Nursing

Discussion: Diagnosis Genetic Disorders
Discussion: Diagnosis Genetic Disorders
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Discussion: Diagnosis and Management of Respiratory, Cardiovascular, and Genetic Disorders Case Studies 1–3
Respiratory disorders such as pneumonia and asthma are among the leading causes of hospitalization in pediatric patients (U.S. Department of Health and Human Services, 2011). With such severe implications associated with many respiratory disorders, advanced practice nurses must be able to quickly identify symptoms, diagnose patients, and recommend appropriate treatment. For this Discussion, consider potential diagnoses and treatments for the patients in the following three case studies.
Case Study 1:
A 14-month-old female presents with a 4-day history of nasal congestion and congested cough. This morning, the mother noted that her daughter was breathing quickly and “it sounds like she has rice cereal popping in her throat.” Oral intake is decreased. Physical examination reveals the following: respiratory rate is 58, lung sounds are diminished in the bases, she has pronounced intercostal and subcostal retractions, expiratory wheezes are heard in all lung fields, and her tympanic membranes are normal. There is moderate, thick, clear rhinorrhea and postnasal drip. Her capillary refill is less than 3 seconds, and she is alert and smiling. Her RSV rapid antigen test is positive.
Case Study 2:
Brian is a 14-year-old known asthmatic with a 2-day history of worsening cough and shortness of breath. He reports using a short-acting beta agonist every 3 hours over the previous 24 hours. He has a long-acting inhaled corticosteroid, but the prescription ran out, and he forgot to get it refilled. He says he came today because he woke up at 2 a.m. coughing and couldn’t stop, thus preventing him from going back to sleep. Over-the-counter cough suppressants don’t help. He denies cigarette smoking, but his clothing smells like smoke. His respiratory rate is 18 and he has prolonged expiration and expiratory wheezes in all lung fields. There are no signs of dyspnea. All other exam findings are normal.
Case Study 3:
A father presents his 9-year-old with a 3-day history of cough. Dad states that his son is coughing up yellow mucus. The boy is afebrile and is sleeping through the night, but the father’s sleep is disturbed listening to his son coughing. Dad says he thinks his son has bronchitis and is requesting treatment. Physical examination reveals the following: respiratory rate is 18, lungs are clear to auscultation, patient is able to take deep breaths without coughing, there is no cervical adenopathy, nasal turbinates are slightly enlarged, and there is moderate clear rhinorrhea.
Case Studies 4–6
Assessing, diagnosing, and treating pediatric patients for many cardiovascular and genetic disorders can be challenging. As an advanced practice nurse who facilitates care for patients presenting with these types of disorders, you must be familiar with current evidence-based clinical guidelines. Because of the clinical implications, you have to know when to treat patients with these disorders and when to refer them for specialized care. In this Discussion, you examine the following case studies and consider appropriate treatment and management plans.
Case Study 4:
Miguel is a 15-year-old male who presents for a sports physical. He is a healthy adolescent with no complaints. He plays basketball. He is 6 feet 5 inches tall and weighs 198 pounds. You note long arms and long thin fingers. He has joint laxity in his wrists, shoulders, and elbows.
Case Study 5:
Trina is a 9-year-old female who weighs 110 pounds. Vital signs are as follows: BP 122/79, P 98, R 20. Her mother reports she is a picky eater and refuses to eat fruits and vegetables. Her physical activity includes soccer practice for 1 hour a week with one game each weekend from September through November. Family history is negative for myocardial infarction, but both parents take medication for dyslipidemia.
Case Study 6:
You see a 2-month-old for a well-child visit. She is breastfed and nurses every 2 to 3 hours during the day, but her mother reports she is not nursing as vigorously as before. She sleeps one 4-hour block at night. Birth weight was 7 pounds 5 ounces. Weight gain over the last 2 weeks reveals gain of 5 ounces per week. Physical examination reveals the following: HEENT exam is benign, lung sounds are clear, a new III/VI systolic ejection murmur is noted along the left lower sternal border, cap refill is brisk, skin is pink and moist, and abdominal exam is benign.
To prepare:
Review “Respiratory Disorders,” “Cardiovascular Disorders,” and “Genetic Disorders” in the Burns et al. text.
Review and select one of the six provided case studies. Analyze the patient information.
Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
Consider strategies for educating patients and families on the treatment and management of the respiratory disorder.
By Day 3
Post an explanation of the differential diagnosis for the patient in the case study you selected. Explain which is the most likely diagnosis for the patient and why. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments. Finally, explain strategies for educating patients and families on the treatment and management of the respiratory, cardiovascular, and/or genetic disorder.
CLINICAL PRACTICE GUIDELINE
Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis
abstract This guideline is a revision of the clinical practice guideline, “Diagnosis and Management of Bronchiolitis,” published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action state- ment indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows: Pediatrics 2014;134:e1474–e1502
DIAGNOSIS
1a. Clinicians should diagnose bronchiolitis and assess disease se- verity on the basis of history and physical examination (Evidence Quality: B; Recommendation Strength: Strong Recommendation).
1b. Clinicians should assess risk factors for severe disease, such as age less than 12 weeks, a history of prematurity, underlying car- diopulmonary disease, or immunodeficiency, when making decisions about evaluation and management of children with bronchiolitis (Evidence Quality: B; Recommendation Strength: Moderate Rec- ommendation).
1c. When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).
TREATMENT
2. Clinicians should not administer albuterol (or salbutamol) to in- fants and children with a diagnosis of bronchiolitis (Evidence Qual- ity: B; Recommendation Strength: Strong Recommendation).
3. Clinicians should not administer epinephrine to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommen- dation Strength: Strong Recommendation).
4a. Nebulized hypertonic saline should not be administered to in- fants with a diagnosis of bronchiolitis in the emergency depart- ment (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).
4b. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on ran- domized controlled trials with inconsistent findings]).
Shawn L. Ralston, MD, FAAP, Allan S. Lieberthal, MD, FAAP, H. Cody Meissner, MD, FAAP, Brian K. Alverson, MD, FAAP, Jill E. Baley, MD, FAAP, Anne M. Gadomski, MD, MPH, FAAP, David W. Johnson, MD, FAAP, Michael J. Light, MD, FAAP, Nizar F. Maraqa, MD, FAAP, Eneida A. Mendonca, MD, PhD, FAAP, FACMI, Kieran J. Phelan, MD, MSc, Joseph J. Zorc, MD, MSCE, FAAP, Danette Stanko-Lopp, MA, MPH, Mark A. Brown, MD, Ian Nathanson, MD, FAAP, Elizabeth Rosenblum, MD, Stephen Sayles III, MD, FACEP, and Sinsi Hernandez-Cancio, JD
KEY WORDS bronchiolitis, infants, children, respiratory syncytial virus, evidence-based, guideline
ABBREVIATIONS AAP—American Academy of Pediatrics AOM—acute otitis media CI—confidence interval ED—emergency department KAS—Key Action Statement LOS—length of stay MD—mean difference PCR—polymerase chain reaction RSV—respiratory syncytial virus SBI—serious bacterial infection
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
The recommendations in this report do not indicate an exclusive course of treatment or serve as a standard ofmedical care. Variations, taking into account individual circumstances, may be appropriate.
