Pneumonia of left Lung|2025

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(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C

 

Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)

 

PATIENT INFORMATION

Name: Mr. DT

Age: 68-year-old

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: PCN, Iodine

Current Medications:

· Atorvastatin tab 20 mg, 1-tab PO at bedtime

· ASA 81mg po daily

· Multi-Vitamin Centrum Silver

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Preventive Care: Coloscopy 5 years ago (Negative)

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

Sexual Orientation: Straight

Nutrition History: Diets off and on, Does not each seafood

Subjective Data:

Chief Complaint: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

 

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

 

Objective Data:

VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.

 

GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.

 

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

 

ASSESSMENT:

Main Diagnosis

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).

 

Differential diagnosis:

· Renal artery stenosis (ICD10 I70.1)

· Chronic kidney disease (ICD10 I12.9)

· Hyperthyroidism (ICD10 E05.90)

PLAN:

 

Labs and Diagnostic Test to be ordered:

· CMP

· Complete blood count (CBC)

· Lipid profile

· Thyroid-stimulating hormone (TSH)

· Urinalysis with Micro

· Electrocardiogram (EKG 12 lead)

 

Pharmacological treatment:

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

· Lisinopril 10mg PO Daily

 

Non-Pharmacologic treatment:

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

· Instruction about medication intake compliance.

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.

· No referrals needed at this time.

 

 

References

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017

(25th ed.). Print (The 5-Minute Consult Series).

 

 

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The nutritional challenges for emerging populations|2025

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What are some of the nutritional challenges for emerging populations? What roles do nutritional deficiency and nutritional excess play in disease?

  Topic 4 DQ 2

Nutrition is the central component in health promotion as nutrition is needed for our body to grow, develop and maintain the normal functioning of the body.It is an essential aspect of living a balanced lifestyle. Food is readily available in most of  Western society, and it is frequently highly refined and high in calories, fat, and sugar These foods are also less costly than healthier alternatives, making nutritious choices more difficult to come by for low-income families and individuals.Food plays an important role in everyday social life, often taking center stage at parties, meetings, and other activities.(Grand Canyon University, 2018 )

The most nutritional challenges for emerging population as people are very busy to take proper diet and nutrition and hence they lack the essential requirements of the daily intake which causes various diseases, obesity etc. Malnutrition has become more common in the United States in recent years. The majority of people believe that eating fast food in fastfood restaurants is less expensive and more convenient. Furthermore, they find it difficult to eat vegetables and fruits because they are costly and time consuming to prepare.The socio-economic factors also have impact on the deficiency diseases because people are unable to avail better food for themselves.(Homeworklib,n.d).

The nutrition deficiency causes malnutrition in which people become weak, and becomes more prone to many of diseases. The excess of nutrition causes toxicity for example, too much of vitamin A causes vitamin toxicity, therefore, nutrition should be maintained at optimum levels to avoid such conditions.

Discuss why nutrition is a central component in health promotion. What are some of the nutritional... (n.d.). Homework Help Online workLib. https://www.homeworklib.com/question/1333777/discu

Respond by using 250-300 words APA format with reference supporting the post positively in discssion

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Knowledge Worker and Nursing Informatics

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The term “knowledge worker” was first coined by management consultant and author Peter Drucker in his book, The Landmarks of Tomorrow (1959). Drucker defined knowledge workers as high-level workers who apply theoretical and analytical knowledge, acquired through formal training, to develop products and services. Does this sound familiar?

Nurses are very much knowledge workers. What has changed since Drucker’s time are the ways that knowledge can be acquired. The volume of data that can now be generated and the tools used to access this data have evolved significantly in recent years and helped healthcare professionals (among many others) to assume the role of knowledge worker in new and powerful ways.

In this Assignment, you will consider the evolving role of the nurse leader and how this evolution has led nurse leaders to assume the role of knowledge worker. You will prepare a PowerPoint presentation with an infographic (graphic that visually represents information, data, or knowledge. Infographics are intended to present information quickly and clearly.) to educate others on the role of nurse as knowledge worker.

Reference: Drucker, P. (1959). The landmarks of tomorrow. New York, NY: HarperCollins Publishers.

To Prepare:

  • Review the concepts of informatics as presented in the Resources.
  • Reflect on the role of a nurse leader as a knowledge worker.
  • Consider how knowledge may be informed by data that is collected/accessed.

The Assignment:

  • Explain the concept of a knowledge worker.
  • Define and explain nursing informatics and highlight the role of a nurse leader as a knowledge worker.
  • Develop a simple infographic to help explain these concepts.

    NOTE: For guidance on infographics, including how to create one in PowerPoint, see “How to Make an Infographic in PowerPoint” presented in the Resources.

