Cardiovascular Assessment
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Assessment Module
Assessment Module 1 | Page Assessment May 2017 Table of Contents About this Module/Overview/Objectives……………………………………………...Page 3 Pre-test…………………………………………………………………………………Pages 4-5 Chapter 1……………………………………………………………………………....Pages 6-12 Overview Focused Assessment vs. Comprehensive Assessment Considerations in preparing for a physical exam Geriatric Assessment Nursing Components Considerations in Elderly Residents Chapter 2……………………………………………………………………………...Pages 12-14 Root Cause of Behaviors Physiologic Social Environmental Psychosocial Chapter 3……………………………………………………………………………...Pages 14-16 Risk Assessment Eyes Ears Hemiparesis Paraplegia Where to place the resident in the room Chapter 4……………………………………………………………...………………Pages 16-18 Texas Board of Nursing and Assessments Federal Nursing Facility Regulations F272: Comprehensive Assessments State Nursing Facility Regulations Chapter 5………………………………………………………………………….......Pages 18-19 Resources “This is me” “This is me: My Care Passport” Alternate Communication Boards Pain, Pain Go Away Presentation Appendices……………………………………………………………………………Pages 20-48 2 | Page Assessment May 2017 About this Module: Assessment is a key component of nursing practice, required for planning and the provision of resident and family centered care. Information that is obtained from an accurate assessment serves as the foundation for age-appropriate nursing care, enhancing the residents’ quality of life and independence. The LVN must have a specific set of skills in order to adequately and effectively assess the resident, including: a physical assessment; a functional assessment; and any additional information about the resident that would be used to develop the care plan. This module will provide you with all of the information necessary to ensure adequate assessments are completed for each resident in the facility, meeting the state and federal requirements for resident assessment. Overview: Conditions such as functional impairment and dementia are common in nursing home residents. -
Nursing Students' Perspectives on Telenursing in Patient Care After
Clinical Simulation in Nursing (2015) 11, 244-250 www.elsevier.com/locate/ecsn Featured Article Nursing Students’ Perspectives on Telenursing in Patient Care After Simulation Inger Ase Reierson, RN, MNSca,*, Hilde Solli, RN, MNSc, CCNa, Ida Torunn Bjørk, RN, MNSc, Dr.polit.a,b aFaculty of Health and Social Studies, Institute of Health Studies, Telemark University College, 3901 Porsgrunn, Norway bFaculty of Medicine, Institute of Health and Society, Department of Nursing Science, University of Oslo, 0318 Oslo, Norway KEYWORDS Abstract telenursing; Background: This article presents the perspectives of undergraduate nursing students on telenursing simulation; in patient care after simulating three telenursing scenarios using real-time video and audio nursing education; technology. information and Methods: An exploratory design using focus group interviews was performed; data were analyzed us- communication ing qualitative content analysis. technology; Results: Five main categories arose: learning a different nursing role, influence on nursing assessment qualitative content and decision making, reflections on the quality of remote comforting and care, empowering the pa- analysis tient, and ethical and economic reflections. Conclusions: Delivering telenursing care was regarded as important yet complex activity. Telenursing simulation should be integrated into undergraduate nursing education. Cite this article: Reierson, I. A., Solli, H., & Bjørk, I. T. (2015, April). Nursing students’ perspectives on telenursing in patient care after simulation. Clinical Simulation in Nursing, 11(4), 244-250. http://dx.doi.org/ 10.1016/j.ecns.2015.02.003. Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/). -
New Patient Medical History Form
