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Diagnostic and Clinical Reasoning Paper Task
The aim of this task is to offer you the chance to develop the scope of your scientific documentation and your thought processes relative to complicated affected person care instances.
1. Choose a affected person encounter out of your present scientific expertise.
2. The affected person encounter you choose must be one of many extra complicated affected person instances that you’ve skilled along with your present scientific affected person inhabitants. Given that you’re to pick complicated instances, this task might not be accomplished for a ‘normal well being, properly youngster, properly girl, routine OB, routine bodily examination (and many others.)’ sort of encounter.
You will have to determine which affected person encounter you might be increasing your documentation for by together with the Typhon Case ID # beneath your title on the title web page of your paper.
three. For this task you’ll make the most of the identical SOAP format that you just do in your ‘expanded’ Typhon encounters. Assemble this task guaranteeing that you just adhere to the writing pointers offered within the sixth version APA guide.
Beneath is the overview of the required components for this task:
*Title Web page (Web page 1): Observe APA pointers for working head on web page 1, and embody Medical Prognosis, Pupil Title, Typhon Case ID #, and Date.
*Subjective (Begin of Web page 2): Observe APA pointers for working head on web page 2 and subsequent pages.
CC: chief criticism – What are they being seen for? That is the rationale that the affected person sought care, acknowledged in their very own phrases, or paraphrased.
HPI: historical past of current sickness – use the “OLDCART” strategy for amassing information and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH: previous medical historical past – This could embody previous sickness/prognosis, circumstances, traumas, hospitalizations, and surgical historical past. Embody dates if potential.
Allergy symptoms: State the offending treatment/meals and the reactions.
Drugs: Names, dosages, and routes of administration.
Social historical past: Associated to the issue, academic degree/literacy, smoking, alcohol, medication, HIV danger, sexually energetic, caffeine, work and different stressors. Cultural and non secular beliefs that affect well being and sickness. Monetary sources.
Click on on the hyperlink beneath to discover the CDC’s data on the ‘social determinants of well being’.
https://www.cdc.gov/socialdeterminants/
Household historical past: Use phrases like maternal, paternal and the ailments and the ages they have been deceased or recognized if recognized.
Well being Upkeep/Promotion: Immunizations, train, eating regimen, and many others. Keep in mind to make use of the US Clinical Preventative Companies Job Drive (USPSTF) pointers for age acceptable indicators. This could mirror what the affected person is presently doing relating to the rules.
Click on on the hyperlink beneath to entry details about present pointers.
https://www.uspreventiveservicestaskforce.org/
Overview of Techniques (ROS): that is to ensure you haven’t missed any vital signs, notably in areas that you haven’t already completely explored whereas discussing the historical past of current sickness. You’ll additionally need to embody any pertinent negatives or positives that may help along with your differential prognosis. For acute episodic (centered) visits (i.e. sprained ankle, sore throat, and many others.) you might be omitting sure areas akin to GYN, Rectal, GI/Abd, and many others. Whereas the record beneath is offered in your comfort it’s not to be thought-about all-encompassing and you might be anticipated to incorporate different methods/classes relevant to your affected person’s chief criticism.
Common: Could embody if affected person has had a fever, chills, fatigue, malaise, and many others.
Pores and skin:
HEENT: head, eyes, ears, nostril and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
*Goal:
Bodily Examination (PE): both restricted for a centered examination or extra intensive for a whole historical past and bodily Assessment. This space ought to verify your findings associated to the prognosis. For acute episodic (centered) visits (i.e. sprained ankle, sore throat, and many others.) you might be omitting sure areas akin to GYN, Rectal, Abd, and many others. All SOAP notes nonetheless ought to have bodily examination of CV and lungs. Whereas the record beneath is offered in your comfort it’s not to be thought-about all-encompassing and you might be anticipated to incorporate different methods/assessments relevant to your affected person’s chief criticism. Be sure that you embody acceptable female and male particular bodily assessments when relevant to the encounter. Your bodily examination data must be organized utilizing the identical physique system format because the ROS part. Applicable medical terminology describing the target examination is obligatory.
VS: very important indicators, top and weight, BMI
Gen: normal assertion of look, if there may be any acute misery.
Pores and skin:
HEENT: head, eyes, ears, nostril and throat
Neck:
CV: cardiovascular
Lungs:
Abd: stomach
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological examination
Psych:
Diagnostic Exams: This space is for checks that have been accomplished through the affected person’s appointment that dominated the differential prognosis in or out (e.g. – Fast Strep Check, CXR, and many others.).