All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
Dedicated to the memory of Dr Caroline Breese Hall.
www.pediatrics.org/cgi/doi/10.1542/peds.2014-2742
doi:10.1542/peds.2014-2742
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2014 by the American Academy of Pediatrics
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Guidance for the Clinician in Rendering Pediatric Care
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5. Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting (Evidence Quality: A; Rec- ommendation Strength: Strong Rec- ommendation).
6a. Clinicians may choose not to ad- minister supplemental oxygen if the oxyhemoglobin saturation ex- ceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommen- dation Strength: Weak Recommen- dation [based on low level evidence and reasoning from first princi- ples]).
6b. Clinicians may choose not to use continuous pulse oximetry for in- fants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low- level evidence and reasoning from first principles]).
7. Clinicians should not use chest physiotherapy for infants and chil- dren with a diagnosis of bron- chiolitis (Evidence Quality: B; Recommendation Strength: Mod- erate Recommendation).
8. Clinicians should not administer antibacterial medications to in- fants and children with a diagno- sis of bronchiolitis unless there is a concomitant bacterial infec- tion, or a strong suspicion of one (Evidence Quality: B; Recommen- dation Strength: Strong Recom- mendation).
9. Clinicians should administer naso- gastric or intravenous fluids for infants with a diagnosis of bron- chiolitis who cannot maintain hy- dration orally (Evidence Quality: X; Recommendation Strength: Strong Recommendation).
PREVENTION
10a. Clinicians should not administer palivizumab to otherwise healthy infants with a gestational age of
29 weeks, 0 days or greater (Evidence Quality: B; Recom- mendation Strength: Strong Recommendation).
10b. Clinicians should administer palivizumab during the first year of life to infants with he- modynamically significant heart disease or chronic lung disease of prematurity defined as pre- term infants<32 weeks 0 days’ gestation who require >21% oxygen for at least the first 28 days of life (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).
10c. Clinicians should administer a maximum 5 monthly doses (15 mg/kg/dose) of palivizumab during the respiratory syncytial virus season to infants who qualify for palivizumab in the first year of life (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).
11a. All people should disinfect hands before and after direct contact with patients, after contact with inanimate objects in the direct vicinity of the patient, and after removing gloves (Evidence Qual- ity: B; Recommendation Strength: Strong Recommendation).
11b. All people should use alcohol- based rubs for hand decontam- ination when caring for children with bronchiolitis. When alcohol- based rubs are not available, individuals should wash their hands with soap and water (Evidence Quality: B; Recom- mendation Strength: Strong Recommendation).
12a. Clinicians should inquire about the exposure of the infant or child to tobacco smoke when assessing infants and chil- dren for bronchiolitis (Evidence Quality: C; Recommendation Strength: Moderate Recom- mendation).
12b. Clinicians should counsel care- givers about exposing the in- fant or child to environmental tobacco smoke and smoking cessation when assessing a child for bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong).
13. Clinicians should encourage ex- clusive breastfeeding for at least 6 months to decrease the mor- bidity of respiratory infections. (Evidence Quality: B; Recommen- dation Strength: Moderate Rec- ommendation).
14. Clinicians and nurses should ed- ucate personnel and family mem- bers on evidence-based diagnosis, treatment, and prevention in bron- chiolitis. (Evidence Quality: C; obser- vational studies; Recommendation Strength: Moderate Recommenda- tion).
INTRODUCTION
In October 2006, the American Acad- emy of Pediatrics (AAP) published the clinical practice guideline “Diagnosis and Management of Bronchiolitis.”1
The guideline offered recommendations ranked according to level of evidence and the benefit-harm relationship. Since completion of the original evidence re- view in July 2004, a significant body of literature on bronchiolitis has been published. This update of the 2006 AAP bronchiolitis guideline evaluates pub- lished evidence, including that used in the 2006 guideline as well as evidence published since 2004. Key action state- ments (KASs) based on that evidence are provided.
The goal of this guideline is to provide an evidence-based approach to the di- agnosis, management, and prevention of bronchiolitis in children from 1 month through 23 months of age. The guideline is intended for pediatricians, family physicians, emergency medicine spe- cialists, hospitalists, nurse practitioners,
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and physician assistants who care for these children. The guideline does not apply to children with immunodeficien- cies, including those with HIV infection or recipients of solid organ or hema- topoietic stem cell transplants. Children with underlying respiratory illnesses, such as recurrent wheezing, chronic neonatal lung disease (also known as bronchopulmonary dysplasia), neuro- muscular disease, or cystic fibrosis and those with hemodynamically significant congenital heart disease are excluded from the sections on management un- less otherwise noted but are included in the discussion of prevention. This guide- line will not address long-term sequelae of bronchiolitis, such as recurrent wheezing or risk of asthma, which is a field with a large and distinct lit- erature.
Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants. Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, and increased mucus production. Signs and symp- toms typically begin with rhinitis and cough, which may progress to tachy- pnea, wheezing, rales, use of accessory muscles, and/or nasal flaring.2
Many viruses that infect the respiratory system cause a similar constellation of signs and symptoms. The most com- mon etiology of bronchiolitis is re- spiratory syncytial virus (RSV), with the highest incidence of infection occurring between December and March in North America; however, regional variations occur3 (Fig 1).4 Ninety percent of chil- dren are infected with RSV in the first 2 years of life,5 and up to 40% will experience lower respiratory tract in- fection during the initial infection.6,7
Infection with RSV does not grant per- manent or long-term immunity, with reinfections common throughout life.8
Other viruses that cause bronchiolitis include human rhinovirus, human meta-
pneumovirus, influenza, adenovirus, coronavirus, human, and parainflu- enza viruses. In a study of inpatients and outpatients with bronchiolitis,9
76% of patients had RSV, 39% had human rhinovirus, 10% had influenza, 2% had coronavirus, 3% had human metapneumovirus, and 1% had para- influenza viruses (some patients had coinfections, so the total is greater than 100%).