NEW PATIENT MEDICAL HISTORY FORM Full Name: Date: Birth Date: Age: ALLERGIES o NO ALLERGIES ALLERGY ALLERGIC REACTION MEDICATIONS MEDICATIONS DOSE TIMES PER DAY (Please list ALL) (Mg., pill, etc.) If you need more room to list medications, please write them on a blank sheet of paper with the required information HEALTH MAINTENANCE SCREENING TEST HISTORY CHolesterol Date: Facility/Provider: Abnormal Result? Y N Colonoscopy/SIGMOID Date: Facility/Provider: Abnormal Result? Y N Mammogram Date: Facility/Provider: Abnormal Result? Y N PAP SMEAR Date: Facility/Provider: Abnormal Result? Y N BONE density Date: Facility/Provider: Abnormal Result? Y N VACCINATION HISTORY Last Tetanus Booster or TdaP: Last Pnuemovax (Pneumonia): Last Flu Vaccine: Last Prevnar: Last Zoster Vaccine (Shingles): PERSONAL MEDICAL HISTORY DISEASE/CONDITION CURRENT PAST COMMENTS Alcoholism/Drug Abuse Asthma Cancer (type:_________________________________) Depression/Anxiety/Bipolar/Suicidal Diabetes (type:_______________________________) Emphysema (COPD) Heart Disease High Blood Pressure (hypertension) High Cholesterol Hypothyroidism/Thyroid Disease Renal (kidney) Disease Migraine Headaches Stroke Other: Other: SURGERIES TYPE (specify left/right) Date Location/Facility WOMEN’S HEALTH HISTORY Date of Last Menstrual Cycle: Age of First Menstruation: _____ Age of Menopause: _____ Total Number of Pregnancies: Number of Live Births: Pregnancy Complications: Patient Name: DOB: family MEDICAL HISTORY o NO Significant Family History IS KNOWN 4 CHECK ALL THat apply Stroke Cancer -
Advanced Interpretation of Adult Vital Signs in Trauma William D
Advanced Interpretation of Adult Vital Signs in Trauma William D. Hampton, DO Emergency Physician 26 March 2015 Learning Objectives 1. Better understand vital signs for what they can tell you (and what they can’t) in the assessment of a trauma patient. 2. Appreciate best practices in obtaining accurate vital signs in trauma patients. 3. Learn what teaching about vital signs is evidence-based and what is not. 4. Explain the importance of vital signs to more accurately triage, diagnose, and confidently disposition our trauma patients. 5. Apply the monitoring (and manipulation of) vital signs to better resuscitate trauma patients. Disclosure Statement • Faculty/Presenters/Authors/Content Reviewers/Planners disclose no conflict of interest relative to this educational activity. Successful Completion • To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. • Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Vital Signs Vital Signs Philosophy: “View vital signs as compensatory to the illness/complaint as opposed to primary.” Crowe, Donald MD. “Vital Sign Rant.” EMRAP: Emergency Medicine Reviews and Perspectives. February, 2010. Vital Signs Truth over Accuracy: • Document the true status of the patient: sick or not? • Complete vital signs on every patient, every time, regardless of the chief complaint. • If vital signs seem misleading or inaccurate, repeat them! • Beware sending a patient home with abnormal vitals (especially tachycardia)! •Treat vital signs the same as any other diagnostics— review them carefully prior to disposition. The Mother’s Vital Sign: Temperature Case #1 - 76-y/o homeless ♂ CC: 76-y/o homeless ♂ brought to the ED by police for eval. -
(June 2000) I. INTRODUCTION WHAT IS DOCUMENTATION and WHY
DRAFT EVALUATION & MANAGEMENT DOCUMENTATION GUIDELINES (June 2000) I. INTRODUCTION WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT? Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates: · the ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her health care over time. · communication and continuity of care among physicians and other health care professionals involved in the patient's care; · accurate and timely claims review and payment; · appropriate utilization review and quality of care evaluations; and · collection of data that may be useful for research and education. An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary. WHAT DO PAYERS WANT AND WHY? Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate: · the site of service; · the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or · that services provided have been accurately reported. II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION The principles of documentation listed below are applicable to all types of medical and surgical Pg. 1 services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. -
Use of Nursing Diagnosis in CA Nursing Schools
