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Course Forum

Topic     Threads                Posts     Last Post

Please Read and Respond

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In this area, please post that you have read and understand South University’s Policies and Guidelines, the Course Resources area, and the announcements posted by your instructor. By posting below you are also acknowledging the South University Honor Code.

ORDER A PLAGIARISM-FREE PAPER HERE

South University Honor Code

“While I attend South University, I will be a fair and honorable student, and will promote fair and honorable conduct in others. I will not cheat, and I will not help others to cheat. I will do my own work, and give proper and truthful reference to those whose work has contributed any amount of content to mine.”    nsg 6340

Unread for topic Please Read and Respond:(4)

View profile card for Funmilayo E Audu

Funmilayo E Audu

Fri at 7:05 PM

Questions for the Professor

Contains unread posts

Celestina, if you need help or have questions on any of the course content, please ask your questions here!      4              11

Unread for topic Questions for the Professor:(4)

View profile card for Angela Brown

Angela Brown

yesterday at 10:48 AM

Autobiography

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Celestina, introduce yourself to the class! Your introduction should cover the following details:

Your name

Your location

Your profession

Your work experience

Your expectations from this course and interest in specific aspects of this course

At least two objectives you hope to achieve through this course and the way you will attain these objectives nsg 6340

In addition, provide answers to the following questions:

What are your career goals?

Where would you like to work?

Discuss your current profession and how this course relates to your professional interests or goals.

Post to the Discussion Area by the due date assigned. Review and comment on the autobiographies of your classmates by the end of the week. Comment on your classmates’ expectations from the course and their areas of interest nsg 6340. The responses should be logical, realistic, and reasonable.

Note: This is a nongraded assignment.   7              17

Unread for topic Autobiography:(10)

View profile card for Celestina Ofodile

Celestina Ofodile

7 hours ago

 

Welcome/ Week 1         Jun 4, 2019 3:12 PM

Welcome to NSG 6340 Adult Health.  I worked as an adult nurse practitioner before becoming a family nurse practitioner.  As an adult nurse practitioner, I worked with many elders.  Working with elders is both rewarding and challenging:  Health care for this population is complex and comprehensive.  I am looking forward to sharing my expertise with you throughout the term.  Week 1 will focus on demographics and biology of aging and health care delivery models nsg 6340.  Assignments include the following
:

 

Autobiography:  Due 06/13/2019

 

Discussion Board:  Initial response is due 06/09/2019 and 2 peer responses are due 06/13/2019

 

Aquifer Case Study:  Due 06/13/2019

 

Q Bank Questions:  Due 06/13/2019

 

APEA Review Course Modules:  Due 06/13/2019

Assignment Forum

https://myclasses.southuniversity.edu/d2l/home/47714

NSG6340 PRACTICUM111: ADULT HEALTH PRIMARY CARE SUO2

Week 1 Discussion

Must post first.

Assignment Title: Discussion Assignment

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 1, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence.  Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable nsg 6340.  Complete your participation for this assignment by end of the week.

 

Week 1 Discussion Prompt

Select an innovative care delivery model for the elderly that you have had experience with or have heard about.  Discuss the risks and benefits of this type of care delivery.  Discuss the measurement of effectiveness of this model.  What are the risks to the elderly population with this type of care delivery.  What challenges still face the care providers?

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.  Patient or lay person medical information portals such as webMD, Medscape, Mayo Clinic, or any disease foundations such as the arthritis foundation, or the diabetic foundation are not acceptable resources for your scholarly work nsg 6340

You must start a thread before you can read and reply to other threads

Week 2 Discussion

Must post first.

Assignment Title: Discussion Assignment

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 2, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence.  Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week nsg 6340.

 

Week 2 Discussion Prompt

Outline a preventive services plan for either a male or female in one of the following age groups.

55-64; 65-74; 75-84; >84

Identify services that include Screening, Counseling, Immunization, and Chemoprophylaxis. Be sure to support your plan with a minimum of 3 sources of high level evidence.

Assignment instructions here.

You must start a thread before you can read and reply to other threads

Week 3 Discussion

Must post first.

 

Assignment Title: Discussion Assignment

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 3, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence. nsg 6340. Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week.

 

Week 3 Discussion Prompt

Select a patient from your clinical practicum (be sure to delete any identifying information) who is over the age of 65 and taking 5 or more medications.  Write a review of the patient’s pharmacotherapy plan identifying pharmacotherapy problems by applying principles of geriatric prescribing and the Beers criteria to your patient.   Identify a plan to manage the patient’s disease profile that follows the Beers criteria and principles of geriatric prescribing.

 

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.  Patient or lay person medical information portals such as webMD, Medscape, Mayo Clinic, or any disease foundations such as the arthritis foundation, or the diabetic foundation are not acceptable resources for your scholarly work nsg 6340.

 

You must start a thread before you can read and reply to other threads

Week 4 Discussion

Must post first.

Assignment Title: Discussion Assignment

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 4, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence.  Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week.

 

Week  Discussion Prompt

You are seeing a 79 y/o male in your clinic.  Mr. A has been a patient of yours for several years.  Today his wife is with him and reports that Mr. A has been more forgetful and she is concerned.  Mr. A made several wrong turns getting home from Church last week, today he was unable to locate the clinic when driving today nsg 6340. He became quite angry when Mrs. A suggested she should drive today.  There is a dent on the fender of the car that Mr. A cannot describe how it happened.  Mr. A also had a bruise on his arm that day.  Mrs. A does not like to leave Mr. A home alone for any period of time any longer as he gets anxious then agitated.  One week ago, Mr. A  called 911 convinced that Mrs. A had been abducted when she was taking the garbage to the curb.  She was only out of the house for 5 minutes.

 

During your exam you conduct a Folstein MMSE.  Mr. A scores 21/30.  When testing for Visual Fields, he shows deficits in bilateral peripheral vision of approximately 15 degrees.  He has slowed motor movements, and decreased rotation of his head/neck, showing limitation of rotation to 40 degrees in both directions without discomfort.   Mr. A has a slightly shuffled gait, but no instability.  The remainder of your workup shows Mr. A does not have further deficits.  Your diagnosis is Early Dementia, and you reassure Mrs. A that the limitations he exhibits in peripheral vision and neck range of motion can be considered a normal aging change for him. nsg 6340.

Discuss the concerns regarding Mr. A’s continued driving.  What assessments should be done to determine Mr. A’s driving skills.  What is the obligation of the provider in this circumstance?   Outline a plan of care for how to proceed with Mr. and Mrs. A.

 

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.  Patient or lay person medical information portals such as webMD, Medscape, Mayo Clinic, or any disease foundations such as the arthritis foundation, or the diabetic foundation are not acceptable resources for your scholarly work.

Submission Details:

Points 20 Assignment instructions here.

You must start a thread before you can read and reply to other threads

Week 5 Discussion

Must post first.

Assignment Title: Discussion Assignment

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 1, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion nsg 6340. Every post in the discussion must be supported by evidence.  Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week.

 

Week  Discussion Prompt

Complete your Aquifer Case Study for this week (FM22:  79 yr old male with new onset of unilateral weakness).  During the evaluation of your patient, you use 2 tools to assess his functional status.  Discuss the tools that you opted to use for the evaluation of your patient.  How were these tools developed, what does the research indicate about the reliability and validity of these instruments.  Identify and discuss a minimum of 2 additional tools that have been developed for similar assessments.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format. nsg 6340. Patient or lay person medical information portals such as webMD, Medscape, Mayo Clinic, or any disease foundations such as the arthritis foundation, or the diabetic foundation are not acceptable resources for your scholarly work.

 

Points 20

You must start a thread before you can read and reply to other threads

Week 6 Discussion

Must post first.

Assignment instructions here.

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 1, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence. nsg 6340. Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week.

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 1, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence.  Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week nsg 6340.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.  Patient or lay person medical information portals such as webMD, Medscape, Mayo Clinic, or any disease foundations such as the arthritis foundation, or the diabetic foundation are not acceptable resources for your scholarly work.

 

 

Week 6 Discussion Prompt

Select one of the topics for this week and outline the demographics, pathophysiology, clinical manifestations, morbidity, mortality, evaluation, and management of the disorder.

 

Submission Details:

Name your document

SU_NSG6340_W6_Project 1-1_LastName_FirstInitial.pdf.

Submit your documents to the Submissions Area by the due date assigned

Points 20

Week 6 Discussion Prompt

Select one of the topics for this week and outline the demographics, pathophysiology, clinical manifestations, morbidity, mortality, evaluation, and management of the disorder.

 

Submission Details:

Name your document

SU_NSG6340_W6_Project 1-1_LastName_FirstInitial.pdf.

Submit your documents to the Submissions Area by the due date assigned

Points 20

You must start a thread before you can read and reply to other threads nsg 6340

Week 7 Discussion

Must post first.

 

 

Assignment Title: Discussion Assignment

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 7, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence. nsg 6340.  Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week.

 

This week you will present a diagnosis to your peers. Review one of the sensory systems, elder abuse, or substance abuse in the elderly that we explored this week and present a diagnosis from these systems.  For example, from vision you might select glaucoma or from hearing, you might select prespycussis.   Identify the incidence, demographics, etiology, clinical presentation, diagnosis and management of the diagnosis that you selected.

 

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.  Use high level research for your diagnosis presentation.  Patient or lay person medical information portals such as webMD, Medscape, Mayo Clinic, or any disease foundations such as the arthritis foundation, or the diabetic foundation are not acceptable resources for your scholarly work.

 

 

Submission Details:

Name your document

SU_NSG6340_W7Project 1_LastName_FirstInitial.pdf.

Submit your documents to the Submissions Area by the due date assigned

Points 20

You must start a thread before you can read and reply to other threads

Week 8 Discussion

Contains unread posts

Assignment Title: Discussion Assignment

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 8, day 3. nsg 6340.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence.  Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week.

 

Week  Discussion Prompt

Select one of the topics for this week and outline the demographics, pathophysiology, clinical manifestations, morbidity, mortality, evaluation, and management of the disorder.

 

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format. Remember to use high levels of research in your discussion posts. Patient or lay person medical information portals such as webMD, Medscape, Mayo Clinic, or any disease foundations such as the arthritis foundation, or the diabetic foundation are not acceptable resources for your scholarly work.

Submission Details:

Name your document

SU_NSG6340_W8Project 1_LastName_FirstInitial.pdf.

Submit your documents to the Submissions Area by the due date assigned

Points 5 1              1

Unread for topic Week 8 Discussion:(1)

View profile card for Angela Brown

Angela Brown

June 4 at 3:05 PM

Week 9 Discussion

Contains unread posts

Assignment Title: Discussion Assignment

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by week 9, day 3.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings on different days. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Every post in the discussion must be supported by evidence.  Cite sources in your responses to other classmates. In addition, you must respond to your professor if applicable.  Complete your participation for this assignment by end of the week.

 

Week 9 Discussion Prompt

Select one of the topics for this week and outline the demographics, pathophysiology, clinical manifestations, morbidity, mortality, evaluation, and management of the disorder.