*Assessment: (quantity every prognosis)
Prognosis/Diagnoses: Begin with the presenting chief criticism prognosis first. Quantity every prognosis. An announcement of present situation of all different power sicknesses that have been addressed through the go to should be included (i.e. HTN-well managed on treatment). Keep in mind the S and O should help this prognosis. Pertinent positives and negatives should be discovered within the write-up.
*Plan: (quantity every plan particular to every prognosis)
These are the interventions that relate to the above prognosis and handle the next elements (they need to be separated out as listed beneath):
Diagnostics: labs, diagnostics testing – checks that you just deliberate for/ordered through the encounter that you just plan to Assessment/consider relative to your work up for the affected person’s chief criticism.
Therapeutic: adjustments in meds, skincare, counseling
Instructional: data shoppers want with the intention to handle their well being issues. Embody follow-up care. Anticipatory steering and counseling.
Session/Collaboration: referrals, or seek the advice of whereas in clinic with one other supplier. If no referral made was there a potential referral you can make and why? Advance care planning.
*Clinical Determination Making
The subsequent part summarizes your essential pondering, decision-making and diagnostic reasoning expertise that gives you the platform to develop in your recognized Typhon affected person encounter. It’s a reflection of the thought course of you utilized in caring for the affected person. Observe the instructions beneath every part and label every space as acceptable. All data must be in your individual phrases.
Pathophysiology:
Embody data in regard to the pathophysiology associated to the primary prognosis or sickness course of. This may help to know how the S and O supported the prognosis you assigned.
Don’t copy and paste from credible sources. Paraphrase supply data as you assemble your dialogue of the pathophysiology and be certain that you present in-text and reference citations for the supply.
Pharmacology: OR (***Alternate – Remedy data):
Select one drug that was prescribed at this go to or that’s taken chronically by the affected person to Assessment. Please embody the title of the drug (generic and model), class, motion, excretion, unwanted effects and interactions, why this specific drug is being prescribed for this specific affected person, what is that this drug supposed to deal with, (particularly antibiotics, what organisms are we treating?). What different drug might be chosen as an alternative that may work, if any? Have in mind the associated fee and comfort for the affected person.
***NOTE: For the reason that affected person encounter you choose for this task is meant to be one of the crucial complicated encounters you’ve gotten with this course inhabitants, the chance exists that you should have a pharmacologic agent to debate for this task requirement. Nevertheless, if there aren’t any pharmacologic brokers to make the most of then select a non-pharmacologic component of the therapeutic plan (e.g. this might be hyperbaric remedy, water remedy, rest coaching, biofeedback, PT, OT, Counseling [e. g. nutritional, emotional, behavior modification, etc.]or a Complementary Various Medical routine [e.g. nutritional therapy, a spiritual intervention, Emotional Freedom Therapy (EFT), journaling, visual imagery, progressive relaxation, Cranial Electrical Stimulation (CES), etc.]
Don’t copy and paste from credible sources. Paraphrase supply data as you assemble your dialogue and be certain that you present in-text and reference citations for the supply.
Clinical Diagnostic Reasoning:
Embody on this part:
1. Differential diagnoses
Embody a listing of the entire diagnoses you thought-about in your record of ‘differential diagnoses. This record could lengthen past the diagnoses recognized within the ‘A’ part of the paper.
2. Precedence prognosis dialogue
Focus on the important thing Assessment [history and physical exam] findings that resulted within the identification of the precedence prognosis/diagnoses indicated within the ‘A’ part of the paper
three. Rationale for key components of the plan of care
As a sophisticated observe pupil you must discover the proof relative to the affected person’s care wants and have the ability to doc the rationale for the weather of the plan.
Briefly present rationales for the important thing components of the plan of care [e.g. if a particular HTN medication is prescribed then reference the current JNC guidelines, if a particular antimicrobial is prescribed provide the source referenced for the decision, etc.]
Present a rationale for any care side included within the plan that isn’t per the care approaches present in your course supplies, EBP, CPGs or encompassed within the ‘group customary of care’.
When utilizing credible sources to help your dialogue don’t copy and paste from the sources. Paraphrase supply data as you assemble your dialogue and be certain that you present in-text and reference citations for the supply.
Moral and or Cultural Issues:
Establish any moral or cultural points associated to this affected person’s care. Embody how these considerations have been addressed.
Focus on the next:
1. Overview the provisions of the ANA Code of Ethics
Select a minimum of one of many provisions of the Code and talk about how your expertise with the affected person encounter aligns with the tenants of the availability OR the way you advocated for the affected person through the encounter to make sure your actions aligned with the tenants of the availability.
