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**THIS DISCUSSION IS DIVIDE IN TWO PARTS –
Discussion: The Role of the RN/APRN in Policy Evaluation
In the Week 8 Discussion, you considered how professional nurses can become involved in policy-making. A critical component of any policy design is evaluation of the results. How comfortable are you with the thought of becoming involved with such matters?
Some nurses may be hesitant to get involved with policy evaluation. The preference may be to focus on the care and well-being of their patients; some nurses may feel ill-equipped to enter the realm of policy and political activities. However, as you have examined previously, who better to advocate for patients and effective programs and polices than nurses? Already patient advocates in interactions with doctors and leadership, why not with government and regulatory agencies?
In this Discussion, you will reflect on the role of professional nurses in policy evaluation.
To Prepare:
Instructions
** Use at least 3 references**
Left handed Right handed Total Female Male Total
© 2016 Keith Rischer/www.KeithRN.com
Cirrhosis
John Richards, 45 years old
Primary Concept
Nutrition
Interrelated Concepts (In order of emphasis)
1. Fluid and Electrolyte Balance
2. Perfusion
3. Cognition
4. Addiction
5. Clinical Judgment
6. Patient Education
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Cirrhosis
History of Present Problem:
John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and worsening
nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has had a poor appetite the
past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic binge drinking on most weekends.
John weighs 150 pounds (68.2 kg) and is 6’0″ (BMI 17.6). You are the nurse responsible for his care.
Personal/Social History:
John is single, has never married, and lives alone in his own apartment. He has struggled with heroin use/abuse in the past,
but has not used in the past two years. John is currently unemployed and has no health insurance. He was diagnosed with
hepatitis C ten years ago but has had minimal follow-up medical care since.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
*Hepatitis C–past history of
IV drug abuse
*ETOH abuse x 25 years
Ibuprofen 600 mg PO prn
for headache
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her
life?
Circle the PMH problem that likely started FIRST.
Underline the PMH problem(s) FOLLOWED as domino(s).
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 100.5 F/38.1 C (oral) Provoking/Palliative: Nothing/nothing
P: 110 (regular) Quality: Ache
R: 20 Region/Radiation: RUQ/epigastric
BP: 128/88 Severity: 6/10
O2 sat: 95% RA Timing: Continuous
© 2016 Keith Rischer/www.KeithRN.com
Orthostatic BP’s:
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Rationale:
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Rationale:
Lab Results:
Position: HR: BP:
Lying 110 128/88
Standing 132 124/80
Current Assessment:
GENERAL
APPEARANCE:
Appears uncomfortable, body tense, occasional facial grimacing
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Pink, warm & dry,1+ pitting edema lower extremities, heart sounds regular–S1S2, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen distended, large–rounded–firm to touch, bowel sounds audible per auscultation in
all 4 quadrants
GU: Voiding without difficulty, urine clear/light orange, loss of pubic hair
SKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and
oral mucosa tacky dry, softball-sized ecchymosis on abdomen
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 12.8 9.5
Hgb (12–16 g/dL) 10.2 11.2
Platelets (150-450 x103/µl) 98 122
Neutrophil % (42–72) 88 75
Band forms (3–5%) 3 0
© 2016 Keith Rischer/www.KeithRN.com
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT
Lab(s):
Clinical Significance: TREND:
Improve/Worsening/Stable:
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
PT/INR: 1.5 UP…worsening
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous:
Sodium (135–145 mEq/L) 135 138
Potassium (3.5–5.0 mEq/L) 3.5 3.8
Glucose (70–110 mg/dL) 78 88
BUN (7–25 mg/dl) 38 25
Creatinine (0.6–1.2 mg/dL) 1.5 1.1
Coags: Current: High/Low/WNL? Previous:
PT/INR (0.9–1.1 nmol/L) 1.5 1.2
Liver Function Test (LFT:) Current: High/Low/WNL? Previous:
Albumin (3.5–5.5 g/dL) 2.5 2.9
Total Bilirubin (0.1–1.0 mg/dL) 4.2 2.2
Alkaline Phosphatase
male: 38–126 U/l female: 70–230 U/l
285 155
ALT (8–20 U/L) 128 65
AST (8–20 U/L) 124 85
Misc. Labs:
Ammonia (11–35 mcg/dL) 35 28
© 2016 Keith Rischer/www.KeithRN.com
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required:
ALT
Value:
128
Critical Value:
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with?