 

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.  Patient or lay person medical information portals such as webMD, Medscape, Mayo Clinic, or any disease foundations such as the arthritis foundation, or the diabetic foundation are not acceptable resources for your scholarly work.

 

 

Submission Details:

Name your document

SU_NSG6340_W9Project 1_LastName_FirstInitial.pdf.

Submit your documents to the Submissions Area by the due date assigned

Points 5

Week 10

Print

The week 10 objectives will address Geriatric Clinical Issues of the Musculoskeletal and Gastrointestinal System nsg 6340.

Your Learning
 
 Objectives for the Week:

Understand the Evaluation and Management of Musculoskeletal System Issues  in Older Adults

Understand the Evaluation and Management of Gastrointestinal System Issues in the Older Adult

Download

0 %
0 of 12 topics complete

Show data table for This chart displays the number of completed topics versus the total number of topics within module Week 10..

List of Topics and Sub-Modules for Week 10

Week 10 Overview

Web Page

 

Week 10 Readings and Articles

Web Page

 

Week American Geriatric Society Review Slides

Web Page

 

Week 10 Lecture 1 Musculoskeletal System

Web Page

 

Week 10 Lecture 2 Dermatology

Web Page

 

Week 10 Discussion

Discussion Topic

 

Assignment instructions here.

Week 10 Project

Assignment

 

Assignment instructions here.

Week 10 Project 2 aq Review Module

Assignment

 

APEA Review Course Modules

You have access to the APEA Review Course Modules Advanced Practice Education Associates (APEA). These questions are designed to help you prepare for your National Certification as an Adult Health Nurse Practitioner.

For the purposes of this course, you will be responsible for completing the APEA Review Course Modules that are assigned each week.

You must submit proof of completion to the assigned 
Submissions Area
. 
This is a required assignment
. Failure to complete the assigned APEA Review Course modules will result in an incomplete in this course and you will not progress.

The communication regarding your login information for APEA comes from the following e-mail address: APEATestingCenter@apeaotc.com.

The subject line of the e-mail will read: Your APEA Online Test Information.

If you have any trouble receiving your login, please contact support@apea.com or by phone at (800) 899-4502, and let your instructor know.

You are assigned the following APEA Review Course Module this week.

Unit 11  Ortho

Please submit your proof of completion of the APEA review course to the
Submissions Area
 by 
the due date assigned
.

Name your document SU_NSG6340_W10_Project2_LastName_FirstInitial.doc.

Points P/F

Course Reflection

Survey

 

Please reflect on your experiences throughout the course and answer the following questions to let us know how your classroom experience was and what we can do to improve our courses going forward. nsg 6340.

Final Exam – Requires Respondus LockDown Browser + Webcam

Quiz

 

Final Exam

After you have completed the assigned reading, have extensively reviewed the assigned lecture material and associated readings/materials, and have completed the weekly Aquifer case study to complete the quiz to assess your learning. This final exam is a comprehensive exam meaning it will cover topics from the entire term.

Submission Details:

Complete the quiz by the end of the week.

Click “Begin Final Exam ” to get started.

Before you begin the exam, please review the exam details below.

There are 100 questions on the final exam

Testing time is 1.2 minutes per question which equates to 2 hours

Only one question will appear on the computer screen at a time. You must answer each question to move onto the next question.

Questions are randomly pulled from a question bank for every student

You cannot go back to previously answered questions to change an answer.

You must complete each quiz or exam in one sitting.

Note: For test integrity purposes, you will not be able to review your quiz/test questions or answers after completion nsg 6340. If you have specific questions, please reach out to your instructor.

Academic Integrity Policy

As a student of South University, I am acquainted with the Academic Integrity Policy. By taking this exam, I signify that I am the individual who is taking the exam, the answers are my own, that I have not received outside help on this exam. I will engage in fair and honorable behavior. I will not cheat or help others to cheat. I will not take screenshots or pictures of the exam. I will promptly report any activity that is suspicious of cheating. I acknowledge that if I am caught of cheating I will receive a zero on the quiz/exam.

Using LockDown Browser and a Webcam for Online Exams

This course requires the use of LockDown Browser and a webcam for online exams. The webcam can be built into your computer or can be the type that plugs in with a USB cable. Watch this 
short video
 to get a basic understanding of LockDown Browser and the webcam feature. A student 
Quick Start Guide (PDF)
is also available nsg 6340.

To ensure LockDown Browser and the webcam are set up properly, do the following:

Start LockDown Browser, log into 
https://myclasses.southuniversity.edu
 and select this course.

Locate and select the Help Center button on the LockDown Browser toolbar.

Run the Webcam Check and, if necessary, resolve any issues.

Run the System & Network Check. If a problem is indicated, see if a solution is provided in the Knowledge Base. Troubleshooting information can also be emailed to our institution’s help desk.

Exit the Help Center and locate the practice quiz named 
Practice Quiz
.

Upon completing and submitting the practice quiz, exit LockDown Browser.

When taking an online exam that requires LockDown Browser and a webcam, remember the following guidelines:

Ensure you’re in a location where you won’t be interrupted.

Turn off all other devices (e.g. tablets, phones, second computers) and place them outside of your reach.

Clear your desk of all external materials not permitted—books, papers, other devices.

Before starting the test, know how much time is available for it, and that you’ve allotted sufficient time to complete it.

Remain at your computer for the duration of the test.

If the computer or networking environment is different than what was used previously with the Webcam Check and System & Network Check in LockDown Browser, run the checks again prior to starting the test.

To produce a good webcam video, do the following:

Avoid wearing baseball caps or hats with brims.

Ensure your computer or tablet is on a firm surface (a desk or table). Do NOT have the computer on your lap, a bed, or other surface where the device (or you) are likely to move.

If using a built-in webcam, avoid tilting the screen after the webcam setup is complete.

Take the exam in a well-lit room and avoid backlighting, such as sitting with your back to a window.

Remember that LockDown Browser will prevent you from accessing other websites or applications; you will be unable to exit the test until all questions are completed and submitted nsg 6340.

If you experience any issues, contact the support center at 1-888-424-4435.

Submission Details:

Complete the exam by the 
due date assigned
.

Click “
Start Exam
!” to get started.

Week 10 CORE Entries

Assignment

 

CORE ENTRIES (Clinical Log)

 

Please read and follow the Student Practicum Expectations with CORE .

Students should  also read and reference the Student Handbooks, all course materials, course announcements, and any documents provided by the faculty during their practicum course for information concerning practicum requirements and/or updates from faculty.

 

CORE Entries are due by the end of day on day 7 each week*. 

Encounters (case logs) for all patients that you see each week must be entered within 7 days of the occurrence in the clinical documentation system (CORE ELMS) or they will not count and you will have to repeat those hours.

*If you have a clinical practicum that goes to the end of day on day 7 of any week, you may enter that day’s hours by end of day of the following week.

 

All case logs must contain at minimum of a short episodic note. The patient encounter used in the complete SOAP note should have the complete SOAP note documented in the case log.

 

Your course faculty will review your submitted cases weekly, providing feedback and approving/disapproving your logs.

 

Students must complete 180 direct patient contact hours for the AGNP program for each practicum course  Clinical hours  must be documented and will be verified by faculty at the end of the session.

Direct patient contact hours include care that involves assessment, diagnosis, treatment, and evaluation of real patients including consultation. Direct care must be provided in the population focused areas of NP practice in primary care. Direct patient contact hours are calculated from Case Logs, not the timesheets.

 

Students are required to have preceptors sign the Verification of Hours Form for each clinical day completed. Hours not verified by a preceptor’s signature will not be counted toward the required hours for the practicum.   The Verification of Hours Form is due during week 10, however it is  good practice to review your form weekly to ensure it matches your CORE entries.  The form can be found in your Student Practicum Experience Handbook nsg 6340.

Create a WORD document attestation that you have completed the required CORE Entries and clinical hours for the week.  The document should include:

Your first and last  name

The course number and title (NSG 6340:  Practicum III:  Adult and Gerontology Health

Statement:  “I completed my CORE clinical entries for week d”

Please submit this document as proof of completion of the CORE Clinical Entries to the 
Submissions Area
 by 
the due date assigned
.

Name your document SU_NSG6340_W10_CORE Entry Attestation_LastName_FirstInitial.doc.

Points P/F

Week 10 SOAP Note

Assignment

 

SOAP NOTE Instructions:

Each week, you are required to submit one SOAP note using the SOAP note template. The SOAP can be for a comprehensive visit or a problem focused visit.  The diagnosis for your patient should be related to the body systems covered in class work this week.

Every component in the template must be filled in regardless of which type of visit you do (comprehensive vs problem focused).  When doing a problem focused visit you will be documenting on pertinent findings, and pertinent negatives only. For any topic area in the template that does not apply to your patient encounter, put in the phrase “Not completed in this focused visit.”

The completed note should be submitted to the 
Submissions Area

Submission Details:

By
 
the due date assigned
, enter your patient encounters into the SU clinical tracking system and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG6340_W10_SOAP_LastName_FirstInitial.doc.

Submit your document to the 
Submissions Area 
by 
the due date assigned nsg 6340
.

Assessing Neurological Symptoms Essay Discussion Week 9

discussion

Discussion: Assessing Neurological Symptoms

Imagine not being able to form new memories. This is the

reality patients with anterograde amnesia face. Although this form of amnesia

is rare, it can result from severe brain trauma. Anterograde amnesia

demonstrates just how impactful brain disorders can be to a patient’s quality

of living. Accurately assessing neurological symptoms is a complex process that

involves the analysis of many factors.

In this Discussion, you will consider case studies that

describe abnormal findings in patients seen in a clinical setting.

Note: By Day 1 of this week, your Instructor will have

assigned you to one of the following specific case studies for this Discussion.

Also, your Discussion post should be in the Episodic/Focused SOAP Note format,

rather than the traditional narrative style Discussion posting format. Refer to

Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week

5 Learning Resources for guidance Assessing Neurological Symptoms Essay Discussion. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

ORDER A PLAGIARISM-FREE PAPER HERE

Case 1: Headaches

A 20-year-old male complains of experiencing intermittent

headaches. The headaches diffuse all over the head, but the greatest intensity

and pressure occurs above the eyes and spreads through the nose, cheekbones,

and jaw.

Case 2: Numbness and Pain

A 47-year-old obese female complains of pain in her right

wrist, with tingling and numbness in the thumb and index and middle fingers for

the past 2 weeks. She has been frustrated because the pain causes her to drop

her hair-styling tools. Assessing Neurological Symptoms Essay Discussion.

Case 3: Drooping of Face

A 33-year-old female comes to your clinic alarmed about

sudden “drooping” on the right side of the face that began this

morning. She complains of excessive tearing and drooling on her right side as

well.

To prepare:

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the

insights they provide about the case study.

Consider what history would be necessary to collect from the

patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be

appropriate to gather more information about the patient’s condition. How would

the results be used to make a diagnosis? Assessing Neurological Symptoms Essay Discussion.