Bronchiolitis is themost common cause of hospitalization among infants during the first 12 months of life. Approximately 100 000 bronchiolitis admissions occur annually in the United States at an estimated cost of $1.73 billion.10 One prospective, population-based study sponsored by the Centers for Disease Control and Prevention reported the
average RSV hospitalization rate was 5.2 per 1000 children younger than 24 months of age during the 5-year pe- riod between 2000 and 2005.11 The highest age-specific rate of RSV hos- pitalization occurred among infants between 30 days and 60 days of age (25.9 per 1000 children). For preterm infants (<37 weeks’ gestation), the RSV hospitalization rate was 4.6 per 1000 children, a number similar to the RSV hospitalization rate for term infants of 5.2 per 1000. Infants born at <30 weeks’ gestation had the highest hospitalization rate at 18.7 children per 1000, although the small number of infants born before 30 weeks’ gestation make this number unreliable. Other studies indicate the RSV hospitalization rate in extremely FIGURE 1 RSV season by US regions. Centers for Disease Control and Prevention. RSV activity—United States, July 2011–Jan 2013. MMWR Morb Mortal Wkly Rep. 2013;62(8):141–144. e1476 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on August 26, 2015pediatrics.aappublications.orgDownloaded from preterm infants is similar to that of term infants.12,13 METHODS In June 2013, the AAP convened a new subcommittee to review and revise the 2006 bronchiolitis guideline. The sub- committee included primary care physi- cians, including general pediatricians, a family physician, and pediatric sub- specialists, including hospitalists, pul- monologists, emergency physicians, a neonatologist, and pediatric infectious disease physicians. The subcommit- tee also included an epidemiologist trained in systematic reviews, a guide- line methodologist/informatician, and a parent representative. All panel mem- bers reviewed the AAP Policy on Conflict of Interest and Voluntary Disclosure and were given an opportunity to declare any potential conflicts. Any conflicts can be found in the author listing at the end of this guideline. All funding was provided by the AAP, with travel assistance from the American Academy of Family Phy- sicians, the American College of Chest Physicians, the American Thoracic Society, and the American College of Emergency Physicians for their liaisons. The evidence search and review included electronic database searches in The Cochrane Library, Medline via Ovid, and CINAHL via EBSCO. The search strategy is shown in the Appendix. Re- lated article searches were conducted in PubMed. The bibliographies of arti- cles identified by database searches were also reviewed by 1 of 4 members of the committee, and references iden- tified in this manner were added to the review. Articles included in the 2003 evidence report on bronchiolitis in preparation of the AAP 2006 guide- line2 also were reviewed. In addition, the committee reviewed articles pub- lished after completion of the sys- tematic review for these updated guidelines. The current literature re- view encompasses the period from 2004 through May 2014. The evidence-based approach to guide- line development requires that the evi- dence in support of a policy be identified, appraised, and summarized and that an explicit link between evidence and rec- ommendations be defined. Evidence- based recommendations reflect the quality of evidence and the balance of benefit and harm that is anticipated when the recommendation is followed. The AAP policy statement “Classify- ing Recommendations for Clinical Practice”14 was followed in designat- ing levels of recommendation (Fig 2; Table 1). A draft version of this clinical practice guideline underwent extensive peer review by committees, councils, and sections within AAP; the American Thoracic Society, American College of Chest Physicians, American Academy of Family Physicians, and American College of Emergency Physicians; other outside organizations; and other in- dividuals identified by the subcom- mittee as experts in the field. The resulting comments were reviewed by the subcommittee and, when ap- propriate, incorporated into the guide- line. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with bronchi- olitis. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis. All AAP guidelines are reviewed every 5 years. FIGURE 2 Integrating evidence quality appraisal with an assessment of the anticipated balance between benefits and harms leads to designation of a policy as a strong recommendation, moderate recommendation, or weak recommendation. PEDIATRICS Volume 134, Number 5, November 2014 e1477 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on August 26, 2015pediatrics.aappublications.orgDownloaded from DIAGNOSIS Key Action Statement 1a Clinicians should diagnose bronchi- olitis and assess disease severity on the basis of history and physical examination (Evidence Quality: B; Recommendation Strength: Strong Recommendation). Action Statement Profile KAS 1a Key Action Statement 1b Clinicians should assess risk fac- tors for severe disease, such as age <12 weeks, a history of pre- maturity, underlying cardiopulmo- nary disease, or immunodeficiency, when making decisions about eval- uation and management of children with bronchiolitis (Evidence Quality: B; Recommendation Strength: Mod- erate Recommendation). Action Statement Profile KAS 1b Key Action Statement 1c When clinicians diagnose bronchi- olitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely (Evidence Qual- ity: B; Recommendation Strength: Moderate Recommendation).

Assignment: Importance of Teams
Assignment: Importance of Teams
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Sample Proposal Template: HCS 325 Resources: The five-step planning process covered in the course and the Sample Business Proposal example
Consider the following scenario:
As the manager of a busy call center for a health care organization, you note that the volume of calls has doubled over the past year. Although you do not have the budget to hire additional staff, you do have an additional $20,000 to spend on your department to improve efficiency and customer satisfaction.
Using the
HCS 325 WEEK 3 Importance of Teams
Sample Proposal Template: HCS 325 Resources: The five-step planning process covered in the course and the Sample Business Proposal example
Consider the following scenario:
As the manager of a busy call center for a health care organization, you note that the volume of calls has doubled over the past year. Although you do not have the budget to hire additional staff, you do have an additional $20,000 to spend on your department to improve efficiency and customer satisfaction.
Using the Sample Proposal Template example, write a 700- to 1,050-word proposal.
Address the following in your proposal:
Explain why teams are essential in a health care organization.
Explain how other industries use teams.
How are they used in other industries, such as aviation, auto racing, or the military?
What best practices from other industries could be applied in the health care industry?
Explain strategies you will use to create an effective team that can help you improve efficiency and customer service in your department.
Explain organizational processes that will impact or influence the decision making process to improve efficiency and customer service.
Explain what resources or tools can be offered to your staff to help with efficiency and customer service using the additional funds available.
Cite 3 references to support your position. One reference may be the course textbook.
Format your proposal according to APA guidelines.
Click the Assignment Files tab to submit your assignment.
example, write a 700- to 1,050-word proposal.
Address the following in your proposal:
Explain why teams are essential in a health care organization.
Explain how other industries use teams.
How are they used in other industries, such as aviation, auto racing, or the military?
What best practices from other industries could be applied in the health care industry?