  • Your PowerPoint should Include the hypothetical scenario you originally shared in the Discussion Forum. Include your examination of the data that you could use, how the data might be accessed/collected, and what knowledge might be derived from that data. Be sure to incorporate feedback received from your colleagues’ responses.

A good example of a scenario that would benefit from access to data is a case where a healthcare centre wants to know the number of patients visiting on a daily basis so as to establish whether the available staff is enough.  Data of this nature can be collected by registering all the patients that come to seek medical services on a daily basis for a period of one month. Upon registering the patient, the data might be stored in the computer and retrieved when needed. The only people that will be allowed to access such information are the staff members (McGonigle, 2017).

The specific knowledge that will be derived from the data on a number of the patient visit is information on whether there is a shortage of labour force. In any case, the health facility will, for instance, establish that the number of patients visiting the facility is too high when compared to the available number of nurses; this will be taken to mean that there is a staff shortage. It will also be interpreted to mean that the current staff is being overworked and so the quality of health services being provided is more likely to be compromised (Sweeney, 2017).

A nurse leader can use clinical reasoning and judgment in the formation of knowledge from this experience to approximate the overall performance of the health facility being managed. The nurse leader could for example reason that since the health facility is understaffed, it may not be performing well. The nurse leader could judge that the patient feedback is more likely to be negative suggesting poor performance. This is due to the fact that feedback from the patients is one of the tools used to tell whether a health facility is performing well or not (McGonigle, 2017).

References

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Sweeney, J. (2017). Healthcare Informatics. Online Journal of Nursing Informatics, 21(1).

**Attached is an example of one presentation**

(8 to 10 slides)

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PICOT STATEMENT PAPER|2025

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Details:

Review the Topic Materials and the work completed in NRS-433V to formulate a PICOT statement for your capstone project.  

THE DOCUMENT IS ATTACHED BELLOW..

THE ASSIGNMENT HAS TO BE FREE OF PLAGIARISM

A PICOT starts with a designated patient population in a particular clinical area and identifies clinical problems or issues that arise from clinical care. The intervention should be an independent, specified nursing change intervention. The intervention cannot require a provider prescription. Include a comparison to a patient population not currently receiving the intervention, and specify the timeframe needed to implement the change process.

Formulate a PICOT statement using the PICOT format provided in the assigned readings. The PICOT statement will provide a framework for your capstone project.

In a paper of 500-750 words, clearly identify the clinical problem and how it can result in a positive patient outcome.

Make sure to address the following on the PICOT statement:

Evidence-Based Solution

Nursing Intervention

Patient Care

Health Care Agency

Nursing Practice

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center

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10 Strategic Points for the Prospectus|2025

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10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

Week Two Assignment Instructions DNP 820

Please read the instructions thoroughly there are strict requirements

I need at least 10 different articles/literature reviews added to the ones in the 815 attachment. I have also included the chart to be filled out All within 5 years and pertinent to the subject.

Tutor MUST have a good command of the English language

The Rubric must be followed, and all the requirements met

This is a thorough professor, and she has strict requirements

I have attached the PICOT and the first 10 points (DNP 815) assignment. This is a continuation of that assignment. Please read the attachments

The following needs to be addressed:

Please note the followings: The introduction and the literature review are complete and thorough. The problem statement is written clearly PICOT is clear and very good Sample: 

· How will you determine the sample size? 

· What are the inclusion/exclusion criteria of the subjects? Methodology: Why is the selected methodology is appropriate? Please justify! 

· Data collection approach needs to be clear. How will you collect your data? What is needed here is to describe the process of collecting data form signing the informed consent until completing the measuring.

· Data analysis-What test will you use to answer your research question? 

Clinical/PICOT Questions:  

“In adult patients with CVC at a Clear Lake Regional Medical Center, does interventional staff education about hub hygiene provided to RN’s who access the CVC impact CLABSI rates compared to standard care over a one-month period?”

P: Patients with Central Venous Catheters

I: Staff re-education related to Hygiene of the hub

C: Other hospitals

O: Reduce probability of CLABSIs

T: Two months

“In Patients > 65 years of age with central line catheters at a Clear Lake Regional Medical Center, how does staff training of key personnel and reinforcement of central line catheter hub hygiene after its insertion, along with the apt cleansing of the insertion site, before every approach compared with other area hospitals, reduce the incidence of CLABSIs (Central Line Associated Blood-stream Infections) over a one-month period?”

