fundamentals M 2 b

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Respond to Kaffy

Ensuring accurate and confidential documentation in nursing is crucial for patient care, legal compliance, and maintaining the integrity of healthcare records. However, nurses face several challenges in achieving this goal. Three prominent challenges include workload, knowledge, and complex documentation systems.

Firstly, nurses often contend with heavy workloads that can make it challenging to dedicate sufficient time to accurate and complete documentation. The demands of patient care, frequent interruptions, and the need to juggle multiple tasks can sometimes hinder their ability to maintain comprehensive records (Cimino, 2013).

Secondly, nurses need to possess a deep understanding of documentation policies, procedures, and the legal implications of inaccuracies or omissions in their records. Knowledge gaps in these areas can result in documentation errors that compromise patient care and expose healthcare facilities to legal risks (Cimino, 2013).

Thirdly, the documentation systems that nurses use can be complex and not always user-friendly. Navigating these systems effectively requires training and familiarity, and any difficulties in system operation can affect the accuracy and confidentiality of documentation (Cimino, 2013).

To overcome these challenges, nurses can take proactive steps:

Workload Management: Nurses can prioritize their documentation tasks and seek opportunities to delegate tasks when possible. Utilizing informatics tools can help automate certain documentation processes, alleviating some of the time constraints (American Nurses Association, 2020).

Knowledge Enhancement: Nurses should seek out training programs related to documentation policies, procedures, and legal implications. They can also collaborate with colleagues or healthcare professionals for guidance and clarification on documentation-related queries.

System Proficiency: To tackle the complexities of documentation systems, nurses should invest time in learning how to use them effectively. They can also report any system-related issues to their supervisors, advocating for improvements where necessary (American Nurses Association, 2020).

The integration of informatics into nursing practice can play a transformative role in addressing these challenges. Informatics tools can:

Automate Documentation: By automating routine documentation tasks like generating nursing notes or medication administration records, informatics can significantly reduce the time burden on nurses, allowing them to allocate more focus to patient care.

Provide Alerts and Reminders: Informatics systems can offer real-time alerts and reminders, ensuring that nurses complete documentation tasks in a timely and accurate manner. These cues can be invaluable in preventing oversights (American Nurses Association, 2020).

In summary, informatics offers a multifaceted solution to the challenges nurses face in documentation. By automating tasks, providing reminders, improving data access, and enhancing security, it empowers nurses to deliver more accurate, complete, and confidential documentation while mitigating the obstacles presented by workload, knowledge, and complex systems.

References

Nursing Documentation and Informatics: A Core Competency for Nurses. (2020). American Nurses Association

Cimino, J. J. (2013). Nursing Documentation: Informatics for the 21st Century. (4th ed.).

Respond to Muni

1.Data Accuracy and Completeness: 

Maintaining the accuracy and completeness of patient information is one of the biggest issues in nursing documentation. The many duties that nurses must complete may cause them to forget to record important patient information or cause mistakes. Keeping the record updated in real-time may also be difficult if the patient's health changes quickly.

Strong observational and documenting abilities would be needed to overcome this difficulty. Peer evaluations, training workshops, and regular audits of medical records can all be beneficial. Electronic health record (EHR) solutions offered by informatics can significantly contribute to the reduction of errors by automatically recording and updating some patient data (such as vital signs from connected monitors).

2.Confidentiality and Privacy: 

Maintaining patient data security In nursing practice, confidentiality is essential. However, problems might occur as a result of unauthorized access, data breaches, or even an inadvertent disclosure of private information during normal conversations.

Nurses can avoid this by properly following HIPAA rules and upholding their professional limits. Staff members should receive comprehensive cybersecurity training and should only access patient data when necessary. Data security can be strengthened with the use of informatics systems like EHRs, which can assist with access controls, encryption, and audit trails to trace who is accessing data.

3.Time Constraints: 

Due to their busy schedules and time constraints, nurses may struggle to accurately and swiftly record patient information. As a result, there can be a delay in recording or inaccurate data.

This challenge can be lessened with good time management techniques and delegating when appropriate. Informatics is involved once again in this situation. Technologies like speech-to-text software and electronic health records (EHRs) help speed up the documentation process and note-taking. Nurses can document data at the point of care more quickly with the use of mobile devices.

Keep in mind to comment on other entries and offer helpful criticism. To improve our collective nursing practice, we may all benefit from exchanging real-world experiences and solutions.

REFERENCE

· https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6111626/

· https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-019-4661-x

· https://www.nuance.com/asset/en_uk/collateral/healthcare/ebook/eb-nuance-nurse-clindoc-screen.pdf

· https://www.frontiersin.org/articles/10.3389/fcomp.2021.624555/full

Assigment .Apa seven . All instructions attached.