2. What is the underlying cause/pathophysiology of this primary problem?
Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome:
Establish peripheral IV
NS 0.9% bolus of 1000 mL
Ondansetron 4 mg IV every
4 hours PRN
Orthostatic BP
PRIORITY Setting: Which Orders Do You Implement First and Why?
(Remember your ABCs!)
Care Provider Orders: Order of Priority: Rationale:
1. Establish peripheral IV
2. NS 0.9% bolus of 1000
mL
3. Ondansetron 4 mg IV
every 4 hours PRN nausea
4. Orthostatic BP
© 2016 Keith Rischer/www.KeithRN.com
Medication Dosage Calculation:
Medication/Dose: Mechanism of Action: Volume/time frame to
Safely Administer:
Nursing Assessment/Considerations:
Ondansetron 4 mg
IV
4mg/2 mL vial IV Push:
Volume every 15 sec?
Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (if more than one, list in order of PRIORITY)
4. What interventions will you initiate based on this priority?
Nursing Interventions: Rationale: Expected Outcome:
5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
6. What is the worst possible/most likely complication to anticipate?
7. What nursing assessments will identify this complication EARLY if it develops?
8. What nursing interventions will you initiate if this complication develops?
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
10. How can the nurse address these psychosocial needs?
© 2016 Keith Rischer/www.KeithRN.com
Evaluation: Six Months Later…
John continues to drink ETOH on a daily basis and has not followed through with his discharge plan when he was
discharged from the hospital six months ago. John is now homeless and lives in a shelter. He was brought into the ED by
emergency medical services (EMS) because he was found wandering aimlessly in the neighborhood and was completely
disoriented.
The primary care provider in the ED orders the following labs: CBC, BMP, LFT, and INR.
1. What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data: Rationale:
RELEVANT Assessment Data: Rationale:
Compare & Contrast: Last Nursing Assessment 6 Months Ago:
Emphasize that the nurse should look back at previous admissions, especially admission H&P, consultation H&P,
discharge summary, and labs/diagnostics as time allows. Discharge summary may be most important if time is of the
essence. An essential component of clinical reasoning is TRENDING clinical data. This TREND can be established from
most recent documentation in the medical record that could be hours, days or even months ago. This data is still relevant
and needed to establish this trend!
Current VS: Current PQRST:
T: 99.5 F/37.5 C (oral) Provoking/Palliative: DENIES
P: 118 (reg) Quality:
R: 22 (reg) Region/Radiation:
BP: 88/50 Severity:
O2 sat: 94% room air Timing:
Current
Assessment:
GENERAL
APPEARANCE:
Disheveled, clothing dirty, has strong body odor, appears unkempt, does not smell of ETOH
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Jaundiced, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Confused and disoriented to person, place, time, and situation (x4)
GI: Abdomen protuberant–distended, bowel sounds audible per auscultation in all 4 quadrants
GU: Voiding without difficulty, urine clear/orange
SKIN: Skin integrity intact, skin is yellow/jaundiced in color with yellow sclera
© 2016 Keith Rischer/www.KeithRN.com
2. Compare the current nursing assessment with his last assessment above. What has changed most
dramatically from his last assessment six months ago that is clinically significant?
3. Has his status improved or not as expected to this point?
Lab Results:
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Last Nursing Assessment 6 Months Ago:
GENERAL
APPEARANCE:
Appears uncomfortable, restless
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation
at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen large–rounded–firm to touch, bowel sounds audible per auscultation in all 4
quadrants
GU: Voiding without difficulty, urine clear/light orange
SKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips
and oral mucosa tacky dry
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 6.9 12.8
Hgb (12–16 g/dL) 8.9 10.2
Platelets (150-450 x103/µl) 47 98
Neutrophil % (42–72) 68 88
Band forms (3–5%) 3 3
Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous:
Sodium (135–145 mEq/L) 127 135
Potassium (3.5–5.0 mEq/L) 2.8 3.5
Glucose (70–110 mg/dL) 74 78
BUN (7–25 mg/dl) 55 38
Creatinine (0.6–1.2 mg/dL) 1.8 1.5
© 2016 Keith Rischer/www.KeithRN.com
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Coags: Current: High/Low/WNL? Previous:
PT/INR (0.9–1.1 nmol/L) 2.6 1.5
Liver Function Test (LFT:) Current: High/Low/WNL? Previous:
Albumin (3.5–5.5 g/dL) 2.2 2.5
Total Bilirubin (0.1–1.0 mg/dL) 7.2 4.2
Alkaline Phosphatase
male: 38–126 U/l female: 70–230 U/l
140 285
ALT (8–20 U/L) 59 128
AST (8–20 U/L) 62 124
Misc. Labs:
Ammonia (11–35 mcg/dL) 78 30
© 2016 Keith Rischer/www.KeithRN.com
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required:
Ammonia
Value:
78
Critical Value:
Medical Management: Rationale for Treatment & Expected Outcomes
Care Provider Orders: Rationale: Expected Outcome:
Lactulose 200 g/300 mL
rectal x1 NOW
Banana bag (thiamine 100
mg-folic acid 1 mgmultivitamin 10 mL) in 1000
mL of 0.9% NS over 2 hours
Potassium Chloride 10 mEq
IVPB (x4) each dose over 1
hour. Recheck potassium per
hospital protocol
Transfer to ICU
4. Does your nursing priority or plan of care need to be modified in any way after this evaluation and assessment of all
clinical data including labs?