Explain strategies you will use to create an effective team that can help you improve efficiency and customer service in your department.
Explain organizational processes that will impact or influence the decision making process to improve efficiency and customer service.
Explain what resources or tools can be offered to your staff to help with efficiency and customer service using the additional funds available.
Cite 3 references to support your position. One reference may be the course textbook.
Format your proposal according to APA guidelines.
Click the Assignment Files tab to submit your assignment.
HCS 325 WEEK 3 Organizational Structure Outline Worksheet
Review the key points identified under Week Three of the Part B: Outline Brainstorm section of the Organizational Structure Outline worksheet.
As a team, brainstorm concepts you need to discuss under the identified key point(s) and review the feedback received by your instructor for the Week Two key points.
Write a 150- to 350-word summary based on your brainstorming for this week and on the feedback given for the previous week. What tasks does your team need to complete to properly support the subjects in the Week Five Organizational Structure Presentation assignment.
Note: Your Learning Team will use this information to complete the Organizational Structure Presentation due in Week Five.
Format your summary according to APA guidelines.
Click the Assignment Files tab to submit your summary and the Organizational Structure Outline worksheet.

Assignment: Care Program Overview
Assignment: Care Program Overview
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Identify one health care program area of activity in a population-based health organization you want to evaluate. You may use the organization where you work or the Moreno Medical Center virtual organization.
You will be creating a proposal for a small-scale research project to evaluate your selected program.
Write a 350-word overview of your topic selection for the Health Care Program Evaluation Proposal, due in Week 8.
Use the following information below as an outline for your overview. An example of how this outline should look can be viewed within the Moreno Medical Center virtual organization for any of the programs listed within the Director of Research, located under the Administration tab.
Program title
Program goal
Program purpose
Program scope
Program audience
Program background
Rationale for developing this evaluation plan
Existing program evaluation program model, if available
References
Format the overview consistent with APA guidelines or the examples found in Moreno Medical Center.
Include a cover page indicating the name of the program.
Click the Assignment Files tab to submit the assignment.
DHA 732 WEEK 4 Draft 1 – Health Care Program Evaluation Proposal
Write a draft of the first three sections of the program evaluation proposal to include the following:
Introduction: This is not a summary of the proposal; it is a brief statement of the plan’s purpose. Start with a clear purpose statement. Add a description of each major section, as presented in the completed plan. This section must be no more than one-half page in length. Review Ch. 1 and 2 of the Posavac (2011) text for further information.
Program Background: Insert updated content with revisions based on facilitator feedback from the Week 2 topic overview assignment. This section must be no more than one-half page in length. Review Ch. 2 & 3 of the Posavac (2011) text for further information.
Literature Review: Describe findings to date from a review and analysis of literature. This section must be one to two pages in length.
Format your draft according to the following:
Title page, including title of the program, author’s name, and institution name
Table of contents, listing headings that are also found in the narrative, and corresponding page numbers
Table of exhibits listing type, number, title, and corresponding page numbers; this includes Table of Tables and Table of Figures
References–there should be one References section for the full proposal
Appendixes (if applicable)–there should be one Appendix section for all appendices
Click the Assignment Files tab to submit the assignment.
DHA 732 WEEK 8 Health Care Program Evaluation Proposal
Complete the final two sections of the proposal:
Ethical, Equity, and Leadership Considerations
Implementing and Monitoring Strategies
Finalize the full proposal for a small-scale research project to evaluate your program.
Your final proposal must be between 8,750 and 10,500 words.
Title page, references page, table of contents, figures, and appendices do not count toward the minimum required length.
All sources must be carefully referenced. Your proposal must include at least 25 references with at least 15 peer-reviewed sources.
Outline your Health Care Program Evaluation Proposal as follows:
Title page, including title of study, author’s name, and institution name
Table of contents, listing headings that are in the narrative, and corresponding page numbers
Table of exhibits listing type, number, title, and corresponding page numbers
Introduction
Program background
Literature review
Theoretical Framework
Program evaluation goals and specific objectives
Evaluation model design
Evaluation methods
Data analysis and reporting
Economic evaluation
Ethical, equity, and leadership considerations
Implementing and monitoring strategies
References
Format the paper consistent with APA guidelines.
Click the Assignment Files tab to submit the assignment.
DHA 732 WEEK 7 Draft 3 – Health Care Program Evaluation Proposal
Write a draft of the next two sections of the program evaluation proposal to include the following:
Data Analysis and Reporting:
What software programs, report generation tools, and analytics will be used for compiling, data mining, storing, and retrieving current and historical data for analysis and reporting?
What are the overall capabilities and limitations of the software?
Is there any known data needed for program evaluation that is not currently accessible through the health care organization’s interfaced information system?
Is there a cost-benefit consideration involving manual collection for analysis and custom reports for reporting warranting economic evaluation or cost analysis?
Economic Evaluation:
Problem or purpose warranting an economic evaluation
The economic- or program-related theory that supports an economic evaluation
Economic or cost analysis questions to be answered related to the purpose
Stipulate if comparing to another program or interventions
Justifying the need for a cost description or analysis
Decision rules
Each type of economic evaluation and cost analysis
Accounting perspective and corresponding costs & benefits to be evaluated
Data and methods used
Resource limitations
Click the Assignment Files tab to submit the assignment.
DHA 732 WEEK 6 Draft 2 – Health Care Program Evaluation Proposal
Write a draft of the next three sections of the program evaluation proposal to include the following:
Program Evaluation Goals and Objectives:
Theoretical Framework
What is the general goal for designing or selecting an evaluation plan based on the theoretical framework and program setting?
What is the specific program and evaluation theory behind similar programs?
What are the common goals and objectives of similar programs?
Is the organization’s program in alignment with similar programs in terms of purpose, stakeholders, resources, goals, and objectives?
What specific questions must the evaluation model answer to evaluate the program for internal and external stakeholders?
What specific processes, output, outcomes, or implementation goals must be evaluated?
What are the objectives of the program evaluation in terms of providing data, information, and resources to internal stakeholders, such as performance dashboards to monitor processes, quality, outputs, resources, costs, revenue, and other implementation and outcome measurements?
Evaluation Model Design:
Provide an overall qualitative or quantitative approach to the evaluation.
Describe from where, whom, and when data will be collected.
Describe the participants and sampling, if appropriate to the program being evaluated.
If evaluating a program involving input or by patients, clients, or consumers, how will participants be recruited or selected, such as for a patient satisfaction survey?
Sampling methods and sample size: Will the program evaluation model evaluate all participants, processes, outputs, or outcomes, or use a research-based sampling method?