Identify at least five possible conditions that may be

considered in a differential diagnosis for the patient.

Note: Before you submit your initial post, replace the

subject line (“Discussion – Week 9”) with “Review of Case Study

___.” Fill in the blank with the number of the case study you were

assigned.

By Day 3

Post an episodic/focused note about the patient in the case

study to which you were assigned using the episodic/focused note template

provided in week 5 resources. Provide evidence from the literature to support

diagnostic tests that would be appropriate for each case. List five different

possible conditions for the patient’s differential diagnosis and justify why

you selected each. Assessing Neurological Symptoms Essay Discussion.

Note: For this Discussion, you are required to complete your

initial post before you will be able to view and respond to your colleagues’

postings. Begin by clicking on the “Post to Discussion Question” link

and then select “Create Thread” to complete your initial post.

Remember, once you click on Submit, you cannot delete or edit your own posts,

and you cannot post anonymously. Please check your post carefully before

clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different

days who were assigned different case studies than you. Analyze the possible

conditions from your colleagues’ differential diagnoses. Determine which of the

conditions you would reject and why. Identify the most likely condition, and justify

your reasoning. Assessing Neurological Symptoms Essay Discussion.

Building a Health History Essay Discussion Week 1

discussion

Discussion: 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.

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: Building a Health History Essay Discussion.

76-year-old Black/African-American male with disabilities

living in an urban setting

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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

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

neighborhood Building a Health History Essay Discussion.

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? Building a Health History Essay Discussion.

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.

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.

By Day 3

Post a description of the interview and communication

techniques you would use with your selected patient. Explain why you would use

these techniques. Identify the risk assessment instrument you selected, and

justify why it would be applicable to the selected patient. Provide at least

five targeted questions you would ask the patient. v.

Note: For this Discussion, you are required to complete your

initial post before you will be able to view and respond to your colleagues’

postings. Begin by clicking on the “Post to Discussion Question” link

and then select “Create Thread” to complete your initial post.

Remember, once you click on Submit, you cannot delete or edit your own posts,

and you cannot post anonymously. Please check your post carefully before

clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different

days who selected a different patient than you, using one or more of the

following approaches:

Share additional interview and communication techniques that

could be effective with your colleague’s selected patient.

Suggest additional health-related risks that might be

considered.

Validate an idea with your own experience and additional

research. Building a Health History Essay Discussion

Asthma and Stepwise Management Essay Week 4

assignment

Asthma and Stepwise Management

Asthma is a respiratory disorder that affects children and adults. Advanced practice nurses often provide treatment to patients with these disorders. Sometimes patients require immediate treatment making it essential that you recognize and distinguish minor asthma symptoms from serious, life-threatening symptoms. Since symptoms and attacks are often induced by a trigger, advanced practice nurses must also help patients identify their triggers and recommend appropriate management options Asthma and Stepwise Management Essay. Like many other disorders, there are various approaches to treating and managing care for

asthmatic patients depending on individual patient factors. One method that supports the clinical decision-making of drug therapy plans for asthmatic patients is the stepwise approach, which you explore in this Assignment.

To prepare:

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Consider drugs used to treat asthmatic patients including

long-term control and quick relief treatment options for patients. Think about

the impact these drugs might have on patients including adults and children.

Review Chapter 25 of the Arcangelo and Peterson text.

Reflect on using the stepwise approach to asthma treatment and management.

Consider how stepwise management assists health care

providers and patients in gaining and maintaining control of the disease.

By Day 7

Write a 2- to 3- page paper that addresses the following:

Describe long-term control and quick relief treatment

options for asthma patients, as well as the impact these drugs might have on

patients.

Explain the stepwise approach to asthma treatment and

management.

Explain how stepwise management assists health care

providers and patients in gaining and maintaining control of the disease.

Asthma and Stepwise Management Essay

nur 2092 Health History Essay

Module

03 Written Assignment – Health History

Conduct a health history on a family member

or friend. Be sure they give you permission. Using the interviewing techniques

learned in Module 2, gather the following information. Use your textbook as

your guide.

Individual Health Assessment Form

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A response is required for EACH item in

EACH category.

Copy this document & record your responses in a text document (e.g.: Word or WordPerfect). That way you can just add the information without retyping the entire document. Please reformat and

delete things as appropriate.

Health History

Biographical data: (2 points)

Initals:____________

Age:

______________ Marital

status: ____M _____ S _____Sep. ____Cohab.

Birth date: _____________________ Number of dependents: ___________________

Educational level: ________________________ Gender: _____F _____ M _____Other

Occupation:

___________________________________¬¬¬¬_________________________

Ethnicity/nationality:

_____________________ Health insurance

____Yes _____No

Source of

history/reliability:________________________________________________

Present health history: (2 points)

Current medical conditions/chronic nur 2092 Health History Essay

illnesses:

Current medications:

Medication/food/environmental allergies:

Past health history: (8 points)

Childhood illnesses: Ask about mumps,

chickenpox, rubella, ear infections, throat infections, pertussis, and asthma.

Hospitalizations/Surgeries: Include reason

for hospitalization, year, and surgical procedures.

Accidents/injuries: Include head injuries

with loss of consciousness, fractures, motor vehicle accidents, burns, and

severe lacerations.

Major diseases or illnesses: Include heart

problems, cancer, seizures, and any significant adult illnesses.

Immunizations (dates of known):

Tetanus _______ Diphtheria ________ Pertussis ________ Mumps ________

Rubella _______ Polio _____________ Hepatitis B ______ Influenza _______

Varicella ______ Other

____________________________________________

Recent travel/military services: Include

travel within past year and recent and past military service.

Date of last examinations:

Physical examination _________ Vision ___________ Dental ___________

Family History (1 point)

Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any

major health issues, and, if indicated, cause and age of death (date of death,

if known). nur 2092 Health History Essay.

Now answer the questions below: (25 points)

1. Was

the person willing to share the information? If they were not, what did you do

to encourage them?

2. Was

there any part of the interview that was more challenging? If so, what part and

how did you deal with it?

3. How

comfortable were you taking a health history?

4. What

interviewing techniques did you use? Were there any that were difficult and if

so, how did you overcome the difficulty?

5. Now

that you have taken a health history discuss how this information can assist

the nurse in determining the health status of a client. nur 2092 Health History Essay.

levine’s conservation model in nursing practice powerpoint presentation

žConservation Model

Myra estrin Levine

 

žMyra E. Levine

žWhy nurses use theory to guide their practice:

oA nursing theory provides the theoretical foundation of the profession.

oTheory defines what nursing is, what it does, and the goals or outcomes of nursing care.

oNursing is the synthesis of many theories.

oOur group identified with Levine’s Conservation Model because it focuses on conserving an individual’s wholeness. It addresses an individual from birth to death and aims to maintain an equilibrium conducive to health.

o

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žPurpose:

The purpose of this project is to describe the use of a conceptual nursing model, Levine’s Conservation Model.

žTheory Overview

Myra Estrin Levine proposed four principles of conservation. The process by which conservation is achieved is adaptation and the desired outcome is integrity or wholeness. Adaptation includes responses based on past experiences (historicity), specific to the need (specificity), and with a variety of levels of possible response (redundancy). The principles of conservation relate to the conservation of energy, structural integrity, personal integrity, and social integrity of the individual.

žLevine’s Nursing model:

Objectives

oDescribe the historical background of the development of Levine’s model for health

oDefine Levine’s three major concepts and four principles of conservation

oPresent the relationship between Levine’s model and concepts in nursing’s metaparadigm

oProvide an example of Levine’s model in a clinical practice

oEvaluation of the Conservation Model

o

o

o

žHistorical background and motivation for development of conservation model

žEducational Background

and accomplishments

žPhilosophic Values and knowledge development levine’s conservation model in nursing practice powerpoint presentation

ž

žMany Teachers influenced the conservation model

ž

ž

žThe Three Major Concepts of the Conservation Model

Wholeness (Holism)

ž

Adaptation

Conservation

žWholeness

oTo understand the whole person, one must first understand the parts of the whole.

o

oLevine used Erickson’s description of wholeness as an open system (Levine, 1969).

o

oLevine believed that humans respond in “ an integrated, singular fashion to environmental changes” (Levine 1966).

žAdaptation

“Adaptation is the process of change whereby the individual retains his integrity within the realities of his internal and external environment” (Levine, 1973).

oAll adaptations vary in degree, and not all are successful.

oConservation is the outcome.

oAdaptation has three characteristics

oHistoricity

oSpecificity

oRedundancy

žConservation

“Conservation describes the way complex systems are able to continue to function even when severely challenged (Levine, 1973).

oThe primary goal of conservation is maintaining wholeness and uniqueness.

oNursing actions reflecting this model are directed at helping the client conserve:

o* Energy  * Personal Integrity

o* Structural Integrity  * Social Integrity

žGlobal Concepts in the Nursing Profession

oHuman Being: Each person has freedom of choice, identity, and self-worth.  Each person expresses themselves as a summary of all contributing parts.

oHealth: Defined in social contexts; the ability to function within reasonable limits.  Health is more than the absence of disease, and changes with time. levine’s conservation model in nursing practice powerpoint presentation

oEnvironment:  Not just the place a person lives, but also the situation.  There is an internal and an external environment, and both contribute to accommodation.

žGlobal Concepts in the Nursing Profession

“The goal of nursing is to promote adaptation and maintain wholeness” (Levine 1971). 

oNursing is not a series of specific tasks but is a human interaction.

oIt is based on knowledge and scientific reasoning, but is an art that each person practices in a unique manner based on each client’s needs.

ž

Each one of the global concepts of nursing has the ability to add to wholeness or to detract from it.

žInterpretation & Inference

Implications & Consequences

žEvaluation of nursing model

oMyra Levine’s conservation model focuses on promoting adaptation and maintaining wholeness using the principles of conservation.

oAccording to Levine (1973) “human beings conserve their bodies’ incredible ability to adapt to environmental stimuli” (Schaefer & Pond, 1994, p.53). levine’s conservation model in nursing practice powerpoint presentation

žOrigins

Levine’s Conservation Model is clearly influenced by other disciplines.  It is not unique to nursing.  It has elements of the physical sciences as evidenced by the principle of energy conservation.  The social sciences are represented in the concept of the perseveration of personal integrity.  The influence of humanities is reflected by the concept of how a person’s social system is part of their environment and all forms of environment have an influence on the person.

žorigins

Levine’s Conservation model was developed as an organizational framework for teaching medical surgical nursing.  It was not intended to be a nursing theory (Schaefer, 2006, p.228).

žLevine’s theory and its uniqueness to nursing

oThe conservation principles are used by the nurse to identify interventions and to maintain wholeness for the patient (Schaefer & Pond, 1994, p.53).

oThis theory is influenced by a person’s wholeness and their ability to adapt and respond to different environmental challenges.

o

žFour Global concepts

This model adequately describes the four global concepts:

o     Human being

o     Environment

o     Health

o     Nursing

All of these concepts represent the factors that influence individuals and their ideas about their own health and how they view healthcare in general which can influence the individual’s treatment goals and outcome.