Hyperlink to realize entry to the ANA Code of Ethics – you have to to scroll all the way down to ‘Choose One’ [option] to progress to the web page the place you should have full entry to the Code:
https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/
2. Focus on precise or potential cultural implications for this encounter – from the affected person’s cultural perspective or your cultural perspective
Hyperlinks to articles that discover the problem of cultural considerations in well being care:
https://pdfs.semanticscholar.org/3e50/d2758210e1bd345ccf16fcf8dfcd2b1b5ec9.pdf
Obstacles to Care:
Assemble a dialogue that summarizes the obstacles/potential obstacles your affected person faces relative to their skill to hunt or obtain healthcare companies and exploration of a minimum of three of the relevant ‘social determinants of well being’ in your affected person.
Focus on the Following:
1. The precise and potential obstacles you recognized in your affected person
Your dialogue wants to incorporate observations about entry to care, monetary obstacles, and non-financial obstacles past entry. Make sure you present in-text citations as acceptable for APA type pointers in your dialogue to help the literature that you just reviewed in figuring out the precise/potential obstacles.
Hyperlinks to article exploring obstacles
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3393009/
https://academic.oup.com/fampra/article/23/3/325/475515
https://www.careatc.com/ehs/3-common-barriers-to-quality-medical-care
2. Three precedence social determinants of well being in your affected person
Your dialogue wants to incorporate exploration of the three social determinants of well being that you just recognized as having probably the most important affect in your affected person’s well being care and well being standing. Make sure you present in-text citations as acceptable for APA type pointers in your dialogue to help the literature that you just reviewed in figuring out the social determinants of well being.
Hyperlink to CDC’s data on Social Determinants of Well being
https://www.cdc.gov/socialdeterminants/
three. Well being care coverage or advocacy initiatives related to your affected person’s care
Embody in your dialogue a minimum of one well being care coverage or initiative that you just recognized within the literature as having the potential to positively affect the recognized precise/potential obstacles or precedence social determinants of well being in your affected person.
Sources in your ‘search’ embody the Herzing Library, Google Scholar, PubMed, and/or the Virginia Henderson Repository https://www.nursingrepository.org/
*Proof based mostly observe:
Proof-Primarily based Follow (EBP) is a considerate integration of the perfect accessible proof, coupled with scientific experience. As such it permits well being practitioners to handle healthcare questions with an evaluative and qualitative strategy. EBP permits the practitioner to evaluate present and previous analysis, scientific pointers, and different data sources with the intention to determine related literature whereas differentiating between high-quality and low-quality findings. Proof-Primarily based Follow consists of the appliance of proof and the analysis of the outcomes to information future observe.
This part is a 1-2 paragraph abstract of all the scholarly proof utilized to finish this task. New sources, subjects or concepts shouldn’t be launched.
Focus on the next:
1. Formulate a well-built Question Assignment.
What scientific questions and phrases did you utilize to direct your search within the library database?
2. Establish articles and different evidence-based sources that reply the Question Assignment. Establish all sources (APA citations) used that knowledgeable your choice making on this specific case.
three. Critically appraise the proof [research study, evidence based or clinical practice guidelines, published care standards, etc.] to evaluate its validity. Touch upon the standard of the analysis or proof based mostly observe pointers used. What’s the degree of proof? How credible is it? Is it a only a suggestion or an anticipated customary of care?
four. Apply the proof and consider for areas of enchancment. How invaluable was the proof in understanding and directing the care on this case? How did it affect your choice making? Have been you capable of assess the end result? In that case, are adjustments wanted?
*Self-Reflection:
Reflection on choice making: That is an space the place you look over the information gathered and after a cautious Assessment of the accessible sources (i.e. textual content books, reference readings) will present a mirrored image of what might need been added or deleted that may have made this notice extra conclusive or full. This isn’t an space to critique the preceptor. Focus on areas might you’ve gotten modified? What areas may you’ve gotten added, maybe extra questions it is best to have requested within the ROS, or extra areas you’ll have assessed for within the PE?
Superior Follow Practitioner Position Assessment: Establish the particular person who drove this plan of care and developed the administration, whereas together with element in the way you advocated for the affected person. It’s solely potential, and fascinating, that you just drove the event of the plan of care. Embody how an individualized strategy was utilized to this affected person’s care. Additionally embody the way you recognized your advocacy for the position of the Nurse Practitioner.
*Reference Web page: Observe APA pointers for developing all reference web page citations and make sure you used APA type for all in-text citations.