Evaluation Methods:
Procedures for data collection: Describe the procedures used, such as retrospective historical performance, program utilization, financial and outcome data, electronic medical records, laboratory or quality software application data capture and reporting, focus group discussion, or questionnaire surveys.
Will the evaluation include capturing quantitative and qualitative data and information?
Click the Assignment Files tab to submit the assignment.
DHA 732 WEEK 5 Case Study Critical Review
Resources: Literature Review section of Draft 1 of your proposal, Ch. 6 of Issel (2014), and Ch. 9 (pages 111-116) of Longest (2015)
Conduct an in-depth critical review of health care programs similar to those from your Literature Review section of your proposal.
Identify ideas relating to the program topic that present theories on the effectiveness of program intervention and evaluation strategies.
Write a critical review and analysis of two or more peer-reviewed articles. You may also use examples of similar programs discussed in scholarly readings.
The review should be no longer than 1,225 words.
Apply and integrate concepts from the course readings in your analysis.
Include the following in your critical review. Use scholarly resources to support your viewpoint for each:
A comparison of the programs
A description of why some program intervention and evaluation strategies are more effective than others.
The stated or perceived program evaluation theories behind each of the programs
An analysis of whether your program is in alignment with similar programs in terms of program purpose, program theory, interventions, stakeholders, resources, goals, and objectives
A summary of the learning garnered in this assignment that can be applied to the development of your own program evaluation plan
Conclusions addressing what you will be adding and/or revising to the Literature Review section of your proposal
Potential goals and objectives to include in your proposal
Format your critical review consistent with APA guidelines.
Click the Assignment Files tab to submit the assignment.

Discussion: Group Dynamics—Intragroup
Discussion: Group Dynamics—Intragroup
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Members of dominant ethnic and racial groups may assume that other groups’ struggles are not their own or assume that those of a given race speak with one voice and react in the same way to their oppression. In reality, people can cope with racial inequalities in a variety of ways, creating complex relationships both between the dominant and oppressed group and among members of the dominant and oppressed groups.
As a social worker, you must understand the many ways in which racial privilege can impact your clients. You must also understand the ways in which racial privilege has impacted your life and the ways you react to the realities of racism. You will likely need to help clients address racial divides and combat racial inequality to empower them.
To prepare: Review “Working With Immigrants and Refugees: The Case of Aaron.”
· Post an explanation of how dominant groups can play a role in marginalizing other groups based on racial and ethnic characteristics.
· Discuss the potential negative impact of a dominant culture on immigrants and refugees, such as Aaron.
· How might racism and prejudice impact his assimilation?
· Furthermore, explain how you would respond to Aaron when he discusses his family’s rejection of his desire to maintain his cultural roots.
· In your explanation, identify specific skills you would employ as a multiculturally sensitive social worker.
References (use at least 2)
Adams, M., Blumenfeld, W. J., Castaneda, C., Hackman, H. W., Peters, M. L., & Zuniga, X. (Eds.). (2013). Readings for diversity and social justice. (3rd ed.). New York, NY: Routledge Press.
Chapter 8, (pp. 65–68)
Chapter 21, (pp. 125–126)
Chapter 22, (pp. 127–133)
Chapter 24, (pp. 135–139)
Plummer, S. B., Makris, S., & Brocksen S. M. (Eds.). (2014). Social work case studies: Foundation year. Baltimore, MD: Walden International Universities Publishing. [Vital Source e-Reader].
“Working With Immigrants and Refugees: The Case of Aaron”

Discussion: Case Unintentional Weight
Discussion: Case Unintentional Weight
Discussion: Case Unintentional Weight
Week 1 discussion For this assignment, you will review the case study below and post a discussion for the class answering the noted questions. You are evaluating a 78 year old white male who comes to your office today with unintentional weight loss of 10lb in the last year, self-reported exhaustion weakness based on grip strength, and slow walking speed, and low physical activity. Notes that he has been feeling worse over the past 6 months and just does not have the strength to do anything anymore. The patient states they are not currently on any medications except a multivitamin. He notes that he lives alone and does not want to leave his house. Answer the following questions with supportive rationale: What questions should you as the patient/family to further assess? What screening tools would be appropriate in this case? Do you have concerns with fraility in this patient? If so why? What referrals should be made if any on this patient? Submission Details: Post your response to the Discussion Area by the due date assigned. Respond to at least two posts by the end of the week.
Unintentional weight gain occurs when you put on weight without increasing your consumption of food or liquid and without decreasing your activity. This occurs when you’re not trying to gain weight. It’s often due to fluid retention, abnormal growths, constipation, or pregnancy.
Unintentional weight gain can be periodic, continuous, or rapid.
Periodic unintentional weight gain includes regular fluctuations in weight. One example of unintentional weight gain is experienced during a woman’s menstrual cycle. Periodic, but longer-term unintentional weight gain is often the result of pregnancy, which lasts nine months.
Rapid unintentional weight gain may be due to medication side effects. Many cases of unintentional weight gain are harmless. But some symptoms experienced along with rapid weight gain may signal a medical emergency.

Assignment: Assessing Genitalia and Rectum
Assignment: Assessing Genitalia and Rectum
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Patients are frequently uncomfortable discussing with health care professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.
GENITALIA ASSESSMENT: Assignment 1: Assessing the Genitalia and Rectum
Subjective:
CC: “I have bumps on my bottom that I want to have checked out.”
HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
PMH: Asthma
Medications: Symbicort 160/4.5mcg
Allergies: NKDA
FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney
Diagnostics: HSV specimen obtained
Assessment:
Chancre
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
To prepare:
With regard to the SOAP note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
To complete:
Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study. Using evidence based resources, answer the following questions and support your answers using current evidence from the literature.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or Why not?
Would diagnostics be appropriate for this case and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature.
CALSS RESOURCES
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 16, “Breasts and Axillae” (pp. 350-369)
This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.
Chapter 18, “Female Genitalia” (pp. 416-465)
In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.
Chapter 19, “Male Genitalia” (pp. 466-484)
The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.
Chapter 20, “Anus, Rectum, and Prostate” (pp. 485-500)
This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 5, “Amenorrhea” (pp. 47-60)
Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.
Chapter 6, “Breast Lumps and Nipple Discharge” (pp. 61-72)
This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.
Chapter 7, “Breast Pain” (pp. 73-80)
Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history.
Chapter 27, “Penile Discharge” (pp. 318-324)
The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam.
Chapter 36, “Vaginal Bleeding” (pp. 419-433)
In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient, as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis.