žapplications

oA theory deals with one or more specific concepts and is usually derived from a conceptual model (Kearney-Nunnery, 2005).

oLevine’s Conservation model is a general guide of systems and statements and uses broad concepts in a logical, organized form that can be used in different settings.  “Conservation principles as a framework are not limited to nursing care in the hospital but can be generalized and used in every environment, hospital, or community (Levine, 1990, 1991)” (Schaefer, 2006, p.233).

žApplications levine’s conservation model in nursing practice powerpoint presentation

This model has been used in varied areas of nursing.  “Conservation principles have been used as frameworks for numerous practice settings in cardiology, obstetrics, gerontology, acute care (neurology), pediatrics, long-term care, emergency care, primary care, neonatology, critical care areas, and in the homeless community” (Savage & Culbert, 1989; Schaefer & Pond, 1991).

žapplications

“Use of an appropriate conceptual model facilitates the design and testing of theory-based interventions and the development of science to support nursing practice”(Mock et al, 2007, p. 512).

žPutting the Conservation Model to Work

ž

You are a labor and delivery nurse working for a local hospital.  You are caring for a teenager who is about to deliver her first child.  In the room are her boyfriend, her mother, and her best friend.  She is quiet and is not making eye contact with care staff, and her family members are watching television.  You sit down next to the bed and ask the patient if there is anything she needs and she replies “no” but your gut instinct tells you there’s more to the picture.  Your assessment skills tell you there is a great potential here for problems.

ž

You ask the patient how she feels about becoming a mother.  She tells you she is scared.  In further conversation, she tells you she is not planning to go back to school because she is embarrassed and afraid of social rejection.  She did not take any birthing classes or childcare education.  She is afraid of pain during active labor, and has questions about pain control options.  She says her mother and her boyfriend have been supportive, but also voices concern about taking care of her mother, who has a physical disability.

žAssessing the situation

oIs this patient demonstrating wholeness?

o

oIs this patient demonstrating adaptation?

o

oIs this patient demonstrating conservation?

žWholeness

Wow.  This patient has issues, right?  Let’s look at the pieces here.  Levine states we have to look at all of the little pieces to see the whole person.  In order to understand our patient, we have to assess her lifestyle, social integration, spirituality, self-image, family dynamic, environment, cultural identity, and anything else she feels may contribute to her identity.  We get a few hints of that in our initial conversation. levine’s conservation model in nursing practice powerpoint presentation

žAdaptation

How well is your patient adapting?  Before you say “poorly” look at what you can build on.  Adaptation is not a “pass or fail” but can vary in degree.  Consider environment, organismic response, and trophicognosis in your response.  This is a new situation for your patient. How is she relating this to past experiences?  What does she perceive as a challenge?  What does she not perceive as a challenge or a goal?

žConservation

Levine describes conservation as “… the way complex systems are able to continue to function even when severely challenged” (1990).  Is your patient conserving energy? Is she conserving structural (physical) integrity?  Is she conserving her personal integrity?  Is she preserving social integrity?  How could you, as a nurse, promote these principles?

žPutting the model to work

žPromoting
wholeness
:  Talk with your patient about what roles for her are important, discuss what parts of her identity have been fragmented.  What is she proud of?  What is she missing?  What are her goals?

žPromoting
adaptation
:  Although your patient has not been to prenatal education and has dropped out of school, she has spent time gathering baby supplies and has stopped hanging out with unsupportive friends.  Build on this.  Encourage her and tell her about other community resources available to her.  Help her explore all of her options and consider her preferences.

ž

žPromoting
conservation
:  Provide her with pain control options, encourage physical rest.  Encourage her to advocate for her needs and allow her to carry out her social roles during her hospital stay by involving friends and family there to support her, if that is what she desires.

ž

Using Levine’s Conservation Model to guide our nursing practice takes conscious effort, but has   the potential to help our patients reach a higher state of health, which is the ultimate goal of nursing practice.

Conservation Model

žReferences

Alligood, M.R.,& Tomey, A.M.(2006). Myra Estrin

Levine :The conservation model. Y. Alexopoulos, & K. Hebberd (Eds.),
Nursing theorists
(pp. 726 – 742).St. Louis, MO: Mosby

Chitty, K. (2007).
Professional Nursing Concepts &Challenges
. St. Louis, Missouri: Saunders. George, J.

Current Nursing. (n.d.). Nursing theories: Levine’s four conservation      principles. Retrieved from http://currentnursing.com on July 2009.

Dalida D. N207 Blogger (2009). Myra Levine’s Conservation Theory.
University of the Philippines Open University

Retrieved from
http://nursingtheories.blogspot.com

George, J. B. (2001). Nursing theories: Base for professional nursing. (5th ed). Pearson Education.

Levine, M. E. (1992). Nightingale redux. In B.S. Barnum (Ed.),
Nightingale’s notes on nursing
(pp. 39-43). Philadelphia: J.B. Lippincott.

Schaefer, K.M. (2006). Nursing Theorists and Their Work. In Y.Alexopaoulos (Ed. “Et al”), Myra Estrin Levine: The Conservation Model (pp. 227-243). St. Louis, Missouri: Mosby Elsevier.

Schaefer, K.M. & Pond, J.B. (1994). Levine’s Conservation Model as a Guide to Nursing Practice.
Nursing Science Quarterly,
7, 53-54. doi: 10.1177/089431849400700204 levine’s conservation model in nursing practice powerpoint presentation

ž

Aquifer High Value Care 04: 80-year-old woman – Medications and value

High Value Care 04: 80-year-old woman – Medications and value

Author(s):
 Susan Merel, MD University of Washington Medicine; Anne Eacker, MD University of Washington Medicine

REASON FOR ADMISSION

HISTORY

You are rounding on Mrs. Miller, a newly admitted 80-year-old patient with a heart failure (HF) exacerbation. She had been discharged from the hospital just 10 days ago after presenting with the same problem after a 5 day hospitalization. Aquifer High Value Care 04: 80-year-old woman – Medications and value.

You review her list of chronic problems:

Problem list

Systolic heart failure due to ischemic cardiomyopathy with EF of 35% on last echocardiogram

Well-controlled diabetes: A1c of 6.5

Chronic kidney disease Stage 3

Recurrent urinary tract infections

Mild cognitive impairment

Osteoarthritis

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You have found no evidence of infection, Mrs. Miller has not changed her diet, and her EKG is unchanged from previous. On rounds today your attending asks you why you think this patient had a second HF exacerbation so soon after discharge. Aquifer High Value Care 04: 80-year-old woman – Medications and value.

Question

Which of the following are likely to contribute to a HF exacerbation requiring readmission? Select all that apply.

Medication nonadherence

Residence in a skilled nursing facility

Chronic kidney disease

Diabetes

Hyponatremia

Medication side effects

References

Flacker J, Park W, Sims A. Hospital discharge information and older patients: do they get what they need? 
J Hosp Med.
 2007;2(5):291-296
.

Amabile CM SA. Keeping your patient with heart failure safe: a review of potentially dangerous medications. 
Arch Intern Med.
 2004;164(7):709-720
.

Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI. Predictors of readmission among elderly survivors of admission with heart failure. 
Am Heart J.
 2000;139(1 Pt 1):72-7
.

DEEP DIVE Aquifer High Value Care 04: 80-year-old woman – Medications and value

References

Journal of Managed Care & Specialty Pharmacy, Volume 22 Issue (5) 2016 May 22 (5): 516-523
.

 

Answer Comment

The correct answers are A, C, D, F.

Medication nonadherence (A)
 and 
medication side effects (F)
 are important risk factors for readmission in patients discharged after a hospitalization for HF.

Medication nonadherence is a pervasive problem; up to 25% of prescriptions ordered are never filled. In one study of elderly patients discharged from a county hospital with medication changes, only about 50% reported getting their prescriptions filled. (See the Expert to learn about the types and prevalence of medication nonadherence.)

Older patients are likely to take multiple medications and are more susceptible to side effects and adverse drug events than younger patients because of comorbidities, frailty, and age-related physiologic changes in drug metabolism and excretion. Drug-induced HF exacerbations are also common. Medications to consider include non-steroidal anti-inflammatories (NSAIDS), corticosteroids, alpha-blockers, calcium-channel blockers, and tricyclic antidepressants.

Elderly patients with 
renal failure (C)
 and 
diabetes (D)
 are at increased risk for readmission after an exacerbation of HF. Both conditions make it more difficult to control heart failure.

Hyponatremia (E) is a common condition in the elderly and may make it more difficult to 
treat
 heart failure, but has not been shown to be associated with HF readmission.

Advanced age and residence in a skilled nursing facility (B) have not been shown to be risk factors for HF readmission.

 

 

REASON FOR ADMISSION

HISTORY

READMISSION QUESTION

HISTORY

Question

Why is readmission to the hospital within 30 days of discharge a concern? Select all that apply.

Association with increased mortality

Increased occurrence in patients with depression

Cost to health care facility

Cost to the patient

SUBMIT

TEACHING POINT

Early readmission, within 30 days of discharge, is associated with an increased rate of all-cause mortality for community-dwelling elderly patients. Patients over age 80, with five or more comorbidities, or depression are at greater risk of early readmission

References

Lum HD, Studenski SA, Degenholtz HB, Hardy SE. Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries. 
J Gen Intern Med.
2012;27(11):1467-74
.

Marcantonio ER, McKean S, Goldfinger M, Kleefield S, Yurkofsky M, Brennan TA. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. 
Am J Med.
 1999;107(1):13-17
.

Centers for Medicare and Medicaid Services. Readmissions Reduction Program
.

 

 

Question

Why is readmission to the hospital within 30 days of discharge a concern? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

Association with increased mortality

Increased occurrence in patients with depression

Cost to health care facility

Cost to the patient

SUBMIT

Answer Comment

The correct answers are A, B, C, D.

All of the above are correct.

Early readmission, within 30 days of discharge, is associated with an 
increased rate of all-cause mortality (A)
 for community-dwelling elderly patients initially admitted for any diagnosis. It is more common in patients who:

Are over age 80

Have five or more comorbidities

Have 
depression (B)
.

The Affordable Care Act currently requires the Center for Medicare and Medicaid Services (CMS) to reduce payments to hospitals in the setting of “excess readmissions” of patients hospitalized for acute myocardial infarction, heart failure, and pneumonia within 30 days of the first hospitalization. If readmission rates exceed the expected rate, a 
penalty is charged to the hospital (C).
 The amount of these penalties will increase in the future, and additional medical conditions will be added.

Even with insurance, Medicare or otherwise, 
most patients still have to pay (D)
 some portion of their health care costs. For example, Medicare Part A covers 80% of inpatient costs. The average cost of inpatient care per day in the U.S. is about $2270. 
Hospital Adjusted Expenses per Inpatient Day 2015
.

