wk3 PRAC

see 3 attachments. Due this Wednesday

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

TEMPLATE

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan:

References

© 2021 Walden University Page 1 of 3

WK3 PRAC. Please use the template and see the exemplar.

Case: The client is 16-year-old female with history of cannabis abuse, ADHD, DMDD. Client reports doing well, sleeping and appetite is good. She reports taking her medication as prescribed and denies any side effects from medications. Client report mood is stable with no behavioral concerns. She reports maintaining good grades at school. Current medications are Intuniv 1mg every morning for ADHD, Focalin XR 5mg Po every morning for adhd, Seroquel 100mg qhs for mood. During this encounter, we discussed diagnosis, rationale, risks, benefit and side effects of medications and treatment with parent. Client and parent verbalized understanding and gave consent for medication and treatment.

 

Expectation.

 

· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

 

· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

 

 

Specifically address the following for the patient, using your SOAP note as a guide:

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

· Objective: What observations did you make during the psychiatric assessment?

· Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.

· Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.

· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

· At least 3 citations and 3 references.

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

 

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric history

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies

· ROS

Read rating descriptions to see the grading standards!

In the Objective section, provide:

· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

Read rating descriptions to see the grading standards!

In the Assessment section, provide:

· Results of the mental status examination, presented in paragraph form.

· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case .

· Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate critical thinking beyond confidentiality and consent for treatment !), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

 

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

 

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

 

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

 

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

 

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

 

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

 

Follow up with PCP as needed and/or for:

 

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

 

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

 

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

 

 

© 2021 Walden University Page 1 of 3

Homework

Nurses often become motivated to change aspects within the larger health care system based on their real-world experience. As such, many nurses take on an advocacy role to influence a change in regulations, policies, and laws that govern the larger health care system.

For this assignment, identify a problem or concern in your state, community, or organization that has the capacity for advocacy through legislation. Research the issue and use the “Advocacy Through Legislation” template to complete this assignment.

You are required to cite to a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide.

case study on moral status

 

Based on “Case Study: Fetal Abnormality” and the required topic study materials, write a 750-1,000-word reflection that answers the following questions:

  1. What is the Christian view of the nature of human persons, and which theory of moral status is it compatible with? How is this related to the intrinsic human value and dignity?
  2. Which theory or theories are being used by Jessica, Marco, Maria, and Dr. Wilson to determine the moral status of the fetus? What from the case study specifically leads you to believe that they hold the theory you selected?
  3. How does the theory determine or influence each of their recommendations for action?
  4. What theory do you agree with? Why? How would that theory determine or influence the recommendation for action?

Remember to support your responses with the topic study materials.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center

Transcultural Health

Diversity has a significant influence on health care. Studying transcultural health care helps health professionals understand different cultures in order to provide holistic and individualized health care. Review the Purnell Model for Cultural Competence, including the theory, framework and 12 domains. Write 750-1,000-word paper exploring the Purnell Model for Cultural Competence. Include the following:

  1. Explain culturally sensitive care and its application within health care.
  2. Explain the theory and organizational framework of the Purnell Model, and discuss its relevance to transcultural health care.
  3. Describe Purnell’s 12 domains of culture, and assess how each of these domains plays an active role in the diversity of health care in your specific field.
  4. Discuss how this model can be applied when working with different cultures in order to become a more culturally competent health care provider.
  5. Cite at least three references, including the course textbook.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

 

This benchmark assignment assesses the following programmatic competency:

BS Health Sciences

1.1 Explain culturally sensitive care and its application within health care.

Homework

Choose a legislator on the state or federal level who is also a nurse and discuss the importance of the legislator/nurse’s role as advocate for improving health care delivery. What specific bills has the legislator/nurse sponsored or supported that have influenced health care.

Research legislation that has occurred within the last 5 years at the state or federal level as a result of nurse advocacy. Describe the legislation and what was accomplished. What additional steps need to be taken to continue advocacy for this issue?

Health community (communicating with different culture).

The ability to communicate, interact with different cultures, and think critically is essential in the medical field. The interactive media scenario you will use for this assignment illustrates a situation that could easily arise when working in health care. To complete this assignment, access the “Allied Health Community” media link in the study materials and complete the following:

  1. Click “Enter” to begin.
  2. Click on the box that says “SCENARIOS.”
  3. Click on “View Scenario” for the “Critical Decision Making for Providers.”
  4. Examine how the described problem might happen in your facility and the impact it could have. Work through this situation by examining all of the choices presented in the scenario.
  5. When you get to the end of the scenarios, one scenario will have the word “Transcultural” on the top right corner. Click on “Transcultural.” Read the scenario and answer the four questions that are provided.

While APA style is not required for this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide located in the Student Success Center.

below is the link:

http://lc.gcumedia.com/hlt307v/allied-health-community/allied-health-community-v1.1.html

Nursing role and scope

Watch the following presentation

Leading change: How nursing can shape health care policy (2015- Columbia University, 31 minutes)

Https://www.youtube.com/watch?v=__F_osVYCa8

Consider your current level of activity in politics and the policy process arena.

Describe your current level of involvement (this could be as only a registered voter, being on policy committees at work, involvement in local, state, or federal legislative activities, nurse’s association involvement, etc.).

Identify a problem in your clinical setting and explain how the problem could be framed as a policy issue. What ethical issues surround the problem? What type of research would best support your problem as a policy issue?