USE OF NURSING DIAGNOSIS IN CALIFORNIA NURSING SCHOOLS AND HOSPITALS January 2018 Funded by generous support from the California Hospital Association (CHA) Copyright 2018 by HealthImpact. All rights reserved. HealthImpact 663 – 13th Street, Suite 300 Oakland, CA 94612 www.healthimpact.org USE OF NURSING DIAGNOSIS IN CALIFORNIA NURSING SCHOOLS AND HOSPITALS INTRODUCTION As part of the effort to define the value of nursing, a common language continues to arise as a central issue in understanding, communicating, and carrying out nursing's unique role in identifying and treating patient response to illness. The diagnostic process and evidence-based interventions developed and subsequently implemented by a practice discipline describe its unique contribution, scope of accountability, and value. The specific responsibility registered nurses (RN) have in assessing patient response to health and illness and determining evidence-based etiology is within the realm of nursing’s autonomous scope of practice, and is referred to as nursing diagnosis. It is an essential element of the nursing process and is followed by implementing specific interventions within nursing’s scope of practice, providing evidence that links professional practice to health outcomes. Conducting a comprehensive nursing assessment leading to the accurate identification of nursing diagnoses guides the development of the plan of care and specific interventions to be carried out. Assessing the patient’s response to health and illness encompasses a wide range of potential problems and actual concerns to be addressed, many of which may not arise from the medical diagnosis and provider orders alone, yet can impede recovery and impact health outcomes. Further, it is critically important to communicate those problems, potential vulnerabilities and related plans of care through broadly understood language unique to nursing. -
Medical Staff Medical Record Policy
Number: MS -012 Effective Date: September 26, 2016 BO Revised:11/28/2016; 11/27/2017; 1/22/2018; 8/27/2018 CaroMont Regional Medical Center Author: Approved: Patrick Russo, MD, Chief-of-Staff Authorized: Todd Davis, MD, EVP, GMO MEDICAL STAFF MEDICAL RECORD POLICY 1. REQUIRED COMPONENTS OF THE MEDICAL RECORD The medical record shall include information to support the patient's diagnosis and condition, justify the patient's care, treatment and services, and document the course and result of the patient's care, and services to promote continuity of care among providers. The components may consist of the following: identification data, history and physical examination, consultations, clinical laboratory findings, radiology reports, procedure and anesthesia consents, medical or surgical treatment, operative report, pathological findings, progress notes, final diagnoses, condition on discharge, autopsy report when performed, other pertinent information and discharge summary. 2. ADMISSION HISTORY AND PHYSICAL EXAMINATION FOR HOSPITAL CARE Please refer to CaroMont Regional Medical Center Medical Staff Bylaws, Section 12.E. A. The history and physical examination (H&P), when required, shall be performed and recorded by a physician, dentist, podiatrist, or privileged practitioner who has an active NC license and has been granted privileges by the hospital. The H&P is the responsibility of the attending physician or designee. Oral surgeons, dentists, and podiatrists are responsible for the history and physical examination pertinent to their area of specialty. B. If a physician has delegated the responsibility of completing or updating an H&P to a privileged practitioner who has been granted privileges to do H&Ps, the H&P and/or update must be countersigned by the supervisor physician within 30 days after discharge to complete the medi_cal record. -
How to Conduct a Medical Record Review