 

 

 

MEDICATION REVIEW

HISTORY

While you are rounding, Mrs. Miller’s daughter arrives with her mother’s home medications in a grocery bag. You express your appreciation that she was able to bring these in for review. They are as follows:

Scheduled medications

Aspirin 81 mg po daily

Calcium carbonate 500 mg po bid

Furosemide 20 mg po daily

Glipizide 5 mg po daily

Lisinopril 10 mg po daily

Metformin 500 mg po bid

Metoprolol XL 50 mg po daily

Multivitamin one tab po daily

Nitrofurantoin 50 mg po daily

Pravastatin 40 mg po daily

Cholecalciferol 800 IU po daily

Naproxen over-the-counter, patient has been taking 500 mg twice a day for a week.

As needed medications

Diphenhydramine 25 mg po q 6 hours prn pruritus

Zolpidem 5 mg po qhs prn insomnia

Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain

Question

After a discussion with the patient and her primary care doctor, which of the following medications would be appropriate to consider discontinuing during this hospitalization? Select all that apply.

Aspirin

Nitrofurantoin

Metoprolol

Diphenhydramine

Naproxen

Vicodin

Zolpidem

SUBMIT

TEACHING POINT

Older patients are at increased risk of adverse drug events.

The Beers Criteria is an evidence-based list developed by experts documenting medications which are potentially inappropriate in the elderly and should be referenced when caring for older patients.

References

Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. 
N Engl J Med.
 2011;365(21):2002-12
.

Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people. 
J Am Geriatr Soc.
 2006;54(10):1516-23
.

Steinman MA, Story PS. Managing medications in clinically complex elders: “There’s got to be a happy medium.” 
JAMA.
 2010;304(14):1592-1601
.

Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. 
J Hosp Med.
 2013;8(1):1-6
.

DEEP DIVE

References

Brater DC. Effects of nonsteroidal anti-inflammatory drugs on renal function: Focus on cyclooxygenase-2-selective inhibition. 
Am J Med.
 1999;107(6A):65S-71S
.

 

 

Question

After a discussion with the patient and her primary care doctor, which of the following medications would be appropriate to consider discontinuing during this hospitalization? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

Aspirin

Nitrofurantoin

Metoprolol

Diphenhydramine

Naproxen

Vicodin

Zolpidem

SUBMIT

Answer Comment

The correct answers are B, D, E, F, G.

Adverse Drug Events in the Elderly

Older patients are at high risk for adverse drug events due to age-related changes in physiology, including changes in drug metabolism.

Older patients generally have more comorbid conditions and are prescribed more medications: 40% of adults over age 65 take 5 to 9 medications and 18% take 10 or more.

Frail elderly patients who take multiple medications are at increased risk for falls, fractures and delirium; these conditions can have serious consequences for an elderly patient’s health and independence.

As many as 10% of hospital admissions in older adults may be related to adverse drug events.

The 
Beers Criteria
 is an evidence-based list developed by experts documenting medications which are potentially inappropriate in the elderly.

Medication

Category

Risks

Nitrofurantoin

Antibiotic

Pulmonary toxicity

Diphenhydramine

Anticholinergic

Side effects include somnolence, confusion, constipation and dry mouth

Naproxen

NSAID

Increased risk of gastrointestinal bleeding, acute kidney injury

Hydrocodone/acetaminophen (Vicodin)

Opioid

Associated with delirium and falls in the elderly

Zolpidem

Sedative-hypnotic (nonbenzodiazepine)

Associated with increased risk of falls, fractures, and delirium in older adults

Nitrofurantoin (B), diphenhydramine (D), naproxen (E), Vicodin (F), and zolpidem (G)
 are all medications which may be appropriate to discontinue:

Nitrofurantoin
is generally an inappropriate medication in the elderly because of its pulmonary toxicity; it is also less effective in patients with a creatinine clearance less than 60 ml/min due to inadequate concentration in the urine. It should not be used for long-term suppression of urinary tract infections in elderly patients. The reason for the nitrofurantoin should be determined and this medication should be stopped or replaced with a safer appropriate antibiotic. If she is taking nitrofurantoin as suppressive therapy to reduce the risk of recurrent UTI’s, the role of suppressive therapy should be reconsidered as the evidence supporting this is not strong.

Diphenhydramine
(Benadryl) should be avoided in all elderly patients because of its strong anticholinergic properties, unless it is necessary for acute treatment of a severe allergic reaction. Side effects include somnolence, constipation, and dry mouth. Anticholinergic drugs (
view list
) increase the risk of both delirium and falls in elderly patients.

Naproxen
is an NSAID. The American Society of Nephrology recommends that patients of all ages with hypertension, heart failure or chronic kidney disease avoid NSAIDs when possible (read the 
ASN’s recommendation
). NSAIDs should also be avoided in many elderly patients, especially those over age 75 or those taking antiplatelet agents, anticoagulants, or corticosteroids because of the increased risk of gastrointestinal bleeding. See the Deep Dive to learn about the physiologic effects of NSAIDs on the kidney. NSAIDs can also contribute to both hypertension and congestive heart failure exacerbations, and should be avoided in patients with these conditions.

Diphenhydramine and NSAIDs are both examples of over-the-counter medications that are inexpensive, but of low value in many patients because of their associated toxicities. It is important to ask about over-the-counter and herbal medications when taking a medication history.

Zolpidem
, which binds the benzodiazepine receptor subunit of the GABA-A receptor complex, is associated with an increased risk of falls, fractures, and delirium in older adults, and is not proven to be very effective in the elderly. Always teach patients about sleep hygiene before considering a sedative-hypnotic.

Vicodin
is an opioid combined with acetaminophen. Opioids can be associated with delirium and falls in the elderly population and should be used with caution. They also carry the risk of addiction.

If the patient has osteoarthritis pain that is refractory to conservative measures, such as exercise, acetaminophen, and physical therapy, judicious use of hydrocodone/acetaminophen is reasonable if it improves her function. Although opioids can be associated with delirium and falls in the elderly population, untreated pain can also contribute to delirium, decreased mobility and decreased quality of life. Opioids should be used with caution in the elderly patient for pain that has been refractory to acetaminophen and non-pharmacologic measures at the lowest effective dose with the goal of improved function. While opioids should be used with caution, they are often appropriate in older adults with refractory pain and would not need to be stopped in this patient if they are used sparingly and improve her function.

Aspirin (A), metoprolol,(C)
 and lisinopril are indicated in this patient because of her systolic heart failure and ischemic cardiomyopathy.

 

 

 

Question

Which of the following contribute to increased drug costs, particularly for elderly patients? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

Medication price inflation has far exceeded general inflation.

The number of medications prescribed to patients is rising over time.

The elderly pay a larger percentage of their prescription medication costs out of pocket.

Medicare Part D pays 80% of the cost of each prescription medication for those over 65.

SUBMIT

Answer Comment

The correct answers are A, B, C.

Nonadherence with medications can increase the use of medical resources. Always ask your patients if they are able to afford their prescriptions. Patients on minimal fixed incomes (most elderly patients) may be unable to afford necessary medications. Aquifer High Value Care 04: 80-year-old woman – Medications and value

Since 1980, prescription 
medication prices have increased (A)
 two to three times faster than all consumer prices.

Prescription drug use in the U.S. has been steadily increasing over time. Between 1999 and 2008, the 
percentage of Americans taking at least one prescription drug increased (B)
 by 10% and use of five or more drugs increased by 70%; spending for prescription drugs doubled during that time period.

Medicare Part D subsidizes the cost of prescription medications; 
however, there is a monthly premium, a yearly deductible, and a per prescription co-pay (C)
, which varies by plan. In addition there is a coverage gap for patients who have more than about $3000 in annual drug costs in 2013. While a patient is in the coverage gap (a.k.a. “donut hole”), he or she pays 79% of the costs of all generic medications and 47.5% of the costs of all brand-name medications. This coverage gap ends at $4750 of drug coverage annually. Because of these costs, not all patients sign up for Medicare Part D.

Medicare Part D does not provide 80% coverage of each prescription (D).

References

Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. Centers for Disease Control. 
NCHS Data Brief.
 No. 42, September 2010:1-8
.

 

 

REASON FOR ADMISSION

HISTORY

READMISSION QUESTION

HISTORY

MEDICATION REVIEW

HISTORY

MEDICATION NON-ADHERENCE

MANAGEMENT

MEDICATION COST

THERAPEUTICS

During her hospitalization, some of Mrs. Miller’s medications have been stopped or changed, and some have been added. Her current medication list in the hospital is as follows:

Hospital Medications

Medications at Home

Scheduled Aquifer High Value Care 04: 80-year-old woman – Medications and value

Aspirin
 81 mg po daily

Aspirin
 81 mg po daily

Calcium carbonate
 500 mg po bid

Calcium carbonate
 500 mg po bid

Cholecalciferol
 800 IU po daily

Cholecalciferol
 800 IU po daily

Furosemide (Lasix)
 40 mg po daily

Furosemide
 20 mg po daily

Glipizide
 5 mg po daily

Glipizide
 5 mg po daily

Lisinopril (Prinivil)
 10 mg po daily

Lisinopril
 10 mg po daily

Metformin
 500 mg po bid

Metformin
 500 mg po bid

Multivitamin
 1 tab po daily

Multivitamin 
1 tab po daily

Carvedilol (Coreg)
 25 mg po bid

Metoprolol XL
 50 mg po daily

Rosuvastatin (Crestor)
 10 mg po daily

Pravastatin
 40 mg po daily

Omeprazole
 20 mg po daily

Nitrofurantoin
 50 mg po daily

Naproxen
 (over-the-counter) patient has been taking 500 mg twice a day for a week

As Needed

Hydrocodone/acetaminophen
 5/500 mg po q 6 hours prn pain

Hydrocodone/acetaminophen
 5/500 mg po q 6 hours prn pain

Benadryl
 25 mg po q 6 hours prn pruritus

Zolpidem
 5 mg po qhs prn insomnia

Question

How could you make this medication list more cost-effective? Document an appropriate discharge medication list here. Aquifer High Value Care 04: 80-year-old woman – Medications and value

Letter Count: 805/1000

SUBMIT

TEACHING POINT

Six Simple Rules for High-Value Medication Prescribing

Have a compelling reason for every medication you prescribe. Consider non-pharmacologic alternatives when appropriate.

Keep your patient’s medication list as short as possible. Discontinue all non-essential medications and review the list for duplicates.

Evaluate affordability before prescribing new medications to patients. This may mean reviewing the patient’s actual copay, generic versus brand name, and the medication tier in their insurance plan. (See High Value Care 06: 65-year-old man – Paying for value: Insurance Part 1.)

Make every effort to prescribe generic equivalent medications. Also be aware of lists of less expensive generic prescriptions available at large chain pharmacies, often for as little as $4 per month.

Collaborate with pharmacists to avoid drug-drug interactions and help provide lower-cost alternatives.

Ask the patient to “teach-back” to show they understand the reason for each medication on the list and how/when to take it.

