Soap Note Rubric as a guide

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 15% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 15%. Copy-paste from websites or textbooks will not be accepted or tolerated.

Please see College Handbook with reference to Academic Misconduct Statement.

The use of tempates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.  

Please review the case presented and answer all the questions at the end of it.

CASE INTRODUCTION

Huddles are such an important part of nursing – they relay pertinent information, increase safety, offer team building opportunities, promote better outcomes for the patient, and ultimately can reduce costs.

Here is your scenario:

Your nurse manager identifies that the staff on your rehabilitation unit, and particularly that you as the evening charge nurse, are resistant and oppositional to an important new patient safety strategy of implementing huddles to improve staff communication.

BRIEF SUMMARY OF CASE 

Paragraph 1  Your nurse manager meets with you, the evening charge nurse, (and with you he had previously begun a disciplinary action process because you refused to implement huddles on the shifts when you was in charge).   You now understands that you (and the staff) were wrong, and you begin to explore with the manager how better to implement huddles on your shift.

Paragraph 2  In a quarterly staff development in-service for the rehab facility’s leaders, a group of nurses and charge nurses, including you, learn about implementing change using Lewin’s five-step Stages of Change (SCM) Model. The nurse manager and you apply this model to their failed implementation of huddles.

Paragraph  3 – You return to your unit and share with the staff that you—and they—were wrong to refuse to implement huddles. You begin to start the process as a change agent.

DISCUSSION GUIDE – QUESTIONS  Worth 2 points each (16 points)

Paragraph 1

1. How does your nurse manager know that you are ready to learn and be a part of the unit change?
2. How was the decision to implement the huddles handled?
3. What is the importance of a huddle?

Paragraph 2

1. What would you do prior to implementing a staff meeting to best communicate new information to the staff?
2. How would you describe Lewin’s Theory of Change? Can you give an example where you have used this theory?
3. What other theories of change are you familiar with, in addition to Lewin’s?

Paragraph 3

1. How would you manage conflict with the other unit staff?
2. How would you handle the resistance to change as noted by the unit staff?

  Mrs. K is exhibiting the signs and symptoms of heart failure.  Heart failure can be caused by left ventricular dysfunction or right ventricular dysfunction.  According to Ramani & Weber (2017), the S3 sound is the commonly known as the third heart sound.  The S3 sound commonly occurs when there is a volume overload in the circulatory system or when there is a ventricular dysfunction.  The S3 sound occurs when the rapid filling of the ventricle ends abruptly.  However, it is unclear as to where the sound originates from.  There are thoughts that the sound may be related to vibrations in the valve cusps or related to tautening of the cardiac muscles.  Auscultation of an S3 heart sound is difficult to hear and often goes unnoticed if heart failure is not being assessed as a possibility.  Auscultation of the heart sound will be heard best in different locations dependent on where the S3 sound originates from.  Ramani & Weber (2017) point out that an S3 sound in the left ventricle would be best heard with the patient in the left lateral decubitus position, in held end expiration, and with the bell of the stethoscope.  When an S3 sound is originating in the right ventricle, the sound would be best heard along the left lower sternal border and the sound would be louder during inspiration.  Some causes of ventricular dysfunction may include ischemia, cardiomyopathy, myocarditis, and cor pulmonale.  The S3 sound is a key factor in the diagnosis of congestive heart failure (Ramani & Weber, 2017).  

            In addition to the S3 heart sound, Mrs. K is exhibiting many other symptoms that are common findings in the assessment of a patient with heart failure.  Symptoms of heart failure may include pulmonary rales, extremity edema, dyspnea, orthopnea, and systemic edema.  According to Long et al. (2019), the most common symptoms associated with acute heart failure include paroxysmal nocturnal dyspnea, orthopnea, and edema.  This is caused from elevated filling pressures of the left ventricle of the heart.  In addition, Mrs. K is exhibiting inspiratory crackles due to the likelihood of pulmonary edema secondary to congestive heart failure.  Because of Mrs. K’s history of myocardial infarction and coronary artery bypass surgery, this may present as a major reason of her congestive heart failure that may have been steadily progressing.  Risk factors for heart failure include uncontrolled hypertension, renal disease, heart disease, diabetes, dysrhythmias, and cardiac ischemia.  Long et al. (2019) outlined the proper diagnostic techniques of heart failure in an emergency room setting.  This includes the auscultation of client’s cardiac rhythm and pulmonary assessment.  It also includes laboratory testing to include a complete blood count, basic metabolic panel, a BNP level, troponin, renal function testing, and liver function testing.  A decreased glomerular filtration rate was associated with increased length in hospital stay and mortality rates.  An electrocardiogram and x-ray imaging was also recommended in the diagnosis of heart failure (Long et al., 2019).

References

Long, B., Koyfman, A., & Gottlieb, M. (2019). Diagnosis of acute heart failure in the emergency 

            department: An evidence-based review. The Western Journal of Emergency Medicine,

            20(6), 875-884. https://doi.org/10.5811/westjem.2019.9.43732

Ramani, S., & Weber, B.N. (2017). Detecting the gallop: the third heart sound and its

            significance. Medical Journal of Australia, 206(5), 198-199. 

            https://doi-org.wilkes.idm.oclc.org/10.5694/mja16.00613

Compose 400 words or more discussion to respond the following:

What are the functions of the deltoid muscle? What is the function of the biceps brachii muscle? Name the three gluteal muscles. What is the function of the gastrocnemius muscle? Define the term posture. What effect might bad posture have on the body? Baseball players, particularly pitchers, often incur rotator cuff injuries. List the muscles that make up the rotator cuff and explain the importance of theses muscles and their plain in the joint stability. Many drugs are administered by intramuscular injection. If the amount to be injected is 2 to 3 ml, which are is used?

 Why is it important to conduct or perform a quality literature review? Characterize or distinguish between the 4 major types of reviews discussed in our textbook? What are the essential components of a quality literature review? 

Use only scholar references only very strict on that