Chapter 37, “Vaginal Discharge and Itching” (pp. 434-445)
This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies.
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
Chapter 3, “Adult Preventative Care Visits” (“Gender Specific Screenings”; pp. 48–49)Note: Download the Physical Examination Objective Data Checklist to use as you complete the Head-to-Toe Physical Assessment Video assignment.
Sabbagh, C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., & Regimbeau, J. M. (2014). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085. doi:10.1016/j.dld.2014.08.045
Retrieved from the Walden Library Databases.
Westhoff, C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10.
Retrieved from the Walden Library databases.
This article describes the benefits of new technology and guidelines for pelvic exams. The authors also detail which guidelines and technology may become obsolete.
Required Media
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 2, “The Breasts,” pp. 434–444)
Section 2 of this chapter focuses on the anatomy and physiology of breasts. The section provides descriptions of breast examinations and common breast conditions.
Chapter 11, “The Female Genitalia and Reproductive System” (pp. 541–562)
In this chapter, the authors provide an overview of the female reproductive system. The authors also describe symptoms of disorders in the reproductive system.
Chapter 12, “The Male Genitalia and Reproductive System” (pp. 563–584)
The authors of this chapter detail the anatomy of the male reproductive system. Additionally, the authors describe how to conduct an exam of the male reproductive system.
Review of Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)

Quality Improvement Program
Quality Improvement Program
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Imagine yourself as a hospital administrator ready to undertake a new quality improvement program for your hospital. In the previous assignment in unit two you explained the history and evolution of quality improvement programs to your employees and detailed how current operations management theory can help in the implementation of any new program developed. Through that effort you prepared the team for development of a new plan for the hospital that will improve patient outcomes for the facility.
Instructions
In this compare-contrast assignment you and your team will decide which approach to use to implement your plan of action. The team has narrowed the approach down to a total quality management strategic approach or management by objectives operations strategy or other proactive continuous quality improvement measures. Weigh the advantages and disadvantages of at least two approaches and decide on the approach the facility will use moving forward with the plan. Explain some of the elements involved in successful healthcare quality improvements efforts. Examine the strategic and tactical planning issues relevant to marketing, opportunity assessment, and external environment analysis in the two approaches. Provide a recommendation for the best quality improvement approach for the facility.
Your paper should be at least 4 pages (not including the title or reference pages) long following APA 6th edition formatting, with a word count of at least 1000.
Requirements
? Weigh the advantages and disadvantages of at least two approaches and decide on the approach the facility will use moving forward with the plan. You will compare and contrast two operational management theories that could help in the implementation of quality improvement programs.
? Examine the strategic and tactical planning issues relevant to marketing, opportunity assessment, and external environment analysis in the two approaches.
? Provide a recommendation for the best quality improvement approach for the facility.
? The assignment should follow the conventions of Standard English (correct grammar, punctuation, and spelling).
The assignment should be double spaced and must use a 12 point and Times New Roman.

Clinical Microsystem Care Model
Clinical Microsystem Care Model
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Now we move into the financial aspect of the project. How will you fund your microsystem you created in the first part of your paper?
The readings start on Nelson p. 155-160. The model to complete and add to the paper is on page 156-157. You will need to either replicate the Clinical Value Compass (CVC) or you can complete it, scan it in and paste it into the paper. Both slides A & B need to be present in the paper.
The CVS discusses the Clinical, Functional, Satisfaction and Costs. This is the money part of the project. If you look in Nelson page 156, the graphic can help you fill it out. Starting at the top of the worksheet:
Slide A:
Outcomes: put your chosen disease here
Aim: what do you want to have happen? Identify your top 4-6 key measures
Next is filling in the data for all 4 sections. This information all should be measurable- check out the CDC and other federal sites that run this type of data analysis. I would look over the last 5 years but some charts review data over 10 years.
Clinical: list the morbidity and complications (again list some stats from the websites)
Functional- for each area list the physical functions of your disease and mental health functions, and then the role. Identify different measures for each one- for example Asthma- physically can swim 100 feet without difficulty
Satisfaction- all about the client and how we can make the client happy. Health care delivery is how we get the health care to them and what they see as the perceived health benefit.
Cost- how much does it cost. I suggest using some Medicare/Medicaid and/or private insurance numbers. We want to show how our interventions will help improve the health of this population and decrease the cost of health care overall.
Slide B is all on page 156-157.
Specific operational definitions is a brief statement of a variable you want to investigate- such as how do they use their inhaler- this should link back to Costs in Slide A. This is the section that expands the costs
Source of data and operational definition is the method by which you will collect the data. You will need to write a procedure so that everyone can replicate the measurement so that the numbers are valid- this is similar to writing research, declaring your research hypothesis and then describing the methods by which the data was collected in your research.
Then define 1-4 of your top variables you would want to investigate. Just fill in the chart.
Here is one example of how Slide B can be set up:
Variable/Owner Operational Definition and Data Source
A. Patient Education on….
Owner: this is the person responsible
This is the specific method of how the information will be obtained, measured, etc. with the data source. I would review the definitions under Tips for this section in the slide B.
There are 4 questions that accompany this section as well and need to be discussed thoroughly.
Strategic learning and innovation. To achieve your vision, how your microsystem will sustain its ability to change and improve as fast as care needs require?
Key processes. To satisfy healthcare consumers, what key processes must your microsystem perfect?
Customers’ view of goodness. How should your microsystem appear to customers? Does the microsystem instill feelings of honesty, competence, and integrity?
Financial Results. To succeed financially, how should your microsystem appear to shareholders and board members

Healing And Autonomy Assignment
Healing And Autonomy Assignment
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Mike and Joanne are the parents of James and Samuel, identical twins born eight years ago. James is currently suffering from acute glomerulonephritis, kidney failure. James was originally brought into the hospital for complications associated with a strep throat infection. The spread of the A streptococcus infection led to the subsequent kidney failure. James’ condition was acute enough to warrant immediate treatment. Usually cases of acute glomerulonephritis caused by strep infection tend to improve on their own, or with an antibiotic. However, James also had elevated blood pressure and enough fluid buildup that required temporary dialysis to relieve.
The attending physician suggested immediate dialysis. After some time of discussion with Joanne, Mike informs the physician that they are going to forego the dialysis and place their faith in God. Mike and Joanne had been moved by a sermon their pastor had given a week ago, and also had witnessed a close friend regain mobility when she was prayed over at a healing service after a serious stroke. They thought it more prudent to take James immediately to a faith healing service instead of putting James through multiple rounds of dialysis. Yet Mike and Joanne agreed to return to the hospital after the faith healing services later in the week, and in hopes that James would be healed by then.