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Week 3: Paper #1 Due

Complementary and alternative medicine (CAM) is becoming increasingly common in the United States and the rest of the western world. Most of nursing education in the United States, Canada, the United Kingdom, Europe, and Australia—often referred to as Western countries—has been under the umbrella of biomedicine, and thus Western nurses are familiar and comfortable with its beliefs, theories, practices, strengths, and limitations. Fewer nurses have studied alternative medical theories and practices and as a result may lack information or even harbor misinformation about these healing practices. Unlike the profession of medicine in general, however, the profession of nursing has traditionally embraced two basic concepts embodied by alternative therapies—holism and humanism—in its approach with clients.
Your assignment is to write a 2-3 page paper discussing how nurses can incorporate alternative medicine into a holistic approach to patient care. Please use references within the last 5 years and submit the work in APA format.

NURSE 5300

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Research methods used frequently in nursing can be classified in different ways. Discuss the classification of research methodologies used in nursing research.

Please include 400 words in your initial post and a scholarly reference. Attached you can find the rubric to follow up.

Vital organs

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Vital Organs / Unconscious State

1. Name some very important organs that
are not vital organs.

2. List the functional description of all the normal vital organs, including today’s exceptions.

3. Is it possible to live without a vital organ? Why? Example?

4. Distinction between assisting or substituting vital organs. Bioethical analysis.

5. Do the following practices assist or substitute the vital organ? Why?

· Dialysis

· Respirator

· Ventilator

· Tracheotomy

· CPR

6.
Read and summarize ERD PART FIVE Introduction.

7. Unconscious state: Definition.

8. Clinical definitions of different states of unconsciousness: Compare and contrast

9. Benefit vs Burden: bioethical analysis.

NURS-6050N

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ADVOCATING FOR THE NURSING ROLE IN PROGRAM DESIGN AND IMPLEMENTATION

As their names imply, the honeyguide bird and the honey badger both share an affinity for honey. Honeyguide birds specialize in finding beehives but struggle to access the honey within. Honey badgers are well-equipped to raid beehives but cannot always find them. However, these two honey-loving species have learned to collaborate on an effective means to meet their objectives. The honeyguide bird guides honey badgers to newly discovered hives. Once the honey badger has ransacked the hive, the honey guide bird safely enters to enjoy the leftover honey.

Much like honeyguide birds and honey badgers, nurses and health professionals from other specialty areas can—and should—collaborate to design effective programs. Nurses bring specialties to the table that make them natural partners to professionals with different specialties. When nurses take the requisite leadership in becoming involved throughout the healthcare system, these partnerships can better design and deliver highly effective programs that meet objectives.

In this Assignment, you will practice this type of leadership by advocating for a healthcare program. Equally as important, you will advocate for a collaborative role of the nurse in the design and implementation of this program. To do this, assume you are preparing to be interviewed by a professional organization/publication regarding your thoughts on the role of the nurse in the design and implementation of new healthcare programs.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 



WEEKLY RESOURCES

To Prepare:

· Review the Resources and reflect on your thinking regarding the role of the nurse in the design and implementation of new healthcare programs.

· Select a healthcare program within your practice and consider the design and implementation of this program.

· Reflect on advocacy efforts and the role of the nurse in relation to healthcare program design and implementation.

The Assignment: (2–4 pages)

In a 2- to 4-page paper, create an interview transcript of your responses to the following interview questions:

·
Tell us about a healthcare program, within your practice. What are the costs and projected outcomes of this program?

·
Who is your target population?

·
What is the role of the nurse in providing input for the design of this healthcare program? Can you provide examples?

·
What is your role as an advocate for your target population for this healthcare program? Do you have input into design decisions? How else do you impact design?

·
What is the role of the nurse in healthcare program implementation? How does this role vary between design and implementation of healthcare programs? Can you provide examples?

·
Who are the members of a healthcare team that you believe are most needed to implement a program? Can you explain why?

BY DAY 7 OF WEEK 8

LEARNING RESOURCES


Required Readings

· Milstead, J. A., & Short, N. M. (2019). 
Health policy and politics: A nurse's guide (6th ed.). Jones & Bartlett Learning.

· Chapter 5, “Public Policy Design” (pp. 87–95 only)

· Chapter 8, “The Impact of EHRs, Big Data, and Evidence-Informed Practice” (pp. 137–146)

· Chapter 9, “Interprofessional Practice” (pp. 152–160 only)

· Chapter 10, “Overview: The Economics and Finance of Health Care” (pp. 183–191 only)

· American Nurses Association (ANA). (n.d.). 


Advocacy

Links to an external site.
. Retrieved September 20, 2018, from https://www.nursingworld.org/practice-policy/advocacy/

· Centers for Disease Control and Prevention (CDC). (n.d.). 


Step by step: Evaluating violence and injury prevention policies: Brief 4: Evaluating policy implementation

Links to an external site.
. Retrieved from https://www.cdc.gov/injury/pdfs/policy/Brief%204-a.pdf

·

Congress.govLinks to an external site.
. (n.d.). Retrieved September 20, 2018, from https://www.congress.gov/

· Klein, K. J., & Sorra, J. S. (1996). 