5. Based on your current evaluation, and assessment of all clinical data, what are your nursing priorities and plan of
care?
John is going to be admitted to ICU. Effective and concise handoffs are essential to excellent
care and if not done well can adversely impact the care of this patient. You have done an
excellent job to this point, now finish strong and give the following SBAR report to the nurse
who will be caring for this patient:
© 2016 Keith Rischer/www.KeithRN.com
Situation:
Name/age:
BRIEF summary of primary problem:
Day of admission/post-op #:
Background:
Primary problem/diagnosis:
RELEVANT past medical history:
RELEVANT background data:
Assessment:
Current vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
TREND of any abnormal clinical data (stable-increasing/decreasing):
How have you advanced the plan of care?
Patient response:
INTERPRETATION of current clinical status (stable/unstable/worsening):
Recommendation:
Suggestions to advance plan of care:
© 2016 Keith Rischer/www.KeithRN.com
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with their medical condition to
prevent future readmission with the same problem?
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
2. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person?
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
2. How can I use what has been learned from this scenario to improve patient care in the future?
In this Week’s Discussion, you will demonstrate your skills related to explaining trauma and intervention to a client. This will require you explain the concepts in a manner that is understandable to the developmental and educational level of the client.
Please see attachment
Jake Levy
Identifying Data: Jake Levy is a 31-year-old, married, Jewish Caucasian male. Jake’s wife, Sheri, is 28 years old. They have two sons, Myles (10) and Levi (8). The family resides in a two-bedroom condominium in a middle-class neighborhood in Rockville, MD. They have been married for 10 years.
Presenting Problem: Jake, an Iraq War veteran, came to the Veterans Affairs Health Care Center (VA) for services because his wife has threatened to leave him if he does not get help. She is particularly concerned about his drinking and lack of involvement in their sons’ lives. She told him his drinking has gotten out of control and is making him mean and distant. Jake reports that he and his wife have been fighting a lot and that he drinks to take the edge off and to help him sleep. Jake expresses fear of losing his job and his family if he does not get help. Jake identifies as the primary provider for his family and believes that this is his responsibility as a husband and father. Jake realizes he may be putting that in jeopardy because of his drinking. He says he has never seen Sheri so angry before, and he saw she was at her limit with him and his behaviors. Family Dynamics: Jake was born in Alabama to a Caucasian, Eurocentric family system. He reports his time growing up to have been within a “normal” family system. However, he states that he was never emotionally close to either parent and viewed himself as fairly independent from a young age. His dad had previously been in the military and was raised with the understanding that his duty is to support his country. His family displayed traditional roles, with his dad supporting the family after he was discharged from military service. Jake was raised to believe that real men do not show weakness and must be the head of the household. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and although her mother lives in the area, she offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. Jake reports that he has not been engaged with his sons at all since his return from Iraq, and he keeps to himself when he is at home.
Employment History: Jake is employed as a human resources assistant for the military. Jake works in an office with civilians and military personnel and mostly gets along with people in the office. Jake is having difficulty getting up in the morning to go to work, which increases the stress between Sheri and himself. Shari is a special education teacher in a local elementary school. Jake thinks it is his responsibility to provide for his family and is having stress over what is happening to him at home and work. He thinks he is failing as a provider. Social History: Jake and Sheri identify as Jewish and attend a local synagogue on major holidays. Jake tends to keep to himself and says he sometimes feels pressured to be more communicative and social. Jake believes he is socially inept 11 and not able to develop friendships. The couple has some friends, since Shari gets involved with the parents in their sons’ school. However, because of Jake’s recent behaviors, they have become socially isolated. He is very worried that Sheri will leave him due to the isolation.