How to Conduct a Medical Record Review WHITE PAPER Summary: This paper defines a recommended process for medical record review. This includes the important first step of defining the “why” behind the review, and marrying the review outcome to organizational goals. Medical record review is perhaps the core responsibility of the CDI profession- z FEATURES al. Although the numbers vary by facility, CDI specialists review an average of 16–24 patient charts daily, a task that compromises the bulk of their workday Aligning record reviews to (ACDIS, 2016).1 During the review, CDI professionals comb the chart for incom- organizational goals .................2 plete, imprecise, illegible, conflicting, or absent documentation of diagnoses, Principles of record procedures, and treatments, as well as supporting clinical indicators. Their review .......................................3 goal is to cultivate a medical record that stands alone as an accurate story of a ED/EMS notes ..........................5 patient encounter, providing a full picture of the patient’s illness and record of History and physical (H&P) ......6 treatment. A complete record allows for continuity of care, reliable collection of Operative note or bedside mortality and morbidity data, quality statistics, and accurate reimbursement. procedures ...............................7 Diagnostics and medications ...8 In their review of the medical record, CDI professionals aim to reconstruct the Progress notes, consults, and patient story from admission to discharge by examining, understanding, and nursing documentation ............9 synthesizing many puzzle pieces from disparate systems and people. This Initial vs. subsequent process requires considerable clinical acumen, critical thinking akin to detective reviews .....................................9 work, and knowledge of coding guidelines and quality measure requirements. -
GUIDELINES for WRITING SOAP NOTES and HISTORY and PHYSICALS
GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS by Lois E. Brenneman, M.S.N, C.S., A.N.P, F.N.P. © 2001 NPCEU Inc. all rights reserved NPCEU INC. PO Box 246 Glen Gardner, NJ 08826 908-537-9767 - FAX 908-537-6409 www.npceu.com Copyright © 2001 NPCEU Inc. All rights reserved No part of this book may be reproduced in any manner whatever, including information storage, or retrieval, in whole or in part (except for brief quotations in critical articles or reviews), without written permission of the publisher: NPCEU, Inc. PO Box 246, Glen Gardner, NJ 08826 908-527-9767, Fax 908-527-6409. Bulk Purchase Discounts. For discounts on orders of 20 copies or more, please fax the number above or write the address above. Please state if you are a non-profit organization and the number of copies you are interested in purchasing. 2 GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS Lois E. Brenneman, M.S.N., C.S., A.N.P., F.N.P. Written documentation for clinical management of patients within health care settings usually include one or more of the following components. - Problem Statement (Chief Complaint) - Subjective (History) - Objective (Physical Exam/Diagnostics) - Assessment (Diagnoses) - Plan (Orders) - Rationale (Clinical Decision Making) Expertise and quality in clinical write-ups is somewhat of an art-form which develops over time as the student/practitioner gains practice and professional experience. In general, students are encouraged to review patient charts, reading as many H/Ps, progress notes and consult reports, as possible. In so doing, one gains insight into a variety of writing styles and methods of conveying clinical information. -
Rules and Regulations of Licensed Practical Nurses
RULES OF THE TENNESSEE BOARD OF NURSING CHAPTER 1000-02 RULES AND REGULATIONS OF LICENSED PRACTICAL NURSES TABLE OF CONTENTS 1000-02-.01 Licensure by Examination 1000-02-.09 Schools - Curriculum, Instruction, Evaluation 1000-02-.02 Licensure Without Examination: Interstate 1000-02-.10 Schools - Educational Facilities Endorsement 1000-02-.11 Definitions 1000-02-.03 Biennial Registration (Renewal) 1000-02-.12 Fees 1000-02-.04 Discipline of Licensees, Unauthorized Practice of 1000-02-.13 Unprofessional Conduct and Negligence, Practical Nursing, Civil Penalties, Screening Habits or Other Cause Panels, Subpoenas, Advisory Rulings, Declaratory 1000-02-.14 Standards of Nursing Competence Orders, and Assessment of Costs 1000-02-.15 Scope of Practice 1000-02-.05 Schools - Approval 1000-02-.16 Interstate Nurse Licensure 1000-02-.06 Schools - Philosophy, Purpose, Administration, 1000-02-.17 Free Health Clinic and Volunteer Practice Organization and Finance Requirements 1000-02-.07 Schools - Faculty 1000-02-.18 Advertising 1000-02-.08 Schools - Students 1000-02-.01 LICENSURE BY EXAMINATION. (1) Application - The application form provided by the Board is to be completed in part by the applicant, signed by him, and attested by a notary public. (a) The name as signed by the applicant will be the name carried in the records of the Board. (See 1000-02-03 (3) for name change regulation.) (b) Part of this application is to be completed by an official of the school of practical nursing from which the applicant graduated. (c) The completed application, accompanied by the statutory fee, shall be submitted to the Board. A filing date for the application is set by the Board for each scheduled examination. -
