Denies lymph node problems

(Available)

Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition.

Example Question:

Do you have any problems with your lymph nodes?

Finding:

Denies history of general throat problems

(Available)

Pro Tip: Throat problems are often linked to sinusitis. Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns.

Example Question:

Do you have a history of throat problems?

Finding:

Denies voice changes

(Found)

Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems.

Example Question:

Have you noticed any changes to your voice?

Finding:

Denies history of tonsil problems

(Available)

Pro Tip: Sinusitis can often lead to tonsil problems. Asking Tina if she has a history of tonsil problems would reveal whether problems with her sinuses have led to tonsil problems. Tina Jones shadow health

Example Question:

Do you have any history of tonsil problems?

Finding:

Denies general neck pain

(Available)

Pro Tip: Neck pain, soreness, or soft tissue damage might result in sinus pain. Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms.

Example Question:

Do you have neck pain?

Family History

Finding:

Asked about relevant family history

Finding:

Reports sister with hay fever

(Available)

Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies.

Example Question:

Do you have any family members with allergies?

Finding:

Denies family history of vision problems

(Found)

Pro Tip: Vision problems are often genetic. Learning about a patient’s family history around vision can help you predict risk.

Example Question:

Do vision problems run in your family?

Finding:

Denies family history of sinus problems

(Available)

Pro Tip: Sinus problems are often genetic. Learning about a patient’s family history around sinus problems can help you predict risk.

Example Question:

Do sinus problems run in your family?

Finding:

Denies family history of ear or hearing problems

(Available)

Pro Tip: Ear problems are often genetic. Learning about a patient’s family history around ear problems can help you predict risk.

Example Question:

Do hearing problems run in your family?

Finding:

Denies family history of mouth, throat, or gland problems

(Available)

Pro Tip: Because problems like mouth or throat cancer can be genetic, it’s important to understand family history to determine risk factors.

Example Question:

Do you have any family history of throat problems?

Finding:

Denies family history of headache or migraine

Sclera 

 Injection

Color nasal

 Pale

 Bluish

Discharge (no point)

No discharge

Clear discharge

Bloody discharge

Purulent discharge

Turbinate Patency 

 Patent

Right: Tympanic Membrane Color right and left ear

 Pearly gray

 

Oral Mucosa (No point)

 Moist and pink

 
Tonsils 

 Edema

Tonsil Grade 

 1+: Tonsils <25% of space between pillars Posterior Oropharynx Color (1/6 point) Pink Erythemic Posterior Oropharynx Texture   Cobblestoning Post Nasal Drip (no point) Clear discharge   Appearance neck  Discoloration   Right: Retina  Cotton wool bodies   Right  20/xx     “It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms.”   “I’m sorry to hear you don’t feel well. I’ll ask you some questions to learn more about your symptoms, and we will make a plan to help you feel better.”   :  “Thank you for letting me know that you’re using throat drops in addition to the medications you usually take. I will ask you a few questions about how you’re using each medication.”   Student Response: After verifying vaccination history you should be able to cross out certain disease such as diphtheria and move on to assess for other relevant causes of the sore throat. For his age I would consider hand-foot-mouth disease, and bacterial or viral pharyngitis. I would need to assess vital signs, including temperature as well as obtain a rapid strep swab and a throat culture swab to asses for bacterial or viral properties and verify if an antibiotic would be needed. He would need an assessment completed involving his eyes, ear, head, neck and throat. Looking for palpable nodes, redness, swelling, tenderness, drainage, loss of hearing, and pain. Model Note: Differential diagnosis includes viral pharyngitis, strep throat, influenza, cold, and sinusitis. To rule out strep, a rapid strep is indicated. Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. Visualization of the throat also gives clues to the diagnosis. White pus pockets and petechiae on the palate are classic signs of strep throat. Erythema alone may indicate viral infection or postnasal drip. If purulent discharge is noted in the posterior pharynx assess for nasal discharge and palpate the appropriate sinuses for the patient’s age. If palpation elicits pain and purulent nasal discharge is reported over the last 7-10 days, consider sinusitis. A negative rapid flu test would rule out influenza. Tina Jones shadow health Tina’s 76-year-old great aunt comes into the clinic for a visit and you find that she frequently asks you to repeat what you say. During the Rinne test, you find that air conduction is greater than bone conduction in her left ear. What is your differential diagnosis? What additional assessments would you perform? Model Note:  Differential diagnosis includes sensorineural hearing loss and anatomical defects. Sensorineural hearing loss is common in old age and can be caused by heredity, diabetes, cerebrovascular disease, excessive noise, ototoxic medications, hyperlipidemia, hypothyroidism, and renal failure. Assessments should include a history of hearing impairment and ear injuries. It is important to inquire about chronic ear infection or other trauma that leads to anatomical abnormalities. An analysis of Tina’s great aunt’s medications and past medications can be used to rule out ototoxicity. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. TSH and T4 levels can rule out hypothyroidism. GFR or creatinine levels can rule out renal failure. Triglycerides, cholesterol, HDL, and LDL levels can be used to rule out hyperlipidemia. A neurological assessment should be completed to rule out cerebral ischemia. If no concrete diagnosis is made, the hearing loss should be attributed to old age.   Suppose you had found that Tina’s pupils were reactive to both direct and consensual light, yet unequal in size. Which condition would you suspect? Correct: Anisocoria is condition in which the pupils are unequal in size. Anisocoria can be found in about 20% of normal individuals. Unequal visual acuity Optic neuritis Glaucoma Anisocoria (Correct Response) Imagine that, during your physical exam with Tina, you had palpated an enlarged left supraclavicular lymph node. What would this finding have indicated? Correct: Malignancies originating in the pelvis or abdomen are likely to metastasize to the left supraclavicular lymph node, also known as Virchow’s node. Nothing, because this is a normal variant A serious pathology (Correct Response) A previous infection of the throat An active infection of the throat If you had observed Arteriovenous (AV) nicking during the retinal exam on Tina, what would you have seen? Correct: AV nicking is the compression of the vein at arteriovenous crossings due to arterial stiffening. This results in bulging of the vein on either side of the artery making the vein appear to stop on either side of the artery. AV nicking is usually a result of chronic hypertension. Transparent arterial walls Opaque arterial walls Tortuous arteries and veins Vein stops on either side of the artery (Correct Response) Suppose that you had detected a click while palpating Tina’s temporomandibular joint (TMJ). What could have been the cause? Model Note:  Crepitus, limited mobility, and pain in the jaw are probable indicators of temporomandibular joint dysfunction (TMJ syndrome). The clicking noises are most likely caused by displacement of the disc between the condyle and fossa (ball and socket) at the temporomandibular joint. If Tina had reported new onset ear pain, what would have been the most useful finding to determine otitis media? Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. This immobility is caused by increased pressure of the middle ear when air or fluid is trapped due to infection and impairment of the Eustachian tube. Tina Jones shadow health Imagine that you inspected Tina’s throat and noted that her tonsils touched each other. How would you grade her tonsils on the tonsillar hypertrophy grading scale? Model Note: Using the standardized tonsillar hypertrophy grading scale, the tonsils are graded 4+ because they touch one another and, therefore, occupy more than 75% of the space between the posterior pillars of the throat. Tina Jones shadow health