Two days later the family returned, and was forced to place James on dialysis, as his condition had deteriorated. Mike felt perplexed and tormented by his decision to not treat James earlier. Had he not enough faith? Was God punishing him or James? To make matters worse, James kidneys had deteriorated such that his dialysis was now not a temporary matter, and was in need of a kidney transplant. Crushed and desperate, Mike and Joanne immediately offered to donate one of their own kidneys to James, but they were not compatible donors. Over the next few weeks, amidst daily rounds of dialysis, some of their close friends and church members also offered to donate a kidney to James. However, none of them were tissue matches.
James’ nephrologist called to schedule a private appointment with Mike and Joanne. James was stable, given the regular dialysis, but would require a kidney transplant within the year. Given the desperate situation, the nephrologist informed Mike and Joanne of a donor that was an ideal tissue match, but as of yet had not been considered—James’ brother Samuel.
Mike vacillates and struggles to decide whether he should have his other son Samuel lose a kidney, or perhaps wait for God to do a miracle this time around. Perhaps this is where the real testing of his faith will come in? “This time around, it is a matter of life and death, what could require greater faith than that?” Mike reasons.
Healing And Autonomy Case Study Assignment
Write a 1,500 word analysis of “Case Study: Healing and Autonomy.” In light of the readings, be sure to address the following questions:
Under the Christian narrative and Christian vision, what sorts of issues are most pressing in this case study?
Should the physician allow Mike to continue making decisions that seem to him to be irrational and harmful to James?
According to the Christian narrative and the discussion of the issues of treatment refusal, patient autonomy, and organ donation in the topic readings, how might one analyze this case?
According to the topic readings and lecture, how ought the Christian think about sickness and health? What should Mike as a Christian do? How should he reason about trusting God and treating James?
Prepare this assignment according to the guidelines found in the APA Style Guide.
NO PLAGIARISM PLEASE, MINIMUM OF 3 REFERENCES

Topic: Heart Failure Concept
Topic: Heart Failure Concept
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Below are the Sub-heading that needs to be in the Concept Map.
Disease
Definition
AETIOLOGY
PATHOGENESIS
PATHOGENESIS
DIAGNOSIS
TREATMENT
COURSE OF DISEASE
PROGNOSIS
PREVENTION
· The separate Reference page for Concept Map. You may have more than 2 reference
· Visually Stimulating, add pictures in the background and visually attractive. Below is an sample example but this concept map needs to look unique and visually very appealing, please.
· Add pictures of heart, lungs what ever connects to the Map and its information.
· I have attached a sample of the concept map of another topic to guide you what information requires in the map.
· 500 words and it is worth 25 Marks.
Assessment 1 – Concept map and guided questions.
Information 1 – Getting started.
Your first assessment is generating a concept map for left heart failure and answering three questions related to a case study about a patient who has an acute exacerbation of heart failure. When preparing your assignment refer to the criteria and standards in the Learning Guide.
You can begin this assessment now by finding readings about heart failure and summarising the information under the headings of the pathophysiology template. This information can then be used for your concept map.
Some readings that you may find helpful to start your assignment are:
Your textbook:
Craft,J.A., Gordon,C.J., Huether,S.E., McCance, K.L., Brashers, V.L. & Rote,N.E.
(2015). Understanding pathophysiology – ANZ adaptation (2nd ed.).
Chatswood, NSW: Elsevier Australia. Chapter 23.
Also:
Aitken, L., Marshall,A. & Chaboyer, W. (2015). ACCCN’s critical care nursing
(3rd ed.). Chatswood, NSW: Elsevier Australia. Chapter 10.
Wagner, K.D. (2014). High acuity nursing (6th ed.). Upper Saddler River, New
Jersey: Pearson. Chapter13.
(These books are available online from the Western Sydney University library).
This is just to begin. You will then find more readings to add to your information.
Remember that the information in your concept map and answers to the questions must correlate with the references that you cite so keep an accurate record when preparing your assignment. The marker of your assessment will check your citations.
An example of a pathophysiology template for a left-sided ischaemic stroke and a concept map using this information has been attached to start you thinking about how you will approach your assignment. The concept map has been generated using Word. However, if you wish, you may prefer to use a concept map template that you may find on the web.
Topic: Left Sided Heart Failure Concept Map
influences
Aetiology
Depletion of blood flow in a cerebral artery resulting from a thrombus or embolus. (1)
Pathogenesis
Occlusion of cerebral artery production of ATP failure of energy pumps influx of sodium and calcium ions and efflux of potassium passive inflow of water cytotoxic oedema destruction of cells in infarct core.
Membrane depolarisation release of glutamate excessive calcium influx into neurons destruction of cells by lipolysis, proteolysis and free radicals.
infarct core and ischaemic penumbra
necrotic tissue not able to conduct impulses interrupting normal function such as motor and sensory transmission and speech.
Risk factors
· Obesity
· Smoking
· Sedentary lifestyle
· Age 1.
· ageg
Clinical features
· Right-sided hemiplegia and weakness
· Sensory loss on right side
· Inability to see the right visual field of each eye
· Aphasia
· Apraxia
· Dysarthria
· Impaired reasoning
· Behavioural changes
· Problems with memory
Diagnosis
· Complete history
· Physical and neurological examination
· Brain MRI or CT scan –differentiate cerebral haemorrhage from ischaemic stroke
· Other tests for vascular imaging – CT angiography, magnetic resonance angiography
Primary prevention
· Don’t smoke
· Diet high in fruit and vegetables
· Diet low in fats and salt
· 30 minutes of exercise daily
· Limit alcohol
1,7
Treatment
Medical
· Reperfusion Thrombolytic (tPA )
Nursing acute phase
· Frequent evaluation of neurological status and vital signs
· Oxygen saturations – administer oxygen if required
· Screen for swallowing – manage hydration and nutrition
· Manage activities of daily living
· Address appropriate communication strategies
· Prevent complications
Rehabilitation
· Passive and active movement
· Encourage activities provided by physiotherapists, speech and occupational therapists e.g. mobility, speech, ADL
· Education-
Secondary prevention
· Neuroprotection – e.g, aspirin
Course of disease
With reperfusion – blood restored to area, many symptoms gradually resolve
Without treatment – ischaemia extends to penumbra –symptoms worsen. Recovery may continue 6 months to a year but left with disability. Requires rehabilitation to optimise function 8
Complications
· Contractures
· Incontinence
· Falls
· Mood disturbances
· Dysarthria and aphasia
·
·
Death of brain tissue resulting from an occluded cerebral artery in the left side of the brain.. 6.
