The first step of the evidence-based practice process is to evaluate a nursing practice environment to identify a nursing problem in the clinical area. When a nursing problem is discovered, the nurse researcher develops a clinical guiding question to address that nursing practice problem.

For this assignment, you will create a clinical guiding question know as a PICOT question. The PICOT question must be relevant to a nursing practice problem. To support your PICOT question, identify six supporting peer-reviewed research articles, as indicated below. The PICOT question and six peer-reviewed research articles you choose will be utilized for subsequent assignments.

Use the “Literature Evaluation Table” to complete this assignment.

1. Select a nursing practice problem of interest to use as the focus of your research. Start with the patient population and identify a clinical problem or issue that arises from the patient population. In 200–250 words, provide a summary of the clinical issue.
2. Following the PICOT format, write a PICOT question in your selected nursing practice problem area of interest. The PICOT question should be applicable to your proposed capstone project (the project students must complete during their final course in the RN-BSN program of study).
3. The PICOT question will provide a framework for your capstone project.
4. Conduct a literature search to locate six research articles focused on your selected nursing practice problem of interest. This literature search should include three quantitative and three qualitative peer-reviewed research articles to support your nursing practice problem.

Note: To assist in your search, remove the words qualitative and quantitative and include words that narrow or broaden your main topic. For example: Search for diabetes and pediatric and dialysis. To determine what research design was used in the articles the search produced, review the abstract and the methods section of the article. The author will provide a description of data collection using qualitative or quantitative methods. Systematic Reviews, Literature Reviews, and Metanalysis articles are good resources and provide a strong level of evidence but are not considered primary research articles.  Therefore, they should not be included in this assignment.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. 

Discussion 1 (Health care reform and role of NP) 

Review

1) How Healthcare reform is impacting primary care

 https://www.ajmc.com/contributor/sophia- bernazzani/2016/03/how-healthcare-reform-is-impactingprimarycare 

    2) Health care reform impacts on nurses: 

https://www.nursingworld.org/~4afc9b/globalassets/practiceandpolicy/health-policy/healthcare-reform-document.pdf

    3) Healthcare Transformation and Changing Roles for Nursing 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266427/pdf/ornur3612.pdf 

For this assignment, you are to complete a clinical case – narrated PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.  

You are to approach this clinical scenario as if it is a real patient in the clinical setting.

Instructions:

Step 1 – Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2 – Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3 – Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.

Example of Steps 1 – 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness

Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.

Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe

Step 5 – Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.

Step 6 – Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a detailed plan of f/u

CLINICAL CASE SCENARIOA 7-month-old male child arrives at your clinic for a well-child examination. His family recently emigrated to the United States from West Africa. His medical history is positive for abdominal pain and his family history is positive for maternal hypertension and paternal hyperlipidemia. The father smokes a pack a day and smokes in the home. The child’s sole source of nutrition is goat’s milk. He appears to be healthy on examination and his point-of-care complete blood count shows large red blood cells. Today, his vitals are as follows: weight 18.3 lbs, height 27.2 inches, BP 80/56, HR 100, RR 26, and Temperature is 98.6 F.

Diagnosis – Megaloblastic Anemia

As you develop your narrated PowerPoint, be sure to address the criteria discussed in the video above and the instructions listed below:

FOLLOW THE TEMPLATE BELOW for the Clinical Case Report – SOAP PowerPoint Assignment:

DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE.

SUBJECTIVE (S): Describes what the patient reports about their condition.
For INITIAL visits gather the info below from the clinical scenario and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION.

Historian (required; unless the patient is 16 y/o and older): document name and relationship of guardian
Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old female here for evaluation of a palmar rash
HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, temporal association, severity) written in paragraph form
PMH (Past Medical History): List any past or present medical conditions, surgeries, or other medical interventions the patient has had. Specify what year they took place
MEDs: List prescription medications the patient is taking. Include dosage and frequency if known. Inquire and document any over-the-counter, herbal, or traditional remedies.
Allergies: List any allergies the patient has and indicate the reaction. e.g. Medications (tetracycline-> shortness of breath), foods, tape, iodine->rash
FH (Family History): List relevant health history of immediate family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc…
SHx (Social history): document parent’s work (current), educational level, living situation (renting, homeless, owner), substance use/abuse (alcohol, tobacco, marijuana, illicit drugs), firearms in-home, relationship status (married, single, divorced, widowed), number of children in the home (in SF or abroad), how recently pt immigrated to the US and from what country of origin (if applicable), the gender of sexual partners, # of partners in last 6 mo, vaginal/anal/oral, protected/unprotected.

Patient Profile: Activities of Daily Living (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a child is 1y/o or younger, provide birth history also)

HRB (Health-related behaviors):
ROS (Review of Systems): Asking about problems by organ system systematically from head-to-toe. Included classic associated symptoms (this includes pertinent negatives and positives).

OBJECTIVE: Physical findings you observe or find on the exam.
1. Age, gender, general appearance
2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Include the Growth Chart
3. Physical Exam: note pertinent positives and negatives (refer to the textbook for classic findings related to present complaint and the diagnosis you believe the patient has)
4. Lab Section – what results do you have?
5. Studies/Radiology/Pap Results Section – what results do you have?

RISK FACTORS: List risk factors for the acute and chronic conditions

ASSESSMENT: What do you think is going on based on the clinical case scenario? This is based on the case. You are to list the acute diagnosis and three differential diagnoses, in order of what is likely, possible, and unlikely (include supporting information that helped you to arrive at these differentials). You must include the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of each diagnosis.

You are to also list any chronic conditions with the ICD-10 codes.