P: Patients > 65 years of age with a Central line

I: Staff training and reinforcement of Central Catheter, Hub Hygiene 

C: Other area hospitals 

O: Reduce probability of CLABSIs

“In adult patients, with define CVC (CVC), does interventional staff education about hub hygiene provided to RN’s who access the CVC impact CLABSI rates compared to pre and post-intervention assessments 

1. I used central Missouri as an example, replace with a description of your site. 

2. While you might be interested in CLASBI rates as a primary variable, there are other patient outcomes that would also be important to consider

3. Ensure you can find validity and reliability measures on CLASBI rates if you cannot, we need to determine another question to help

4. How are your two comparison groups different, as they are currently stated the groups seem very much the same, could you state, standard care instead of pre and post intervention assessments? 

5. One month is the longest time you can use for a prospective project

Please note the following regarding the instructors grading

IMPORTANT INFORMATION ABOUT MY GRADING STYLE

As you prepare for written papers and manuscripts I’d like to give you some details about my grading style. I provide significant feedback on your papers, this is because I believe you should be working towards improving your writing so that at the end of this program you are able to successfully write your DPI project. In order to write well, you need feedback and you need to review that feedback and make progress on the next written work. To that end I always grade accordingly. This means that if I provide feedback one an item (for example APA format of your reference page) I expect that this will be improved on the next written submission. Otherwise I will deduct additional points. In addition, some other criteria to get down pat now. References should always

1. Be current, no older than 5 years that means 5 years from your proposed graduation date (2014-2019). Otherwise you will have to redo everything in DNP 955.

2. Be primary sources. You can no longer cite Young declared literary war in 1956 (as cited by Brown 2006). You must cite Young 1956. That means go find that paper and read it and make sure that you agree with what Brown said. What if you don’t agree due to some very valid points? Then the literary war is not what occurred, but instead you have concerns regarding point ____, ____, and ____.

3. You may no longer cite textbooks, they are 1) secondary sources and 2) not current enough, and please use peer reviewed manuscripts.

One more item that is not a reference. You may not use direct quotes any longer. There is no need. This may be difficult at first, but you are moving towards a different type of writing. This is manuscript writing (scientific writing). Scientific writing is terse, clear, and concise. No frilly words. In order to avoid the use of direct quotes you will synthesize the literature. There is a great resource for synthesizing the literature under Resources – Add-ons. These are also some other great writing resources there.

Details:

In the prospectus, proposal, and scholarly project there are 10 strategic points that need to be clear, simple, correct, and aligned to ensure the research is doable, valuable, and credible. The 10 strategic points emerge from researching literature on a topic that is based on or aligned with the learner’s personal passion, future career purpose, and degree area. These 10 points provide a guiding vision for DPI Project. In this assignment, you will continue the work begun in DNP-815, working on your draft of a document addressing the 10 key strategic points that define your intended research focus and approach.

General Requirements:

Use the following information to ensure successful completion of the assignment:

  • Locate      the “The 10 Strategic Points for the      Prospectus, Proposal, and Direct Practice Improvement Project” that      you completed in DNP-815.
  • Doctoral      learners are required to use APA style for their writing assignments. The      APA Style Guide is located in the      Student Success Center. An abstract is not required.
  • This      assignment uses a rubric. Please Review the rubric prior to the beginning to become familiar with the      expectations for successful completion.
  • You      are required to submit this assignment to Turnitin. Please refer to the      directions in the Student Success Center.

Directions:

Use the “The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project” resource to draft statements for each of the 10 points for your intended research study.

You worked on this last in DNP 815. Pick up from where you left off (if you transferred in and did not complete this, you will have to begin fresh). Please include a copy of your last instructor feedback when you submit this assignment. You can either copy and paste the instructor feedback into your current paper (as an appendix and clearly marked); or upload two separate papers. I expect significant improvement from your last submission.

Please review the 10 Strategic Points document for additional instructions and an example. Add references to this document, I suggest 5-10 at this point. You need to realize that your literature review chapter will need at least 50+ articles by the time you get to DNP 955, so work on expanding your literature search each week, to include more and more to this paper as you move through each course. If you cannot locate 50+ articles you can ask your faculty for assistance or chose a different topic.

For the methodology and design sections. Methodology should cover the broad methods you plan to use (qualitative, quantitative, or mixed methods). The design portion will then go into more detail and discuss the design (i.e. correlational, cross-sectional, pre/posttest, etc.). Describe each and explain why your chosen methodology and design are appropriate to your topic and project questions. You may NOT use qualitative, GCU leadership does not support a qualitative methodology.

Intervention. You must have an intervention that you implement. Since you cannot evaluate a project that has already been implemented, please write up a description of your intervention and what your role will be in implementing this intervention. This is not a section listed on your 10 Strategic Points document as of yet, so add it after the methodology and design sections. Describe step by step what the intervention consists of, how it is evidence based, how you will implement, and your role in implementation.

Data collection should go step by step (extremely over-detailed) on how you will collect the data. Tell me about all instruments, surveys, and/or questions you will ask of participants. One MUST be a valid and reliable tool.