Nursing Research

Part 3. Review of the Literature

In this post you will provide a comprehensive Review of the Literature that you have found in your research about your PICOT question topic. Please see your textbook for the proper way to write a comprehensive review of the literature (ROL). You must review at least (at minimum) FIVE recent (< 5 years old) NURSING scholarly research articles related to your topic. You may add/discuss additional websites, textbooks or older articles but you must discuss and reference at least FIVE articles as described above.

You are required to attach your FIVE SCHOLARLY NURSING JOURNAL ARTICLES to your initial post.

Example – please note this is an older previous students work and so some references are older than 5 years.

Be sure to provide the PICOT question to begin this post.

PICOT Question:

P=Patient Population

I=Intervention

C=Comparison

O=Outcome

T=Time (duration):

In patients in the hospital, (P)

how does frequently provided patient hand washing (I)

compared with patient initiated hand washing (C)

affect hospital acquired infection (O)

within the hospital stay (T)

Review of the Literature:

Although there is a substantial amount of literature on the effect of hand washing in health care workers, there is not as much pertaining to patient hand hygiene and hospital acquired infection (HAI). Strigley, Furness, Gardam (2014), provide a study to measure the instances of hand washing. There were faults to the measurement but it did provide a system to specifically document the act of hand washing. The results reveal that there is a level of decrease of microorganisms on hands, which then leads to a decrease of transmission of infections (Strigley, Furness, Gardam, 2014). Aziz (2014) reveals that hand washing ranked as the number one most important infection prevention and control measure. The organizational staff is a key to this study (Aziz, 2014). Hand hygiene protocols are important to initiate to start the cycle of prevention (Gujral, 2015). In the study by Fox, Wavra, Drake, Mulligan, Bennet, Nelson, Kirkwood, Jones, and Badger (2015) results indicate a hand washing decreased catheter associated urinary tract infection although it was not a significant change. A limitation is that the study was limited to the critical care unit. In contrast, DiDiodato’s (2013) broader study of 12 million residents in Ontario showed a significant reduction in incidences of HAI related to hand washing. Further research is needed to study specifically the effect of the patient’s role in hand washing and HAI. Nursing research allows us to comprise new strategies to help bring awareness of hand hygiene to patients.

References

Aziz, A. (2014). Hand hygiene compliance for patient safety. British Journal of Healthcare Management, 20 (9), 428-434. Retrieved from http://www.magonlinelibrary.com/toc/bjhc/current

Fox, C., Wavra, T., Drake, D., Mulligan, D., Bennet Y., Nelson, C., Kirkwood, P., Jones, L., Bader, M. (2015). Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses hand washing. American Journal of Critical Care, 24(3), 216-224. DOI: http://dx.doi.org/10.4037/ajcc2015898

Gujral, H. (2015.) Survey shows importance of hand washing for infection prevention. American Nurse Today, 10 (10), 20. Retrieved from hEp://www.nursingworld.org/AmericanNurseToday

Strigley, J., Furness, C., Gardam, M. (2014). Measurement of patient hand hygiene in multiorgan transplant units using a novel technology: An observation study. Infection Control & Hospital Epidemiology, 35 (11), 1336-1341. DOI:http://dx.doi.org/10.1086/678419

DiDiodato, G. (2013). Has improved hand hygiene compliance reduced the risk of hospital-acquired infections among hospitalized patients in Ontario? Analysis of publicly reported patient safety days from 2008 to 2011. Infection Control & Hospital Epidemiology, 34 (6), 605-610.

Assistance

Please assist

1. Amoxicillin

2. Docusate (Colace)

3. Aspirin

4. Nitroglycerine

5. Metoprolol (Lopressor)

6. Ferrous Sulfate

7. Oxycodone/acetaminophen ( Percocet)

8. Ibuprofen (Advil)

9. Furosemide (Lasix)

10. Potassium Chloride

Benzodiazepine –temazepam (Restoril) Non-benzodiazepine – zolpidem (Ambien), baclofen (Lioresal), dantrolene (Dantrium) – celecoxib (Celebrex), tramadol (Ultram), morphine, – butorphanol (Stadol), pentazocine (Talwin), naloxone (Narcan), allopurinol (Zyloprim), prednisone (Deltasone), ondansetron (Zofran), prochlorperazine (Compazine), dimenhydrinate (Dramamine), metoclopramide (Reglan), psyllium (Metamucil), docusate sodium (Colace docusate sodium and senna (Peri-Colace), bisacodyl (Dulcolax), oxybutynin chloride (Ditropan), – bethanechol (Urecholine), aspirin, ibuprofen (Advil, Motrin)

Give the generic name, list indication, side effects, adverse effects, nursing indications/considerations and patient education.

There is an example included.

 

Research Problems and Designs

Would your problem identified in the Week 2 discussion question “Hospital Safety Culture” lend itself to a qualitative or quantitative design? What level of evidence (research design) would best address the problem? What type of study was performed to arrive to the conclusion? Explain your answer.

Use the same article to evaluate what type of research design it is.

Jones, K. J., Skinner, A., Xu, L., Sun, J., & Mueller, K. (2008). The AHRQ hospital survey on patient safety culture: a tool to plan and evaluate patient safety programs. Advances in patient safety: new directions and alternative approaches (Vol. 2: culture and redesign).