Follow the Soap Note Rubric as a guide
Use APA format and must include a minimum of 2 Scholarly Citations.
Must be your own work and in your own words.
The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
An older client was recently discharged from the hospital for evaluation of seizure activity. His history reveals that he has late-stage Alzheimer’s disease, Parkinson’s disease, hypertension, and type II diabetes mellitus, which is controlled by diet. He lives at home, where his wife and daughter take care of him. His discharge medications include phenytoin (Dilantin), 100 mg BID; hydrochlorothiazide (HydroDIURIL), 50 mg QD; levodopa (Sinemet), 25/100 TID; and haloperidol (Haldol), 1 mg before bed. The client has been referred for home care nursing follow-up.
Questions:
Case Study: Roslyn, a six-year-old, is attending public school for the first time. Her parents brought her to the clinic and stated, “she appears to have pain in her legs and won’t participate in playtime.” The parents noticed recently Roslyn appears pale and acts weak. Roslyn is diagnosed with sickle cell anemia. After her parents and siblings undergo genetic testing, it is found that Roslyn is the only family member with the disease.
What are the three most important things you learned this week?
What questions remain uppermost in your mind?
Is there anything you did not understand?
Just a few sentences for each question based on powerpoint
Announcements
Office hours – Wed Feb 22 at 1030am
Writing the HPI and other note writing resources
Canvas
Course related questions?
What were your takeaways from the learning materials?
Podcast – diet and exercise as treatments
Quiz question #5 – depressive disorder due to another medical condition
TMS/ECT/ketamine treatment – research is ongoing, effects of ketamine are variable, ECT is effective, past hx of efficacy of ECT can predict future outcomes
Refer for ECT/TMS evaluation
Differences between MDD and dysthymia – diagnoses can co-exist, may change diagnoses over time
ECT for treatment resistant cases
DSM description of co-existing diagnoses – something like bereavement can cause symptoms that meet criteria for MDD
What questions do you have?
When is ECT recommended/used?
What would warrant ECT during pregnancy?
Anticonvulsants during ECT – hold the night before treatment
Is a seizure disorder a contraindication to ECT? No?
Review of pathophysiology of depressive disorders
What can contribute to depressive symptoms?
Heterogeneous diagnostic category
The only depressive disorders diagnoses that require a certain etiology are medication/substance induced and due to a medical condition
Assessing patients presenting with depressive symptoms
Terminology: Depressed vs. distressed
Communication approaches
Other factors: Grief and loss, stress, trauma, medical conditions
Specific symptomatology
Duration and course of illness
Appearance on MSE
SAFE-T
Treatment options
It’s not all about medication
What are other evidence based treatment recommendations?
How to make treatment decisions
How to talk about these with patients
DSM Depressive disorders category
Disruptive mood dysregulation disorder (DMDD)
Major depressive disorder (MDD)
Persistent depressive disorder (dysthymia)
Premenstrual dysphoric disorder
Substance/medication induced depressive disorder
Depressive disorder due to another medical condition
Other specified depressive disorder
Unspecified depressive disorder
DMDD (F34.8)
History of this diagnosis (new to DSM-5)
Diagnosed between the ages of 6 and 18, age of onset before 10
Severe recurrent temper outbursts that are not developmentally appropriate
Differentiating between mood elevation/mania/hypomania
Childhood bipolar should not be diagnosed based on irritability, distractibility, poor judgment
Elated mood, decreased need for sleep (not the same as insomnia), and episodicity are more diagnostic
Note mutually exclusive diagnoses: ODD, IED, bipolar
Can be diagnosed along with: MDD, ADHD, substance use disorders, conduct disorder
MDD (F32 [single episode] or 33 [recurrent episodes] plus
Heterogenous diagnostic category, several diagnoses were combined in DSM-III
Can be episodic or chronic based on DSM criteria
At least 5 criteria need to be met (must incl. depressed mood OR loss of interest or pleasure), at least two weeks, change from previous level of functioning
Mutually exclusive with psychotic disorders (but there is MDD with psychotic features)
No history of manic or hypomanic episodes
Specifiers (next slide)
Specifiers
With anxious distress
With mixed features – includes at least 3 specific manic/hypomanic symptoms present nearly every day for the majority of days of the MDE
With melancholic features
With atypical features
With mood congruent or mood incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern
In partial remission, in full remission
Mild, moderate, severe
Dysthymia (F34.1)
Used to be considered a personality trait (depressive personality disorder)
Depressed mood more days than not for at least 2 years (chronic)
In children/adolescents, mood can be irritable and lasting 1 year
Also needs 2 or more of 6 other symptoms
If full criteria for MDD have been met at some point, MDD should be diagnosed
No manic or hypomanic episodes or cyclothymia or psychotic disorders
Specifiers (next slide)
Dysthymia specifiers
Many are the same as MDD
With early onset (prior to age 21), with late onset (21 or older)
With pure dysthymic syndrome
With persistent MDE
With intermittent MDE, with current episode
With intermittent MDE, without current episode
Premenstrual dysphoric disorder (N94.3)
In the majority of menstrual cycles in the past year, at least 5 symptoms must be present in the week before the onset of menses and improve with onset of menses
Symptoms are not the result of an exacerbation of another disorder
Substance/medication induced depressive disorder (various ICDs)
Prominent and persistent disturbance in mood, includes depressed mood or anhedonia
Requires direct evidence that symptoms developed after exposure to the substance, and the substance is capable of producing the symptoms
Not better explained by a different depressive disorder
Does not occur during delirium
Depressive disorder due to another medical condition (F06.31, 32, or 34)
Mood symptoms must be the direct physiologic effect of the medical condition
Symptoms are not better explained by another disorder
Does not occur in the context of delirium
Other specified depressive disorder (F32.8)
Depressive symptoms with an explanation of why the symptoms don’t meet criteria for another disorder
Examples of designations:
Recurrent brief depression
Short-duration depressive episode
Depressive episode with insufficient symptoms
Unspecified depressive disorder (F32.9)
Symptoms do not meet full criteria for another disorder and no explanation of why
May include situations where there is insufficient information to make another diagnosis
Group work
Start out by discussing group norms for communication and workflow, will you use google docs, how will you all agree when the assignment is ready to submit, etc.