Data Analysis. Tell me the specific statistics you will use. Start with descriptive statistics, which ones will you use, why (cite current primary sources). Then tell me how you will compare your data (which statistic), what your p value will be before you start your data collection.

Apply Rubrics

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analysis paper

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Chief complaint: Paranoia

Demographic data: K.P is a 20-year-old Caucasian female in her second year of college at Alabama State University.

HPI: K.P and her father present to the clinic for CC of paranoia. She reports being dismissed last week from the university due to her erratic behaviors. Recently she has been found wandering at night dressed in inappropriate clothing, disturbing students at the campus library yelling out profanities. She reports loss of interest in her studies, missing classes, and grades started to drop. She lost 15lbs in one month because she fears her roommate is trying to kill her by poisoning her meals. K.P strongly believes that she is a nun and says that she wants to join a local religious group. She continuously picks at her nose as she believes she has stigmata there. She also thinks that she wears a crown of thorns. Her father states that his daughter thought process is all over the place, and often looking over her shoulders as though someone is trying to harm her.

Past Medical History: Hypothyroidism

Past Surgical History: Strabismus surgery

Medications: Multivitamin and Levothyroxine 125mcg daily

Allergies: NKDA

Social History: K.P last attended Alabama State University in her second year, now she lives back home with her father, Larry, and older brother Tommy. Her mother died from breast cancer when she was nine years old. She is currently unemployed; last employment was six months ago at the campus bookstore. She walked off the job after threatening a customer for looking at her the wrong way. Her father is supporting financially. The patient reports she smokes marijuana occasionally at her friend’s house. She denies using tobacco and drinks alcohol five times a month when partying with friends on the weekends. She gets max fours of sleep due to staying up all night. She is sexually active with her current boyfriend and reports using condoms sometimes.

Subjective:

Review of System:

Constitutional symptoms- Report weight loss of 15lbs within a month and trouble sleeping. Denies fever, chills, and weakness.

HEENT- Denies visual issues. No glasses or corrective lenses. Denies throat or swallowing issues. Denies hearing changes, nasal congestion.

Neurologic-Denies lightheadedness, headache, numbness, tingling, and sensation changes.

Cardiovascular- Denies Chest pain, palpitation, Hx of murmurs, activity intolerance.

Respiratory- Denies coughing up blood, Shortness of breath, and wheezing.

Gastrointestinal-Decreased appetite in fear of someone poisoning her food. Denies heartburn, bloating, nausea/vomiting, diarrhea, constipation, epigastric pain, and change in bowel habits.

Genitourinary- Denies difficulty or burning in urination, frequent urination at night, and blood in urine.

Musculoskeletal- Denies pain, stiffness, swelling, crepitus, and limited range of motion.

Integumentary- Denies rashes, itching, and changes in hair or nails.

Endocrine: Reported intermittent cold intolerance due to hypothyroidism. Denies increased appetite, thirst, urine production, and excessive sweating.

Psychiatric: Reported increasing anxiety and nervousness, mood swings, trouble concentrating, sleeping problem- sleep for 4 hours each night. Denies depression and suicidal/Homicidal Ideation.

Objective:

Vital signs: BP 113/65, T 96.5, P 100, R 18 Sao2 99% on room air

General: 20-year-old Caucasian female appears stated age appears anxious. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear in distress.

Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.

HEENT: Head normocephalic. Hair thin and distribution even throughout scalp. Mild red sclera. Conjunctiva: white, PERRLA, EOMs intact. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender Nares patent with thin white exudate noted. No deviated septum noted. Sinuses non-tender to palpation. Oropharynx pink, moist, no lesions, or exudate. Teeth in good repair, four cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.

Respiratory: Lungs clear to auscultation bilaterally. Respirations unlabored. No wheezes or rales noted.

Cardiovascular: S1 and S2 noted, no murmurs noted, peripheral pulses equal bilaterally, no peripheral edema

Gastrointestinal: Abdomen round, soft, bowel sounds noted in all four quadrants. No organomegaly noted.

Musculoskeletal: Full range of motion to bilateral upper and lower extremities. No tenderness to palpation.

Mental Status Exam:

Appearance and behavior: K.P is a young Caucasian woman dressed appropriately for a visit with good eye contact. Repetitive scratching of her nose was noted during the examination. Speech: normal rate and rhythm. Thought form: No, abnormality. Thought content: The patient is noted to have delusional thought content, as mentioned in the history. She does not have suicidal ideations. Mood: K.P is anxious about her future regarding joining a religious group. Perception: experiences delusions during the interview relating herself to a nun that wears a crown of thorns and believes she is subconsciously connected to the Archbishop of Italy. Cognitive function: Patient is oriented to person, place, and time. She is noted to have good attention and concentration. No abnormalities of memory and average intellect. Insight: K.P has no insight into her current mental health issues.