The challenge of innovation implementationLinks to an external site.
. 
Academy of Management Review, 21(4), 1055–1080.

· Sacristán, J., & Dilla, T. D. (2015). 

No big data without small data: Learning health care systems begin and end with the individual patientLinks to an external site.
. 
Journal of Evaluation in Clinical Practice, 21(6), 1014–1017.

· Tummers, L., & Bekkers, V. (2014). 

Policy implementation, street level bureaucracy, and the importance of discretionLinks to an external site.
. 
Public Management Review, 16(4), 527–547.

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the 
Turnitin Drafts from the 
Start Here area. 

1. To submit your completed assignment, save your Assignment as 
WK8Assgn+LastName+Firstinitial

2. Then, click on 
Start Assignment near the top of the page.

3. Next, click on 
Upload File and select 
Submit Assignment for review.

mental health

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Rasmussen University – Mental Health Care Plan

A. Patient identifiers:

Age: Gender: Ht: Wt. Code Status:

Isolation:

Development Stage (Erikson): Give the stage and rationale for your evaluation

Health Status

Date of admission:

Activity level: Diet:

Fall risk (indicate reason)

Client’s description of health status

Allergies: (include type of reaction)

Reason for admission:

Past medical history that relates to admission:

Socio-cultural Orientation

Cultural and Ethnic Background with current practices:

Socialization:

Family system: (Support system)

Spiritual:

Occupation: (across the lifespan)

Patterns of living: (define past and current)

Barriers to independent living:

Healthcare systems elements (continued) ALLERGIES:

Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.

DEFINE 1: What the medications Mechanism of Action AND 2: Why the patient is taking the medication?

Medication Classification Dosage Rationale Possible negative outcomes

Psychiatric Diagnosis and DSM 5 Diagnostic Criteria

History of Present Psychiatric Illness

(Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services)

CON
CEPT MAP

Pathophysiology – (to the cellular level)

Medical Diagnosis

Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)

Complications

Treatment (Medical, medications, intervention and supportive)

Risk Factors (chemical, environmental, psychological, physiological and genetic)

Nursing Diagnosis

Problem statement: (NANDA)

Related to: (What is happening in the body to cause the issue?)

Manifested by: (Specific symptoms)

General Appearance

Presenting Appearance (nutritional status, physical deformities, hearing impaired, glasses, injuries, cane)
Basic Grooming and Hygiene (clean, disheveled and whether it is appropriate attire for the weather)

Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest),
posture (slouched, erect),
any noticeable mannerisms or gestures

Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise)

Manner and Approach

Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)

Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing).
Coping and stress tolerance.

Speech (normal rate and volume, pressured, slow, loud, quiet, impoverished)

Expressive Language (no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling)

Receptive Language (normal, able to comprehend questions,

Orientation, Alertness, and Thought Process

Recall and Memory (recalls recent and past events in their personal history).
Recalls three words (e.g., Cadillac, zebra, and purple)
Orientation (person, place, time, presidents, your name)

Alertness (sleepy, alert, dull and uninterested, highly distractible)
Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)

Concentration and Attention (naming the days of the week or months of the year in reverse order, spelling the word “world”, their own last name, or the ABC's backwards)

Thought Processes (loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization).
Values and belief system

Hallucinations and Delusions (presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications)

Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)

Mood and Affect

Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry).
Affect or how they felt at a given moment (comments can include range of emotions such as broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation.

Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset)
Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful, pessimistic, optimistic)

Response to Failure on Test Items (unaware, frustrated, anxious, obsessed, unaffected)
Impulsivity (poor, effected by substance use)
Anxiety (note level of anxiety, any behaviors that indicated anxiety, ways they handled it)

Lab

Range

Value

Reason Obtained

Risk Assessment:

Suicidal and Homicidal Ideation

(ideation but no plan or intent, clear/unclear plan but no intent) Self-Injurious Behavior (cutting, burning) Hypersexual, Elopement, Non-adherence to treatment

Discharge Plans and Instruction: Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program

Teaching Assessment and Client / Family Education:

(Disease process, medication, coping, relaxation, diet, exercise, hygiene) Include barriers to learning and preferred learning styles

NRS DX:

Problem Statement:

R/T: (What is the cause of the symptom?)

Manifested by: (specific symptoms)

Short term goal: Create a SMART goal that relates to hospital stay.

Long term goal: Create a SMART goal that is appropriate for discharge.

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)

Was it met or not met there is no partially met.

References:

Phases of Burning

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 A burn injury can severely affect a patient’s physical and emotional well-being. As a nurse you may be in charge of taking care of a patient during any of the three phases of burns. Please complete the Phases of Burn Injury table to better understand the needs of a burn patient and ways to meet those needs. 

Principles of Research and Evidence-Based Practice

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Discuss the principles of research and evidence-based practice and how to effectively implement them for advanced practice nurses.

see below

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see below

cap 4

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Please see attachment for instructions