Consider assigning group leads for all of the modules you’ll be working on with this group
Group leader should be responsible for creating working documents, submitting assignments, and organizing the work for the week
Two assignments for each week: case study and mini-paper
Mini-paper is due as a DB post by Wednesday, case study is due as an assignment submission by Saturday
Student responsibilities
You are responsible for developing a working knowledge and understanding of all of the other diagnoses in the week’s diagnostic category
You are responsible for reviewing all other group mini-paper DB submissions and using them to guide your studying of the other diagnoses for that week
You are responsible for sharing anything you are confused about on your one minute paper for the week
There is no requirement for responses to DB posts, but feel free to reply if you want
Other follow ups
Be sure to rotate tasks/jobs within your group so everyone gets a chance to write different sections of the note
Check in at the beginning of each week’s class to review how things went the previous week and whether you need to revise any of your group norms
APA format NOT needed
Citations – do not need to cite the DSM, if you are mentioning statistics/numbers, etc., let us know where you got them from with a link or name of the reference
Paraphrase the information to “teach” your classmates
DSM diagnostic criteria vs. symptom presentation
Review your problem or issue and the study materials to formulate a PICOT question for your capstone project change proposal. A PICOT question starts with a designated patient population in a particular clinical area and identifies clinical problems or issues that arise from clinical care. The intervention used to address the problem must be a nursing practice intervention. Include a comparison of the nursing intervention to a patient population not currently receiving the nursing intervention, and specify the timeframe needed to implement the change process. Formulate a PICOT question using the PICOT format (provided in the assigned readings) that addresses the clinical nursing problem.
The PICOT question will provide a framework for your capstone project change proposal.
In a paper of 500-750 words, clearly identify the clinical problem and how it can result in a positive patient outcome.
Describe the problem in the PICOT question as it relates to the following:
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.
From your work or clinical experience, identify a potential practice problem and formulate an evidence-based practice question. create proposal for an evidence-based practice solution that includes the following.
· Describe a potential practice problem
· Formulate an evidence-based practice question
· Locate and review two current, peer-reviewed, research articles that address the identified clinical problem
· Appraise research findings
· Propose an evidence-based practice solution
Discussion Topic: On what policy issues might nurses lobby Congress? What strategies might nurse use to have their voices heard?
Requirements
– The discussion must address the topic
– Rationale must be provided
– Use at least 600 words (no included 1st page or references in the 600 words)
– May use examples from your nursing practice
– Formatted and cited in current APA 7
– Use 3 academic sources, not older than 5 years.
– Not Websites are allowed.
– Plagiarism is NOT permitted
Directions:
Main post:
Technology in healthcare continues to advance. You have learned about technologies to facilitate communication, Clinical information Systems, and the Electronic Medical Record.
What impact will communication technology, Clinical information Systems, and the Electronic Medical Record have on the future of healthcare?
Provide an example on how you see the above technologies advancing to improve the provision of safe, quality care to clients,
How it will positively impact nursing staff?
Peer replies:
Evaluate how the recommended technology can have a negative impact on the nurse’s workload and staff satisfaction
Provide a viable solution to the potential problem.
Please make your initial post by midweek, and respond to at least two other student’s post by the end of the week. All posts require references AND in-text citations in full APA format. Information must be paraphrased and not quoted. Please check the Course Calendar for specific due dates. NOTE: Finalized postings must be submitted by deadlines. Any edits after deadline will be counted as late submissions and deducted accordingly. If you need to make any corrections for clarity’s sake only, you can write an addendum as a reply to yourself. The initial post will still be the one receiving full grade.
“The Final Word”
Give a brief summary evaluation of your community’s health, the major strengths of your community, and the hopes for your community in the future. Also, discuss what has resonated with you in this course.
Submission Instructions:
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