References

Bulger J, Nickel W, Messler J, et al. Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. 
J Hosp Med.
 2013;8(9):486-92
.

 

 

The medication list can be made more cost effective by ensuring the list is as short as possible and ensuring that there is a compelling reason for each prescribed medication. When appropriate, non-pharmacologic alternatives and generic equivalent medications should be considered. It will also be important to find out if there are other lower-cost alternative medications used to treat same health condition and have them replace the medications on the list. Lastly, I will collaborate with pharmacists to help suggest lower-cost alternatives.

 

Furosemide (Lasix) 40 mg po daily

Multivitamin 1-tab po daily

Aspirin 81 mg po daily

Lisinopril 10 mg po daily

Pravastatin 40 mg po daily

Metformin 500 mg po bid

Rosuvastatin (Crestor) 10 mg po daily

Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain

 

Answer Comment

The table below outlines a suggested higher-value medication list for this patient, with a comparison of actual monthly costs of the 
initial
 and the 
higher-value
 medication list, without consideration of her prescription drug plan coverage:

Initial hospital medication list

Cost for 30-day

supply ($)

Higher-value medication list

Cost* for 30-day

supply ($)

Aspirin
 81 mg po daily

0.30

Aspirin
 81 mg po daily

0.30

Calcium supplement with Vitamin D

1.20

Calcium supplement with Vitamin D

1.20

Coreg (carvedilol)
 25 mg po bid

164.24

Metoprolol XL
 50 mg po daily

17.65

Crestor (rosuvastatin)
 10 mg po daily

188.29

Atorvastatin
 40 mg po daily

17.00

Furosemide
 40 mg po daily

3.37

Furosemide
 40 mg po daily

3.37

Glipizide
 5 mg po daily

4.00

Glipizide
 5 mg po daily

4.00

Metformin
 500 mg po bid

4.00

Metformin
 500 mg po bid

4.00

Multivitamin

0.90

(discontinued)

–

Prinivil (lisinopril)
 10 mg po daily

44.44

Lisinopril
 10 mg po daily

4.00

Omeprazole
 20 mg po daily

10.25

(discontinued)

–

Hydrocodone/acetaminophen
 5/500 mg po q 6 hours prn severe pain, thirty tabs

17.00

Hydrocodone/acetaminophen
 5/500 mg po q 6 hours prn severe pain

17.00

Total cost for a one-month supply

$437.99

Total cost for a one-month supply

$68.52

*Costs are based on GoodRx.com using the zip code 98115 and cheapest Costco prices for over-the-counter medications.

Using a 
Medicare Part D plan,
 the per-month cost for these medications using the higher value medication list could be reduced to about $20/month out of pocket, including the monthly premium, copay, and annual deductible. However, many patients do not sign up for Medicare Part D due to the cost.

Discontinue nonessential medications started during a hospital stay.

In the hospital, this patient was started on a proton pump inhibitor, omeprazole. Proton pump inhibitors are sometimes started as prophylaxis against stress ulcers, but there is 
no evidence to support this
outside of the intensive care unit, and proton-pump inhibitors are associated with an increased risk of pneumonia and 
difficile
 colitis.

Always switch back to generics from brand-name hospital formulary medications.

Hospital formularies often contain expensive brand-name medications obtained through special pricing arrangements between the hospital and pharmaceutical companies.

In this case, generic lisinopril was substituted for the brand name Prinivil and carvedilol was substituted for brand name Coreg. Although brand name Crestor is available as generic rosuvastatin, another high intensity statin, atorvastatin, was less expensive in Mrs. Miller’s town. Aquifer High Value Care 04: 80-year-old woman – Medications and value

If there is no generic for the brand-name drug chosen, consider whether it is appropriate to switch to a drug in the same class that does have a generic option available.

 

 

 

CARE DISCUSSION

CARE DISCUSSION

It is hospital day four. Mrs. Miller’s dyspnea has resolved, and she is near her goal weight. You plan to discharge her later this morning.

Question

What is the 
best
 way to educate your patient about her medications before discharge? Choose the single best answer.

Use the teach-back method to review the medication list with the patient and her daughter.

Have the nurse review the medication list with the patient and her daughter.

Ask the clinical pharmacist to do discharge medication education.

Order home health nursing and have the nurse check to make sure she is taking her medications correctly.

SUBMIT

TEACHING POINT

The teach-back method assesses the patient’s recall and comprehension of any new concept. It is an effective method for both assessing a patient’s understanding of a situation and providing education. It should be used to educate patients about their medications before hospital discharge.

References

Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. 
Arch Intern Med.
 2005;165(16):1842-1847
.

Wong JD, Bajcar JM, Wong GG, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. 
Ann Pharmacother.
 2008;42(10):1373-1379
.

White M, Garbez R, Carroll M, Brinker E, Howie-Esquivel J. Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? 
J Cardiovasc Nurs.
2013;28(2):137-46
.

Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication wtih diabetic patients who have low health literacy. 
Arch Intern Med.
 2003;163(1):83-90
.

 

Question

What is the 
best
 way to educate your patient about her medications before discharge? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

Use the teach-back method to review the medication list with the patient and her daughter.

Have the nurse review the medication list with the patient and her daughter.

Ask the clinical pharmacist to do discharge medication education.

Order home health nursing and have the nurse check to make sure she is taking her medications correctly.

SUBMIT

Answer Comment

The correct answer is A.

Discrepancies between what a patient is prescribed upon discharge from the hospital and what they actually take at home are common and are associated with a higher rate of hospital readmission, as happened in this case. Thoughtful patient education may improve adherence and reduce the chance of readmission. The 
teach-back method (A)
, in which a clinician assesses the patient’s recall and comprehension of any new concept, is an effective method for both assessing a patient’s understanding of a situation and providing education if the patient cannot demonstrate understanding. Using teach-back simply involves asking patients to restate information that has been presented to them. It allows the provider to check the patient’s understanding, reinforce important concepts, and engage in open dialogue.

Answers B and C are not the best answers as it is not clear that the nurse and pharmacist will use the teach back method. Ordering home health nursing and having the nurse check to make sure she is taking her medications correctly (D) is a strategy to identify medication nonadherence after it occurs. The best strategy should prevent nonadherence.

View guidelines for using teach-back in patient education.

Mrs. Miller receives her discharge instructions:

Mrs. Miller discharge instructions

Click here for a transcript of the video above.

 

DISCHARGE FOLLOW-UP

CARE DISCUSSION

You see Mrs. Miller in clinic with your preceptor three months later. Mrs. Miller has not been rehospitalized, and her heart failure has been stable. She has had one fall without serious injuries and continues to have trouble with her memory.

Your preceptor asks you to review the patient’s diabetes control during this visit. She has been on metformin and glipizide, and a recent HbA1C was 6.5%. She has stage II chronic kidney disease with a recent creatinine of 1.2 mg/dL and eGFR of 45. She watches her diet carefully, and in fact has lost ten pounds in the past year. Her BMI is 25. Aquifer High Value Care 04: 80-year-old woman – Medications and value

Question

What should you do today regarding Mrs. Miller’s diabetes management? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

Continue her metformin and glipizide; recheck a HbA1C in three months

Continue her metformin but stop the glipizide

Reduce the metformin to 500 mg po daily and stop the glipizide

Stop her metformin but continue the glipizide

Stop both her metformin and her glipizide

SUBMIT

Answer Comment

The correct answer is B.

Reducing medications in the elderly reduces harm. Elderly patients on more than 4 medications are at higher risk of adverse events such as falls.

Mrs. Miller is a frail, community-dwelling elderly person, with a life expectancy that is likely less than 10 years. See the Expert for more information regarding prognosis in the elderly. Her goal HbA1C should be about 8% based on 
current guidelines
 (see guideline #3).

Comorbidities

Goal HbA1C

Healthy older adults with long life expectancy

7-7.5%

Older adults with comorbidities and life expectancy <10 years 7.5-8% Multiple comorbidities and shorter life expectancy, including most patients in long-term care facilities 8-9% Because Mrs. Miller’s HbA1C was 6.5%, and because she had fallen and is at increased risk of falling with hypoglycemia, her glipizide should be stopped, thus answers (A) and (D) are incorrect. In the future, the metformin could be decreased (C) or stopped (E) depending on her A1c and renal function. Her weight should be monitored closely because weight loss in the elderly is a marker of frailty and may reflect difficulties with self-care in a patient with cognitive impairment. Glipizide should be stopped before metformin because of the risk of hypoglycemia with sulfonylureas and better evidence for efficacy and safety in the older population with metformin. TEACHING POINT Reducing medications in the elderly reduces harm. Considering an elderly patient’s life expectancy before offering interventions is an important part of high-value care in this population. References Sue Kirkman M, Briscoe VJ, Clark N, et al. Diabetes in older adults: a consensus report.  J Am Geriatr Soc.  2012;60(12):2342-56 . DEEP DIVE References Yourman L, Lee S. Prognostic Indices for Older Adults: A Systematic Review.  JAMA.  2012;307(2);182-192 . This is the final page of the case. We value your perspective on the learning experience. After completing three required feedback ratings you can finish the case and access the case summary. Aquifer High Value Care 04: 80-year-old woman – Medications and value

Organizational Structures and Leadership sample essay

In most health care settings, it is unlikely that you would hear the terms “ad hoc” or “matrix” as you walk down the hallway. Although it is helpful for any organization to delineate pathways of responsibility and authority in an organizational chart, the lived experience of these structures is most apparent through the inquiries and behaviors people share everyday.

BUY A PLAGIARISM-FREE PAPER HERE

In your own workplace, you may find yourself wondering, who should I turn to when I have a practice dilemma? or Where can I go to learn more about this issue? Organizational Structures and Leadership sample essay. These questions speak to the intricacies of formal and informal organizational structure and leadership.

To prepare:

· Review the information presented in Chapter 12 of the course text. Focus on the information about formal versus informal structure as well as the types of organizational structures. Organizational Structures and Leadership sample essay.

· Consider the overall structure or hierarchy of your organization or one with which you are familiar. Which organizational structure best describes your organization—line (or bureaucratic), ad hoc, matrix, service line, or flat? 
Note:
 It is possible to have a combination of structures in one organization. Is decision making centralized or decentralized in this organization?

· What is the role of committees, task forces, and councils in the organization, and who is invited to join? Consider how this relates to formal and informal leadership.

· Reflect on how decisions are made within a specific department or unit. Which stakeholders provide input or influence the decision-making process? Assess this in terms of formal and informal leadership.

· To support your analysis, consider your own experiences and investigate these matters by speaking with others at the organization and reviewing available documents. Be sure to consider how the concepts of formal and informal structure and leadership relate to one another and are demonstrated in the organization and in the particular department or unit. Organizational Structures and Leadership sample essay.

Post 
a depiction of your organization’s formal structure, indicating whether it is best described as line, ad hoc, matrix, service line, flat, or a combination. Describe how decisions are made within the organization and within one department or unit in particular, noting relevant attributes of centralized/decentralized decision making. Explain the influence of formal and informal leadership on decision making within this department or unit. Organizational Structures and Leadership sample essay.