Prognosis
One in five likely to die within one month.
Of those who recover about 90% will experience some impairment. 9
causes
Atherosclerosis
Prevents formation of
4,7
6,7
5
1,2,4
1,2,3
Leads to need for immediate
diagnoses
Diagnosed by
Results in
Pathophysiology template
Disease: Ischaemic stroke affecting the dominant left cerebral hemisphere
Definition : An ischaemic stroke is death of brain tissue resulting from an occluded artery caused either by an atherosclerotic obstruction or embolus that interrupts blood supply to the area of the brain supplied by the occluded artery. The sudden loss of blood circulation results in a corresponding loss of neurologic function (Jauch, 2014).
AETIOLOGY:
A depletion of blood flow in a cerebral artery resulting from a:
· Thrombus –atherosclerotic plaque that has ruptured in a cerebral artery
· Embolus
· from heart e.g. left atrial thrombus, left ventricular thrombus, atrial fibrillation
· from carotid artery (Craft &Gordon,2011)
PATHOGENESIS:
· Interruption of blood flow to cerebral tissue initiates a biochemical ischaemic cascade.
· Mitochondrial production of ATP ceases ?depolarisation ? influx of sodium and calcium and efflux of potassium. Passive inflow of water into cells causes cytotoxic oedema and destruction of cells in infarct core.
· Membrane depolarization also stimulates the release of neurotransmitters. Glutamate release ?excessive calcium influx into nearby neurons (exocitotoxicity) ?destruction of cells by lipolysis, proteolysis and free radicals.
· Mitochondria break down releasing toxins and apoptotic factors.
· Injured brain tissue triggers inflammatory response ?release of inflammatory mediators ?cell death and oedema
?destruction of cells in infarct core ?necrosis
?ischaemic penumbra around core has diminished blood flow but preserved cellular metabolism.
Areas of necrotic tissue are not able to conduct nerve impulses so functions such as initiating and conveying motor impulses, receiving and interpreting sensory information and speech control will be interrupted.
(Bautista, 2014; Craft & Gordon, 2011; Maas & Safdieh,2009).
CLINICAL MANIFESTATIONS:
Just superior to the medullary junction, 90% of axons in the left pyramid cross to the right right motor dysfunction.
The middle cerebral artery supplies the frontal, temporal and parietal lobes as well as the basal ganglia and internal capsule. (Tocco,2011).
Therefore specific clinical manifestations include:
· Hemiplegia and weakness on right side of body
· Sensory loss on right side
· Inability to see the right visual field of each eye
· Aphasia
· Apraxia
· Dysarthria
· Impaired reasoning
· Behavioural changes
· Problems with memory
(Bautista, 2014; Craft & Gordon, 2011).
DIAGNOSIS
· Complete history
· Physical and neurological examination
· Brain MRI or CT scan – Essential in differentiating cerebral haemorrhage from ischaemic stroke. MRI is superior as cerebral ischaemia can be identified within minutes and can identify small areas of stroke.
· Other tests for vascular imaging can be used e.g. CT angiography, magnetic resonance angiography
(Silverman & Rymer, 2009).
TREATMENT
The emphasis of ischaemic stroke treatment is placed on salvaging potentially reversible ischemic penumbra brain tissue, preventing secondary stroke and minimising longterm disability. (Jaunch, 2014).
· Reperfusion
· thrombolytic agent (e.g.tPA)
· intra-arterial technique
· Neuroprotection
-antithrombotic therapy (e.g. aspirin)
· Nursing management
Acute phase
· frequent evaluation of neurological status
· frequent evaluation of vital signs
· Monitor oxygen saturation – administer oxygen if required
· Screen for swallowing deficits and manage appropriate hydration and nutrition strategies
· Manage activities of daily living
· Screen for communication deficits and address appropriate communication strategies
· Prevent complications e,g pressure areas, contractures, DVT
· Assess urinary and faecal continence and address appropriately
Rehabilitation
· begin as early as possible by preventing complications, passive and active movement and mobilizing as early as possible.
· Support and encourage activities provided by physiotherapists, occupational therapists and speech therapists
· Education – e.g. lifestyle modification, adherence to medications
(National Stroke Foundation, 2010).
COURSE OF DISEASE
· With reperfusion – blood is restored to the area and signs and symptoms gradually resolve
· Without treatment – Course is determined by severity of stroke. Ischaemia will extend to penumbra as stroke evolves, signs and symptoms worsen. As cerebral oedema resolves, and with structural and functional reorganisation recovery may continue for 6 months to a year. (peak recovery in about 3 months). Requires rehabilitation to optimise function.
(Teasell & Hussein, 2014).
· Complications
Contractures
Fatigue
Incontinence
Mood disturbances
Falls
Dysarthria and aphasia
PROGNOSIS
· Stroke prognosis is influenced by factors such as age and stroke severity.
· One in five likely to die within one month of suffering ischaemic stroke.
· Of those who recover about 90% will experience some impairment
(Dashe,2014)
PREVENTION
Eliminating modifiable risk factors will prevent an ischaemic stroke.
· Don’t smoke
· Diet high in fruit and vegetables, low in fats and salt
· 30 minutes of moderate-intensity physical activity on most days of the week
· Maintain healthy BMI
· Limit alcohol to no more than two standard drinks per day
(National Stroke Foundation, 2010)
If a history of atrial fibrillation – ensure adherence to anticoagulation therapy.
References
Bautista, C. (2014). Disorders of Brain Function. In S. Grossman & C. Porth (Eds),
Porth’s pathophysiology: Concepts of altered health states (9th ed.). (pp489-
524). Philadelphia: Lippincott Williams & Wilkins.
Craft, J. & Gordon, C. (2011), Alterations of Neurological Function across the
Lifespan. In J.Craft, C.Gordon & A. Tiziani (Eds). Understanding
Pathophysiology (pp 188-226). Sydney, Australia:Elsevier Australia.
Dashe, J. F. (2014). Stroke prognosis in adults. UpToDate. Retrieved from:
http://www.uptodate.com/contents/stroke-prognosis-in-adults
Jaunch, E.C. (2014). Ischemic stroke treatment and management, Retrieved from:
http://emedicine.medscape.com/article/1916852-overview
Maas, E.B. & Rymer, M.M. (2009). Ischaemic stroke: Pathophysiology and Principles
of Localization. Neurology 13 .Retrieved from:
http://www.turner-white.com/pdf/brm_Neur_V13P1.pdf
National Stroke Foundation (2010). Clinical guidelines for stroke management
2010. Melbourne Australia.
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