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Tina Jones Health Assessment|2025

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ASSESSMENT INFORMATION for students

Throughout your training we are committed to your learning by providing a training and assessment framework that ensures the knowledge gained through training is translated into practical on the job improvements.

You are going to be assessed for:

Your skills and knowledge using written and observation activities that apply to your workplace.

Your ability to apply your learning.

Your ability to recognise common principles and actively use these on the job.

All of your assessment and training is provided as a positive learning tool. Your assessor will guide your learning and provide feedback on your responses to the assessment materials until you have been deemed competent in this unit.

How you will be assessed

The process we follow is known as competency-based assessment. This means that evidence of your current skills and knowledge will be measured against national standards of best practice, not against the learning you have undertaken either recently or in the past. Some of the assessment will be concerned with how you apply your skills and knowledge in your workplace, and some in the training room as required by each unit.

The assessment tasks have been designed to enable you to demonstrate the required skills and knowledge and produce the critical evidence to successfully demonstrate competency at the required standard.

Your assessor will ensure that you are ready for assessment and will explain the assessment process. Your assessment tasks will outline the evidence to be collected and how it will be collected, for example; a written activity, case study, or demonstration and observation.

The assessor will also have determined if you have any special needs to be considered during assessment. Changes can be made to the way assessment is undertaken to account for special needs and this is called making Reasonable Adjustment.

 

What happens if your result is ‘Not Yet Competent’ for one or more assessment tasks?

Our assessment process is designed to answer the question “has the desired learning outcome been achieved yet?” If the answer is “Not yet”, then we work with you to see how we can get there.

In the case that one or more of your assessments has been marked ‘NYC’, your trainer will provide you with the necessary feedback and guidance, in order for you to resubmit your responses.

 

What if you disagree on the assessment outcome?

You can appeal against a decision made in regards to your assessment. An appeal should only be made if you have been assessed as ‘Not Yet Competent’ against a specific unit and you feel you have sufficient grounds to believe that you are entitled to be assessed as competent. You must be able to adequately demonstrate that you have the skills and experience to be able to meet the requirements of units you are appealing the assessment of.

Your trainer will outline the appeals process, which is available to the student. You can request a form to make an appeal and submit it to your trainer, the course coordinator, or the administration officer. The RTO will examine the appeal and you will be advised of the outcome within 14 days. Any additional information you wish to provide may be attached to the appeal form.

 

What if I believe I am already competent before training?

If you believe you already have the knowledge and skills to be able to demonstrate competence in this unit, speak with your trainer, as you may be able to apply for Recognition of Prior Learning (RPL).

 

Assessor Responsibilities

Assessors need to be aware of their responsibilities and carry them out appropriately. To do this they need to:

Ensure that participants are assessed fairly based on the outcome of the language, literacy and numeracy review completed at enrolment.

Ensure that all documentation is signed by the student, trainer, workplace supervisor and assessor when units and certificates are complete, to ensure that there is no follow-up required from an administration perspective.

Ensure that their own qualifications are current.

When required, request the manager or supervisor to determine that the student is ‘satisfactorily’ demonstrating the requirements for each unit. ‘Satisfactorily’ means consistently meeting the standard expected from an experienced operator.

When required, ensure supervisors and students sign off on third party assessment forms or third party report.

Follow the recommendations from moderation and validation meetings.

How should I format my assessments?

Your assessments should be typed in a 11 or 12 size font for ease of reading. You must include a footer on each page with the student name, unit code and date. Your assessment needs to be submitted as a hardcopy or electronic copy as requested by your trainer.

 

How long should my answers be?

The length of your answers will be guided by the description in each assessment, for example:

Type of Answer Answer Guidelines

 
Short Answer 4 typed lines = 50 words, or

5 lines of handwritten text
Long Answer 8 typed lines = 100 words, or

10 lines of handwritten text = of a foolscap page
Brief Report 500 words = 1 page typed report, or

50 lines of handwritten text = 1foolscap handwritten pages
Mid Report 1,000 words = 2 page typed report

100 lines of handwritten text = 3 foolscap handwritten pages
Long Report 2,000 words = 4 page typed report

200 lines of handwritten text = 6 foolscap handwritten pages

 

How should I reference the sources of information I use in my assessments?

Include a reference list at the end of your work on a separate page. You should reference the sources you have used in your assessments in the Harvard Style. For example:

Website Name – Page or Document Name, Retrieved insert the date. Webpage link.

For a book: Author surname, author initial Year of publication, Title of book, Publisher, City, State

 

assessment guide

The following table shows you how to achieve a satisfactory result against the criteria for each type of assessment task.