Learning Resources

Required Readings

Marquis, B. L., & Huston, C. J. (2017). 
Leadership roles and management functions in nursing: Theory and application 
(9th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

· Chapter 2, “Classical Views of Leadership and Management” Organizational Structures and Leadership sample essay.

 

The information introduced through this chapter relates to this week’s Discussion, and will also be referred to in future weeks of the course.

 

· Chapter 3, “Twenty-First Century Thinking About Leadership and Management”

 

This chapter examines new thinking about leadership and management and how this may influence the future of nursing.

 

· Review Chapter 12, “Organizational Structure”

Allmark, P., Baxter, S., Goyder, E., Guillaume, L. & Crofton-Martin, G. (2013), Assessing the health benefits of advice services: Using research evidence and logic model methods to explore complex pathways. 
Health & Social Care in the Community, 21
, 59–68. doi:10.1111/j.1365-2524.2012.01087.x Organizational Structures and Leadership sample essay

 

This manuscript examines causal pathways between the provision of advice services and improvements in health. It may also be useful to commissioners and practitioners in making decisions regarding development and commissioning of advice services.

Downey, M., Parslow, S., & Smart, M. (2011). The hidden treasure in nursing leadership: Informal leaders. 
Journal of Nursing Management, 19
(4), 517–521.

Retrieved from the Walden Library databases. Organizational Structures and Leadership sample essay.

 

Informal leaders can have a strong impact in the workplace. This article explores the value informal leaders can provide.

Stetler, C. B., Ritchie, J. A., Rycroft-Malone, J., & Charns, M. P. (2014). Leadership for evidence-based practice: strategic and functional behaviors for institutionalizing EBP. 
Worldviews on Evidence-Based Nursing
, 
11
(4), 219–226. doi:10.1111/wvn.12044

Retrieved from the Walden Library databases.

Required Media

Laureate Education (Producer). (2012a). 
Diverse organizational structures.
Baltimore, MD: Author. Organizational Structures and Leadership sample essay.

High Value Care 03: 65-year-old woman – Adult preventive care and value

Author(s):
 Heather Harrell, MD University of Florida College of Medicine

PREVENTIVE CARE REVIEW

TEACHING

You are rotating in the outpatient clinic with Dr. Pritti, who asks you to see Lynda Jacobsen, a 65-year-old homemaker here for her “Welcome to Medicare” wellness visit. She reports no acute concerns but wants to get “every test Medicare will cover” as she plans to live to be 100. You recall there is more to prevention than just ordering tests.

Question

Which of the following are major categories of preventive care? Select all that apply.

Stages of change

Screening examinations

Diagnostic testing

Behavioral counseling

Immunizations

Prescription medications

Integrative care plans

SUBMIT

CONTINUE

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Answer Comment

The correct answers are B, D, E.

The four major categories of preventive care are:

Screening (B),

Behavioral counseling (D)
,

Immunizations (E)
, and

Chemoprevention
.

“Stages of change” (A) is a model used to help assess an individual’s readiness to make a behavioral change and can be helpful when performing behavioral counseling.

Tests used for screening are often the same as those used for diagnosis. However, the 
purpose
 of screening tests is not just to identify potential disease but to identify diseases in time to prevent consequences and complications. Diagnostic testing (C) is performed to determine the cause of a symptom and prescription medications (F) are used to manage health problems.

An “integrative care plan” (G) could mean applying integrative medicine (a blend of allopathic medicine and complementary medicine) into a preventive medicine plan, but this term is also used in many other contexts and is not a major category of preventive care.

HISTORY

HISTORY

You interview Ms. Jacobsen and learn that she enjoys good health. She is transferring her care from her gynecologist, Dr. Archy, because her friends said that at her age she needs an internist. She had seen Dr. Archy for the past 15 years, ever since she underwent a hysterectomy for uterine fibroids (leiomyomas, or benign tumors of the uterine muscle).

You review Dr. Archy’s records:

Test Results

Pap smears annually: All normal

Breast examinations annually: All normal

Mammograms annually: All normal

Colonoscopy 5 years ago: Normal

Bone densitometry every 2 years: Normal

Fasting lipid profile annually: Most recent LDL 98 mg/dL; HDL 50 mg/dL; triglycerides 78 mg/dL

Immunizations

Annual flu vaccine

Herpes zoster vaccine (Zostavax) 1 year ago

Ms. Jacobsen follows a low-fat diet and takes a daily multivitamin. She attends Zumba classes three times a week and sees a personal trainer weekly for weight training. She does not use tobacco products and drinks 2 to 3 alcoholic beverages a night with her dinner.

The physical examination is normal, including a BP of 120/70 mmHg and BMI of 24.9.

As you leave the room to speak with Dr. Pritti, Ms. Jacobsen hands you a flier she picked up at her church advertising “Vital Life,” a mobile screening bus that offers the following tests:

Comprehensive metabolic testing

Fasting lipid panel

Advanced cardiac screen (C reactive protein, lipoprotein a, homocysteine)

ECG

Vascular disease screen (ankle-brachial index, ultrasound of abdominal aorta and carotid arteries)

EBCT scan of the chest for coronary artery disease

Bone densitometry

She asks you to give the flier to Dr. Pritti and let her know she wants every test that Medicare will cover. You would like to see if the tests she is interested in are recommended for someone of her age and with her medical conditions.

Question

Which of the following are reliable sources for high quality, evidence-based preventive care recommendations? Select all that apply.

U.S. Preventive Services Task Force (USPSTF)

Centers for Disease Control and Prevention (CDC)

Agency for Healthcare Research and Quality (AHRQ)

Choosing Wisely® Campaign

“Prevention” website

Answer Comment

The correct answers are A, B, C, D.

Preventive Care Guidelines

There are numerous guidelines that pertain to preventive care, and it can be difficult to decide which are reliable. 
Health and Medicine Division (formerly The Institute of Medicine (IOM)
 has proposed the following eight standards that should be part of guideline development:

Standard 1: Establishing Transparency

Standard 2: Management of Conflict of Interest

Standard 3: Guideline development group composition

Standard 4: Clinical practice guideline-systematic review intersection

Standard 5: Establishing evidence foundations for and rating strength of recommendations

Standard 6: Articulation of recommendations

Standard 7: External review

Standard 8: Updating

The 
USPSTF
 (A)
 is considered by many to be the gold standard in this country for evidence-based preventive care recommendations. It is the reference used by Medicare to determine which screening tests will be covered.

The USPSTF used to make immunization recommendations but now defers to the 
CDC
 (B)
 guidelines because the CDC has its own rigorous review process.

AHRQ
 (C)
 relies primarily on the USPSTF recommendations.

Choosing Wisely®
 (D)
 is an initiative of the American Board of Internal Medicine Foundation that has been joined by over 50 specialty societies. Unlike the USPSTF, which focuses more on what preventive care physicians should recommend, Choosing Wisely® is a compilation of evidence-based lists of tests (both preventive and diagnostic) and treatments that physicians and patients should question because they are of low value.

While some commercial internet websites, such as 
“Prevention”
 or other media (E) base their recommendations on guidelines that follow the standards described above, this is not always the case. These types of websites contain obvious conflicts of interest with advertisers and sponsors. Additionally, anecdotes and low quality studies are weighted similarly to high quality evidence, the process by which recommendations are made is unclear, and there is no clear peer review process.

 

 

 

 

PREVENTIVE SERVICES GUIDELINES

TEACHING

You know Dr. Pritti will ask for your thoughts, so you decide to use the 
electronic preventive services selector (ePSS)
 app that you downloaded from the AHRQ website. The app will show you all of the USPSTF preventive service recommendations for a sexually active, nonsmoking woman 65 years of age listed by grade.

The USPSTF grades their recommendations based on the amount and quality of evidence supporting each intervention.

USPSTF Grade Definitions after July 2012

View full table provided by US Preventive Services Task Force

Grade

Definition

A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

C

The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgement and patient preferences. There is at least moderate certainty that the net benefit is small.

D

The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

I Statement

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Question

Match each test listed on the Vital Life brochure with its USPSTF grade. (For each item, select an option from the list box.)

Bone densitometry  — select an option — Grade B Grade C Grade D Grade I

Fasting lipid panel  — select an option — Grade B Grade C Grade D Grade I

Abdominal aorta ultrasound  — select an option — Grade B Grade C Grade D Grade I

Carotid artery ultrasound  — select an option — Grade B Grade C Grade D Grade I

ECG  — select an option — Grade B Grade C Grade D Grade I

Advanced cardiac screen (C reactive protein, lipoprotein-a, homocysteine)  — select an option — Grade B Grade C Grade D Grade I

Ankle-brachial index  — select an option — Grade B Grade C Grade D Grade I

EBCT (Electronic Beam Computed Tomography) scan of the chest for coronary artery disease  — select an option — Grade B Grade C Grade D Grade I

SUBMIT

CONTINUE

 

 

Question

Match each test listed on the Vital Life brochure with its USPSTF grade. (For each item, select an option from the list box.)

PARTIALLY CORRECT

Bone densitometry  — select an option — Grade B Grade C Grade D Grade I
Grade B

Fasting lipid panel  — select an option — Grade B Grade C Grade D Grade I
Grade C

Abdominal aorta ultrasound  — select an option — Grade B Grade C Grade D Grade I
Grade D

Carotid artery ultrasound  — select an option — Grade B Grade C Grade D Grade I
Grade D

ECG  — select an option — Grade B Grade C Grade D Grade I
Grade D

Advanced cardiac screen (C reactive protein, lipoprotein-a, homocysteine)  — select an option — Grade B Grade C Grade D Grade I
Grade I

Ankle-brachial index  — select an option — Grade B Grade C Grade D Grade I
Grade I

EBCT (Electronic Beam Computed Tomography) scan of the chest for coronary artery disease  — select an option — Grade B Grade C Grade D Grade I
Grade I

SUBMIT

Answer Comment

Correct answers:

Grade A

Blood Pressure screening

Grade B

Bone densitometry

Grade C

Fasting lipid panel

Grade D

Abdominal aorta ultrasound

Carotid artery doppler

ECG

Grade I

Advanced cardiac screen

Ankle-brachial index

EBCT

The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Use the National Heart, Lung, and Blood Institute’s (NHBLI’s) 10-year cardiac 
risk calculator
to calculate Ms. Jacobsen’s cardiac risk. Even though her lipid levels fall just within normal limits (total cholesterol 199 mg/dL and HDL 41 mg/dL), Ms. Jacobsen’s cardiac risk is low, so screening her would fall into the USPSTF’s Grade C category.

(Note that the latest 
AHA/ACC guidelines
 recommended checking lipids to calculate 10 year ASCVD risk every four – six years in healthy adults aged 40 – 75.)

Similarly, the USPSTF recommends (Grade B) 
bone densitometry
 in women 65 or younger if they are at increased risk of fracture (i.e., have a 10-year fracture risk of ≥ 9.3%, or that of a 65-year-old white woman).