Clinical Characteristics and Prognosis Of
Lyu et al. BMC Cardiovascular Disorders (2019) 19:209 https://doi.org/10.1186/s12872-019-1177-1 RESEARCH ARTICLE Open Access Clinical characteristics and prognosis of heart failure with mid-range ejection fraction: insights from a multi-centre registry study in China Lyu Siqi, Yu Litian* , Tan Huiqiong, Liu Shaoshuai, Liu Xiaoning, Guo Xiao and Zhu Jun Abstract Background: Heart failure (HF) with mid-range ejection fraction (EF) (HFmrEF) has attracted increasing attention in recent years. However, the understanding of HFmrEF remains limited, especially among Asian patients. Therefore, analysis of a Chinese HF registry was undertaken to explore the clinical characteristics and prognosis of HFmrEF. Methods: A total of 755 HF patients from a multi-centre registry were classified into three groups based on EF measured by echocardiogram at recruitment: HF with reduced EF (HFrEF) (n = 211), HFmrEF (n = 201), and HF with preserved EF (HFpEF) (n = 343). Clinical data were carefully collected and analyzed at baseline. The primary endpoint was all-cause mortality and cardiovascular mortality while the secondary endpoints included hospitalization due to HF and major adverse cardiac events (MACE) during 1-year follow-up. Cox regression and Logistic regression were performed to identify the association between the three EF strata and 1-year outcomes. Results: The prevalence of HFmrEF was 26.6% in the observed HF patients. Most of the clinical characteristics of HFmrEF were intermediate between HFrEF and HFpEF. But a significantly higher ratio of prior myocardial infarction (p = 0.002), ischemic heart disease etiology (p = 0.004), antiplatelet drug use (p = 0.009), angioplasty or stent implantation (p = 0.003) were observed in patients with HFmrEF patients than those with HFpEF and HFrEF. -
The Contribution of the Medical History for the Diagnosis of Simulated Cases by Medical Students
International Journal of Medical Education. 2012;3:78-82 ISSN: 2042-6372 DOI: 10.5116/ijme.4f8a.e48c The contribution of the medical history for the diagnosis of simulated cases by medical students Tomoko Tsukamoto, Yoshiyuki Ohira, Kazutaka Noda, Toshihiko Takada, Masatomi Ikusaka Department of General Medicine, Chiba University Hospital, Japan Correspondence: Tomoko Tsukamoto, Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba city, Chiba, 260-8677 Japan. Email: [email protected] Accepted: April 15, 2012 Abstract Objectives: The case history is an important part of diag- rates were compared using analysis of the χ2-test. nostic reasoning. The patient management problem method Results: Sixty students (63.8%) made a correct diagnosis, has been used in various studies, but may not reflect the which was based on the history in 43 students (71.7%), actual reasoning process because a list of choices is given to physical findings in 11 students (18.3%), and laboratory the subjects in advance. This study investigated the contri- data in 6 students (10.0%). Compared with students who bution of the history to making the correct diagnosis by considered the correct diagnosis in their differential diagno- using clinical case simulation, in which students obtained sis after taking a history, students who failed to do so were clinical information by themselves. 5.0 times (95%CI = 2.5-9.8) more likely to make a final Methods: A prospective study was conducted. Ninety-four misdiagnosis (χ2(1) = 30.73; p<0.001). fifth-year medical students from Chiba University who Conclusions: History taking is especially important for underwent supervised clinical clerkships in 2009 were making a correct diagnosis when students perform clinical surveyed.