Assessment Method Satisfactory Result Non-Satisfactory Result
You will receive an overall result of Competent or Not Yet Competent for the unit. The assessment process is made up of a number of assessment methods. You are required to achieve a satisfactory result in each of these to be deemed competent overall. Your assessment may include the following assessment types.
Questions All questions answered correctly Incorrect answers for one or more questions
  Answers address the question in full; referring to appropriate sources from your workbook and/or workplace Answers do not address the question in full. Does not refer to appropriate or correct sources.
Third Party Report Supervisor or manager observes work performance and confirms that you consistently meet the standards expected from an experienced operator Could not demonstrate consistency. Could not demonstrate the ability to achieve the required standard
Written Activity The assessor will mark the activity against the detailed guidelines/instructions Does not follow guidelines/instructions
  Attachments if requested are attached Requested supplementary items are not attached
  All requirements of the written activity are addressed/covered. Response does not address the requirements in full; is missing a response for one or more areas.
  Responses must refer to appropriate sources from your workbook and/or workplace One or more of the requirements are answered incorrectly.

Does not refer to or utilise appropriate or correct sources of information
Observation All elements, criteria, knowledge and performance evidence and critical aspects of evidence, are demonstrated at the appropriate AQF level Could not demonstrate elements, criteria, knowledge and performance evidence and/or critical aspects of evidence, at the appropriate AQF level
Case Study All comprehension questions answered correctly; demonstrating an application of knowledge of the topic case study. Lack of demonstrated comprehension of the underpinning knowledge (remove) required to complete the case study questions correctly. One or more questions are answered incorrectly.
  Answers address the question in full; referring to appropriate sources from your workbook and/or workplace Answers do not address the question in full; do not refer to appropriate sources.

 

Assessment Cover Sheet
Student’s name:  
Assessors Name:   Date:
Is the Student ready for assessment? Yes No
Has the assessment process been explained? Yes No
Does the Student understand which evidence is to be collected and how? Yes No
Have the Student’s rights and the appeal system been fully explained? Yes No
Have you discussed any special needs to be considered during assessment? Yes No
The following documents must be completed and attached
Written Activity Checklist

The student will complete the written activity provided to them by the assessor.

The Written Activity Checklist will be completed by the assessor.

 S NYS
Observation / Demonstration

The student will demonstrate a range of skills and the assessor will observe where appropriate to the unit.

The Observation Checklist will be completed by the assessor.

 S NYS
Questioning Checklist

The student will answer a range of questions either verbally or written.

The Questioning Checklist will be completed by the assessor.

 S NYS
I agree to undertake assessment in the knowledge that information gathered will only be used for professional development purposes and can only be accessed by the RTO:
Overall Outcome Competent Not yet Competent
Student Signature: Date:
Assessor Signature: Date:

Assessment cover sheet

 

written activity

1. For this task you are to write an information guide for new employees about communicating effectively in the health and community services industry. In your guide you will need to include information on the following topics:

a. Effectively communicating with people

 

 

b. Collaborating with colleagues

 

 

c. Constraints to communication and strategies to address them

 

 

d. Reporting problems identified in work activities

 

 

e. Workplace correspondence and documentation requirements

 

 

f. Continuous improvement participation

 

 

2. For this task you must research each of the following topics, and complete a basic report on your findings. To guide your research please answer the following questions:

a. When communicating with others in the community sector what legislation and ethical consideration need to be made?

 

 

b. Where might you locate information on the application of legal and ethical aspects of health and community services work?

 

 

c. How can you ensure you make ethical decisions at all times?

 

 

d. What is the difference between motivational interviewing and coercive approach?

 

 

e. What is the difference between collaboration and confrontation?

 

 

f. What are the influences on communication?

 

 

g. Why is grammar, speed and pronunciation for verbal communication important?

 

 

h. Why is non-verbal communication important to use and recognise?

 

 

i. Choose a community service organisation that you are familiar with and discuss the structure, function and interrelationships they have.

 

 

j. What digital media is often used in the community service sector and how is it used?

 

 

 

 

Questions

The following questions may be answered verbally with your assessor or you may write down your answers. Please discuss this with your assessor before you commence. Short Answers are required which is approximately 4 typed lines = 50 words, or 5 lines of handwritten text.

Your assessor will take down dot points as a minimum if you choose to answer them verbally.

Answer the following questions either verbally with your assessor or in writing.