Mental Health History: Jake reports that since his return to civilian life 10 months ago, he has difficulty sleeping, frequent heart palpitations, and moodiness. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling. Jake says that he does not really understand what PTSD is but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expresses concern that he will never feel “normal” again and says that when he drinks alcohol, his symptoms and the intensity of his emotions ease. Jake describes that he sometimes thinks he is back in Iraq, which makes him feel uneasy and watchful. He hates the experience and tries to numb it. He has difficulty sleeping and is irritable, so he isolates himself and soothes this with drinking. He talks about always feeling “ready to go.” He says he is exhausted from being always alert and looking for potential problems around him. Every sound seems to startle him. He shares that he often thinks about what happened “over there” but tries to push it out of his mind. Nighttime is the worst, as he has terrible recurring nightmares of one particular event. He says he wakes up shaking and sweating most nights. He adds that drinking is the one thing that seems to give him a little relief. Educational History: Sheri has a bachelor’s degree in special education from a local college. Jake has a high school diploma but wanted to attend college upon his return from the military. Military History: Jake is an Iraqi War veteran. He enlisted in the Marines at 21 years old when he and Shari got married due to Sheri being pregnant. The family was stationed in several states prior to Jake being deployed to Iraq. Jake left the service 10 months ago. Sheri and Jake had used military housing since his marriage, making it easier to support the family. On military bases, there was a lot of social support and both Jake and Sheri took full advantage of the social systems available to them during that time. Medical History: Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Jake reports sometimes feeling inadequate because of the reduction in the use of his hand and tries to push through because he worries how the injury will impact his responsibilities as a provider, husband, and father. Jake considers himself resilient enough to overcome this disadvantage and “be able to do the things I need to do.” Sheri is in good physical condition and has recently found out that she is pregnant with their third child. Legal History: Jake and Sheri deny having criminal histories. Alcohol and Drug Use History: As teenagers, Jake and Sheri used marijuana and drank. Both deny current use of marijuana but report they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports that he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Jake spends his evenings on the couch drinking beer and watching TV or playing video games. Shari reports that Jake drinks more than he realizes, doubling what Jake has reported. Strengths: Jake is cognizant of his limitations and has worked on overcoming his physical challenges. Jake is resilient. Jake did not have any disciplinary actions taken against him in the military. He is dedicated to his wife and family. Jake Levy: father, 31 years old Sheri Levy: mother, 28 years old Myles Levy: son, 10 years old Levi Levy: son, 8 years old
In your opinion, what might be some team responsibilities that are not covered in any of these roles? Could you see yourself becoming a scrum master? Why or why not?
Behavior Analysis ABA
Describe your experiences with social skills interventions.
Describe a behavioral reductive technique used to address the social skill concern.
What was the end result?
An initial posting of roughly 200-300 words is due by TUESDAY, January 26th -AT 11:59 PM.
Read the article (https://www.acefitness.org/education-and-resources/professional/expert-articles/7578/exercising-with-a-face-covering-safety-do-s-and-don-ts/) and response. To achieve full credit, you will want to target the following items:
– 2 pages in length, double-spaced.
– Focus on what was learned or appreciated. Support this with critical thinking comments.
– Describe at least 1 application of this article.
– Discuss at least 2 question that arise from reflecting on the article.
– Articles will be submitted in LearningHub on or before the due date specified in course schedule.
PLEASE FOLLOW THE INSTRUCTIONS BELOW
4 REFERENCES
ZERO PLGIARISM
TOPIC: Avoidant/Restrictive Food Intake Disorder
Feeding, eating, and elimination disorders can be difficult to detect and treat. Parents need education and information to determine if their infant, child, or adolescent may have these types of disorders. A Parent Guide can be a useful tool to help both the clinician and the parent in understanding the child or adolescent and providing behavioral strategies for helping families work with these disorders. For this Discussion, you will be assigned a feeding, eating, or elimination disorder.
In this Discussion, you work with your group again to develop a Parent Guide for your assigned feeding, eating, or elimination disorder.
To Prepare for this Assignment:
Using evidence-based research, design and develop a Parent Guide for your assigned disorder including:
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