If Ms. Jacobsen’s bone density was unknown, her risk of fracture calculated by 
FRAX
(a fracture risk assessment tool developed by the World Health Organization) would be 12% for any fracture and 2.3% for a hip fracture.

Jacobsen, however, has previously been screened and was determined to have normal bone density. When her known normal femoral neck bone density is included in the FRAX calculation, her 10-year risk of fracture is reduced to 6.5% (any fracture) and 0.1% (hip fracture). So, the B recommendation does not apply to Ms. Jacobsen.

Obtaining screening 
ultrasounds
 (for 
abdominal aorta
 aneurysm in women and 
carotid artery
 stenosis) and performing 
ECG
s in low-risk adults both receive Grade D recommendations from the USPSTF. This means there is evidence that routine testing may result in greater harm than benefit to the patient. The recommendation is therefore against ordering these tests for screening purposes. Aquifer High Value Care 04: 80-year-old woman – Medications and value

There is insufficient evidence (Grade I) about using nontraditional coronary artery disease risk factors, including electronic beam computed tomography (
EBCT
) results, 
C reactive protein, lipoprotein-a, homocysteine,
 and 
ankle-brachial indices
 to make recommendations for or against these interventions.

 

 

TESTING RISKS AND BENEFITS

TEACHING

Dr. Pritti asks you, 
“What do you think of this brochure? Would you recommend we order any of these things?”

You answer, “I looked at the USPSTF guidelines, and it seems like she isn’t due for any of the tests she is requesting, though it does look like she needs a pneumonia vaccine and the TdaP booster, as she hasn’t had those.

“She is expecting to get her blood drawn, and I’m afraid she will be upset if we don’t do it. I don’t think it will really harm her to get a little blood work if it keeps her from getting upset. However, we can tell her we checked her blood pressure as recommended on the brochure and that it looks normal.”

Dr. Pritti responds, 
“I agree with your vaccine recommendations, and I also agree that it is important to incorporate a patient’s goals into our decision-making. However, I’m not sure I agree that there is 
no
 potential harm to testing without a clear indication.”

Question

What are potential harms of minimally invasive tests like blood work or an EKG? Select all that apply.

Falsely abnormal tests

Incidental findings

Financial cost to the patient

Financial cost to society

Anemia

Time spent reviewing tests that could be spent in other ways of more direct benefit to patients

Patient anxiety

Answer Comment

The correct answers are A, B, C, D, F, G.

All tests have the possibility of yielding a 
falsely abnormal result (A)
 or 
incidental finding (B),
 either of which can lead to further testing and 
patient anxiety (G).
 For example, a third to half of patients with angiographically normal coronary arteries have Q or ST wave abnormalities, or T wave inversions on a resting ECG.

Likewise, most tests impose a 
financial cost to the patient (C)
 (see High Value Care 06: 65-year-old man – Paying for value: Insurance Part 1 for more information).

A screening test is performed in a patient who, by definition, has 
no symptoms
. Thus, if the result yields no clear benefit to the patient, then the testing is completely unnecessary. This is in contrast to a patient 
with symptoms,
who requires evaluation: even though there is a cost and the potential for false positive results, the testing is necessary, and there is potential for the patient to benefit from it. Aquifer High Value Care 04: 80-year-old woman – Medications and value

While not all tests have a 
financial cost to society (D)
 – indeed, it is financially beneficial to screen for some diseases – tests without a clear benefit to the patient are also costly for society (see the Expert button for more about population health).

Reviewing the results of tests requires time (F)
 and, given current time constraints in ambulatory medicine, time spent reviewing results of unnecessary testing is wasted time that is of no value to patients or the healthcare system.

Anemia (E) is a potential consequence of repeated blood draws, such as can occur during a hospitalization, but a single blood draw for outpatient tests will not cause anemia.

 

 

 

TESTING COSTS

THERAPEUTICS

You tell Dr. Pritti, “That went better than I thought it would. I noticed you didn’t repeat my physical examination. Should I not have done all of that?”

Dr. Pritti answers, “Technically, the only parts of the physical examination that her ‘Welcome to Medicare’ visit requires blood pressure, BMI, and vision screen, which I reviewed and did not need to repeat. The rationale is that it is unlikely we will pick up any significant abnormal findings in a healthy, asymptomatic patient. Thus, our time would be better spent assessing risk and counseling. There are many good reasons to perform a physical examination, but based on your insights about her expectations and concerns about her alcohol use, I wanted to make sure we had time to address those issues. As it turned out we did need that time today.”

More of Ms. Jacobsen’s records arrive on the fax and you discover that her yearly “routine blood work” consisted of a CBC with differential, lipid panel, comprehensive metabolic panel, and thyroid stimulating hormone. You confirm that her bone densities, pap smears, and mammograms were all normal. Aquifer High Value Care 04: 80-year-old woman – Medications and value.

Now that you have reviewed a few of the preventive care guidelines, you identify many potential areas of waste in Ms. Jacobsen’s past care. You wonder what was the financial cost of past testing that was not of clear benefit to her and decide to make a comparison:

Cost of Testing Over 15 Years

Cost of Testing

You ask Dr. Pritti, “I guess I knew that all tests have a potential downside, but I was also concerned about her alcohol consumption, and I wondered whether you ever would compromise on something a patient wants in order to put them in a better mood when you need to discuss something they need to change like alcohol or diet?”

Dr. Pritti responds, “That’s a good question, and I don’t want to give you the impression that shared decision making can’t accommodate reasonable compromises. Why don’t we go into the room together and I will try to role-model the process for you.”

 

Question

Which of the five major steps to behavior change were applied?

Assess

Advise

Agree

Assist

Arrange

Assurance

SUBMIT

This is the final page of the case. We value your perspective on the learning experience. After completing three required feedback ratings you can finish the case and access the case summary.

 

 

TEACHING

CARE DISCUSSION WITH PATIENT

CARE DISCUSSION

You reflect on the interaction you just observed.

Question

Which of the five major steps to behavior change were applied?

The best options are indicated below. Your selections are indicated by the shaded boxes.

Assess

Advise

Agree

Assist

Arrange

Assurance

SUBMIT

Answer Comment

The correct answers are A, B, C, D, E.

The “5 As”

The five major steps to intervention-also known as the “5 As”-are:

Assess

Advise

Agree

Assist

Arrange

You 
assessed (A)
Ms. Jacobsen’s alcohol use, which allowed you to identify a problem Aquifer High Value Care 04: 80-year-old woman – Medications and value.

Dr. Pritti 
advised (B)
 her to cut down her alcohol using clear, personalized language.

Ms. Jacobsen 
agreed (C)
 and, with you and Dr. Pritti, collaboratively set specific goals.

Dr. Pritti 
arranged (E)
 follow up by telephone in a week.

Although 
assist (D)
 is one of the 5 As, it was not clear that Ms. Jacobsen required further assistance.

Assurance (F) is not one of the five major steps to intervention.

Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care

Aquifer High Value Care 04: 80-year-old woman – Medications and value

Assignment: Application: Systems Theory

As noted in the Learning Resources, systems theory provides a meaningful and beneficial means of examining challenges in health care organizations. To do this effectively, however, it is essential to assess all system components, as some may be relatively healthy while others are problematic.

For this Assignment, you apply systems theory to the examination of a problem in a department or a unit within a health care organization. (Note: You may use the same problem you identified for the Discussion as long as it meets the criteria for this Essay assignments: NURS 6053 Interprofessional Organizational & Systems Leadership assignment.)

BUY A PLAGIARISM-FREE PAPER HERE

To prepare:

Review the Meyer article, “Nursing Services Delivery Theory: An Open System Approach,” in this week’s Learning Resources. Focus especially on the information presented in Table 1 (p. 2831) and Figure 2 (p. 2833). Assignment: Application: Systems Theory.

Reflect on your organization or one with which you are familiar. Within a particular department or unit in this organization, identify a problem the staff is encountering

Using Table 1 in the Meyer article as a guide, analyze the department or unit, identifying inputs, throughput, output, cycles of events, and negative feedback. Consider whether the problem you have selected relates to input, throughput, output, cycles of events, and/or negative feedback. Essay assignments: NURS 6053 Interprofessional Organizational & Systems Leadership Paper.

Think about how you could address the problem: Consider what a desired outcome would be, then formulate related goals and objectives, and translate those goals into policies and procedures.

Research professional standards that are pertinent to your identified problem.

Reflect on the organization’s mission statement and values. In addition, consider how addressing this problem would uphold the mission and values, while improving the organizational culture and climate. (Depending on the organization you have selected, you may have explored these in the Week 1 Discussion.) Assignment: Application: Systems Theory. Essay assignments: NURS 6053 Interprofessional Organizational & Systems Leadership Paper.

To complete:

By Day 7

Write a 3- to 5-page Essay assignments: NURS 6053 Interprofessional Organizational & Systems Leadership paper (page count does not include title and reference page) that addresses the following:

Describe a department or unit within a health care organization using systems theory terminology. Include a description of inputs, throughput, output, cycles of events, and negative feedback Assignment: Application: Systems Theory.

Describe the problem you identified within the department or unit using an open- systems approach, and state where the problem exists using the systems theory model (input, throughput, output, cycles of events, or negative feedback). Essay assignments: NURS 6053 Interprofessional Organizational & Systems Leadership Paper.

Based on this information, explain how you would address the problem as follows:

Formulate a desired outcome.

Identify goals and objectives that would facilitate that outcome.

Translate those goals and objectives into policies and procedures for the department or unit.

Describe relevant professional standards. Essay assignments: NURS 6053 Interprofessional Organizational & Systems Leadership Paper

Explain how your proposed resolution to the problem would uphold the organization’s mission and values and improve the culture and climate.

The Assignment, Systems Theory, is due by Day 7 of Week 2.

Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements. All papers submitted must use this formatting.

This Assignment is due by Day 7 of Week 2 (this week) and must be submitted through the Week 2 Assignment Link.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK2Assgn+last name+first initial.(extension)” as the name Assignment: Application: Systems Theory.

Click the Week 2 Assignment Rubric to review the Grading Criteria for the Assignment.

Click the Week 2 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.

Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK2Assgn+last name+first initial.(extension)” and click Open.

If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.

Note: I am retired military officer: Decision making within the organizational hierarchy is typically decentralized. The top-level leaders make decisions on the organization’s goals, but decisions are made at all levels of management creating the decentralized hierarchy. Also, the formal leadership style at this organization is a combination of transactional, transformational, situational and serving leader style Assignment: Application: Systems Theory.

Note: The military culture is a unique organization in its own ways such as its mission, vision, strategic planning, and military community lifestyle. The current organization primary mission is to Treat- Teach -Train. That being said, its mission is based on deployment platforms and a teaching hospital.

Vision Statement: Superior Health Care and Readiness through prevention, innovation and partnerships (Local communities hospital and VA)

***I have included my week 1 writing discussion for reference. Assignment: Application: Systems Theory.