1. What are the different categories of communication?

 

 

 

2. What can you do to communicate effectively with people?

 

 

3. Write two examples each of open questions and closed questions.

 

 

 

 

4. What can you do to collaborate with colleagues effectively?

 

 

 

 

5. List six examples of industry terminology that you would use in verbal, written and digital communications.

 

 

6. What can you do to address communication constraints?

 

 

7. Discuss two strategies to handle conflict and maintain a tension-free workplace.

 

 

8. What are two pieces of legislation, regulations or Acts do you need to comply with in community services?

 

 

9. Who should you report any unresolved conflicts, breach or non-adherence to standard operating procedures, or any issues impacting on the rights of you or your client to?

 

 

10. How would you promote and model changes in the workplace?

 

 

11. List six different types of documentation you may need to complete to organisational standards in your workplace.

 

 

12. How can you contribute to continuous improvement in your workplace?

 

 

13. Who can you seek advice from in relation to improving your skills and knowledge?

 

 

14. Who would you speak to in relation to accessing options for skills development and training?

 

 

15. Define each of the following:

a. Privacy, confidentiality and disclosure

b. Discrimination

c. Duty of care

d. Mandatory reporting

e. Translation

f. Informed consent

g. Work role boundaries – responsibilities and limitations

h. Child protection across all health and community services contexts, including duty of care when child is not the client, indicators of risk and adult disclosure

 

 

16. Discuss the following two techniques in relation to communication:

a. Reflecting

b. Summarising

 

 

17. What is the difference between collaboration and confrontation?

 

 

18. What are the potential constraints to effective communication?

 

 

Developed by Enhance Your Future Pty Ltd 4 CHCCOM005 Communicate and work in health or community services Version 2 Course code and name

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Tina Jones Health Assessment|2025

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Name:

Section:

 

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

 

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

 

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

 

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

 

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin:

Hematologic:

Endocrine:

 

 

 

© 2021 Walden University Page 1 of 1

 

 

 

© 20

21

 

Walden University

 

 

Page

1

 

of

2

 

 

 

Name:

 

Section:

 

 

Week 4

 

Shadow Health Digital Clinical Experience Health History Documentation

 

 

SUBJECTIVE DATA:

Include what the patient tells you, but organize the information.

 

 

Chief Complaint (CC):

 

History of Present Illness

(HPI):

 

Medications:

 

Allergies:

 

Past Medical History (PMH):

 

Past Surgical History (PSH):

 

Sexual/Reproductive History:

 

Personal/Social History:

 

Immunization History:

 

Health Maintenance:

 

Significant Family History (

Include history of parents,

maternal/p

aternal

Grandparents, siblings,

and children):

 

 

Review of Systems:

From head

–

to

–

toe, include each system that covers the Chief Complaint,

History of Present Illness, and History).

 

Remember that the information you include in this

section is based on what t

he patient tells you. To ensure that you include all essentials in your

case, refer to Chapter 2 of the Sullivan text.

 

 

General:

Include any recent weight changes, weakness, fatigue, or fever, but

do not

restate HPI data here

.

 

 

HEENT:

 

 

Neck:

 

 

© 2021 Walden University Page 1 of 2

 

 

Name:

Section:

 

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

 

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

 

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings,

and children):

 

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,

History of Present Illness, and History). Remember that the information you include in this

section is based on what the patient tells you. To ensure that you include all essentials in your

case, refer to Chapter 2 of the Sullivan text.

 

General: Include any recent weight changes, weakness, fatigue, or fever, but do not

restate HPI data here.

HEENT:

Neck:

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Academic Success and Professional Development Plan Part 6|2025

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At some point in every construction project, efforts turn from design and the focus moves to actual construction. With the vision in place and the tools secured, the blueprint can be finalized and approved. Then it is time to put on hardhats and begin work.

Throughout the course you have developed aspects of your Academic and Professional Development Plan. You have thought a great deal about your vision and goals, your academic and professional network of support, research strategies and other tools you will need, the integrity of your work, and the value of consulting the work of others. With your portfolio in place, it is now time to finalize your blueprint for success.

Much as builders remain cognizant of the building standards as they plan and begin construction, nurses must remain mindful of the formal standards of practice that govern their specialties. A good understanding of these standards can help ensure that your success plan includes any steps necessary to excel within your chosen specialty.

In this Assignment you will continue developing your Academic Success and Professional Development Plan by developing the final component–a review of your specialty standards of practice. You will also submit your final version of the document, including Parts 1–5.

To Prepare:

  • Review the standards of practice related to your chosen specialty- Psychiatric Mental Health Nurse practitioner.
  • Download the Nursing Specialty Comparison Matrix.
  • Examine professional organizations related to the specialization you have chosen and identify at least one to focus on for this Assignment.
  • Reflect on the thoughts you shared in the Discussion forum regarding your choice of a specialty, any challenges you have encountered in making this choice, and any feedback you have received from colleagues in the Discussion.

The Assignment:
Complete the following items and incorporate them into the final version of your Academic Success and Professional Development Plan.

  • Complete the Nursing Specialty Comparison Matrix, comparing at least two nursing specialties that include your selected specialization and second-preferred specialization- Selected specialization is Psychiatric mental health nurse practitioner and the second -preferred specialization is Family nurse practitioner.
  • Write a 2- to 3-paragraph justification statement identifying your reasons for choosing your MSN specialization. Incorporate feedback you received from colleagues in this Module’s Discussion forum.
  • Identify the professional organization related to your chosen specialization for this Assignment, and explain how you can become an active member of this organization.    – American psychiatric nurses association.

Note: Your final version of the Academic Success and Professional Development Plan should include all components as presented the Academic Success and Professional Development Plan template.

Complete the following items and incorporate them into the final version of your Academic Success and Professional Development Plan:

·   Complete the Nursing Specialty Comparison Matrix comparing at least two nursing specialties, including your selected specialization and second-preferred specialization.

·   Write a 2-3 paragraph justification statement identifying your reasons for choosing your MSN specialization. Incorporate feedback you received from colleagues in this week’s Discussion Forum.

·   Identify the professional organization related to the specialization you have chosen to focus on for this Assignment and explain how you can become an active member of this organization.–

Levels of Achievement:  Excellent 77 (77%) – 85 (85%)    Good 68 (68%) – 76 (76%)    Fair 59 (59%) – 67 (67%)    Poor 0 (0%) – 58 (58%)

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance.  A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.–

Levels of Achievement:  Excellent 5 (5%) – 5 (5%)    Good 4 (4%) – 4 (4%)    Fair 3.5 (3.5%) – 3.5 (3.5%)    Poor 0 (0%) – 3 (3%)

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–

Levels of Achievement:  Excellent 5 (5%) – 5 (5%)    Good 4 (4%) – 4 (4%)    Fair 3.5 (3.5%) – 3.5 (3.5%)    Poor 0 (0%) – 3 (3%)

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.–

Levels of Achievement:  Excellent 5 (5%) – 5 (5%)    Good 4 (4%) – 4 (4%)    Fair 3.5 (3.5%) – 3.5 (3.5%)    Poor 0 (0%) – 3 (3%)

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characteristics would lead a provider to suspect domestic violence|2025

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 Topic 5 DQ 2

What characteristics would lead a provider to suspect domestic violence, child abuse, or elder abuse is taking place within a family? Discuss your facility’s procedure for reporting these types of abuse.

Violence and abuse is described as any intentional physical, mental, or psychological harm inflicted on a vulnerable person. This includes punching, berating, screaming, and other types of intentional cruelty. Domestic violence also involves threats or mild verbal or physical attacks, and victims seek to comply with the abuser’s demands. Victims feel trapped, reliant, helpless, and powerless. They can experience depression as a result of being stuck in the abuser’s power and control loop. As a victim’s self-esteem deteriorates as a result of prolonged abuse, he or she will blame themselves for the violence and be unable to see a way out of the situation. Neglect is described as any deliberate or unintentional lack of concern for someone’s well-being, such as failing to meet a dependent’s basic needs. Child abuse, child neglect, dependent adult abuse, dependent adult neglect, and domestic violence are all examples of abuse and neglect

If a family member shows apparent signs of bruising, malnutrition, depression, extreme fear, extortion, or other similar factors, a mandatory leader can suspect violence or neglect. However, this list is little and not an exhaustive, and other elements which exist. There is no one-size-fits-all solution, but mandatory reporters are expected to search for trends of concern and various indicators of problems; they are expected to ask questions if required and to report anything they believe, even if they are not 100 percent certain.

A instructor, for example, can suspect child abuse if a student is chronically underweight and seems desperate to eat all they can while at school. If a woman arrives at the emergency room with severe bruises and physical injuries that do not seem to match her reasons for the medical problems, a nurse may suspect domestic abuse. A mental health professional may suspect elder abuse if a senior citizen pays large sums of money to a single person or if a family member micromanages their finances.

A required reporter must be aware of the appropriate authority to which the alleged violence and neglect should be reported. In the case of child violence, each state has a department of child services (also known as social services) that should be contacted through the appropriate channels, such as hot lines. Domestic abuse should be reported to local law enforcement. Adult services agencies in each state deal with elder abuse and other forms of maltreatment of dependent adult.

References

Child abuse – reporting procedures. (2019). Better Health Channel. https://www.betterhealth.vic.gov.au/health/healthyliving/child-abuse-reporting-procedures

Elder abuse: Types, signs, and reporting. (2020, June 11). Find Assisted Living, Memory Care and Senior Living | A Place for Mom. https://www.aplaceformom.com/caregiver-resources/articles/elder-abuse

Respond to the post in discussion using 200-300 words in APA format with reference to support the post.

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