NATIONAL CLINICAL GUIDELINES: List the guidelines you will use to guide your treatment and management plan

TREATMENT & MANAGEMENT PLAN: Number problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and include A – F below for each diagnosis and G – H after you’ve addressed all conditions.

Example:
1. HTN
a) Vaccines administered this visit & vaccine administration forms given,
b) Medication-include dosage amounts and mg/kg for drug and number of days,
c) Laboratory tests ordered
d) Diagnostic tests ordered
e) Non-pharmaceutical treatments
f) Patient/Family education including preventive care

2. HLD
a) Vaccines administered this visit & vaccine administration forms given,
b) Medication-include dosage amounts and mg/kg for drug and number of days,
c) Laboratory tests ordered
d) Diagnostic tests ordered
e) Non-pharmaceutical treatments
f) Patient/Family education including preventive care
Also discussed:
g) Anticipatory guidance for next well-child visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
Return to the clinic:
h) Follow-up appointment with a detailed plan for f/u and any referrals

1.) choose any Neurologic medication and choose any disease that can be treated by that neurologic medication you choose.

2.) I uploaded two forms. the medication form is what you will use to answer the questions about the medication you choose. 

3.) while the system disorder form is what you will use to answer the questions about the disease you choose

4.) then you write half a page reflection explaining the relationship between the medication and the disease, also how the medication treats the disease. APA Reference and no plagirizm.

Identify one evidence-based intervention to reduce health disparities in the selected population.

The hot spot I chose is Arizona and the selected population is the lesbian, gay, bisexual, transgender and queer (LGBTQ) community. I chose this state because I worked as a nurse in Arizona in cities like Phoenix, Scotsdale and a few others. One of the Phoenix LGBT Communities is located in the North close to Roosevelt Avenue. I was in this state for 5 years and my first apartment rental was from a gay young man. I did community nursing where I visited patients at home. It is not easy discussing this subject but I feel very strongly about this minority and what they have to go through. I have had the privilege to work very closely with families who are either gay or have gay children. To be honest, my biases were finally broken down as I allowed myself to feel deep empathy for these folks after listening to some of their stories and the plight they face.

By addressing the health disparities that are so prevalent in this community and the need for health equity through evidence-based solutions; by developing a therapeutic framework to expressly ground the principles of health equity concerning this community that is so stigmatized, advance practice nurses, stakeholders and funders of this process can incorporate practices that are inclusive as they embark on working with this population.

Specifically, since I have worked closely with families with teen-age youths that are either lesbian, or gay, I understand what this community goes through at home, at school and with their neighbors. In one of the instances, I had parked my car in front of the patient’s house when I came to do an oasis assessment. The harassing neighbors that hated the family because the two ‘moms’ were lesbians, came and pitched a basketball hoop very close to my car and told the parents of my patient to ask me to move my car because her kids wanted to play basketball on the street. This was just a hate-driven move against anyone that associated with the lesbians. Now we are talking about neighbors that do have a large yard and could pitch a basketball net anywhere in their yard. This incivility resulted in an altercation between the two families. The family I came to work with had just bought the home but since the purchase it was one form of harassment after another. It was not until I worked with them and other gay families that I discovered what this community suffered. Seeing their plight and listening to their stories I was forced to examine my own biases against this minority group of people.

Anyway, that aside, one issue that the family discussed with me is that of healthcare inequality and how they had suffered discrimination this area amongst other areas. I consider evidence-based interventions and strategies that could leverage science to promote equity-focused healthcare for youths and families as a worthy cause. Starting an educational organization whose curriculum is run by LGBTQ researchers, educators, program designers, relevant publishers,/writers/editors, and techies, all contributing their sympathetic skills and talents to advance advocacy to improve lives and promote equity has become something I would very much like to pursue. I now reside in Massachusetts and I keep running into the same issue in community nursing as well as school nursing.

My interest for this Arizona community runs deep with good reason. I find myself driven by their mission to advance healthcare equity and opportunities for youths and families especially those parents that are reluctant about getting fair healthcare treatment. I also saw how their children found it difficult maintaining a steady attendance in school due to the fear of stigmatization and ridicule. Laws are in place to protect, but the public is still not sensitive enough to the needs of this community and are very subtle in the way they practice discrimination and bias within the healthcare industry.

Advanced practice nurses have a responsibility to educate nurses in our hospitals and healthcare facilities. Our doctors also need proper education on how not to discriminate against the LGBT community. Advance practice nurses must educate school nurses to exercise their leadership roles in fostering safety by being supportive in our school environment. They must deal with the unfairness and inequality to bridge the gap in gender discrimination and health disparities. Collaborating with the school and the community to advocate for change in policy will go a long way to improve outcomes (Shattuck et al.)

Here in Massachusetts, I once visited the The Alnite Alliance Group made up of connected voices that meet monthly and presently, they do zoom meetings and consider this place a safe hangout location where all LGBTQ members can assemble and be free to express their challenges.

In the near future, I intend to build a strong, dynamic partnership and collaboration with this group so I could better inform the interdisciplinary team to seek strategies that foster funding for LGBTQ cultural competence while lessening the healthcare disparities. It all begins with educating the public and raising awareness about their gender and sexual orientation/identification. My motto is, fairness for all especially when it comes to healthcare. Everyone deserves fairness, whether or not we disagree with their lifestyle choices and orientation. The masses need to understand that everyone deserves to live in a safe and healthy community and to participate equally in economic opportunities, affordable and medically precise and inclusive healthcare services.

Through education and training and evidence-based research, I hope to positively make an impact in areas such as reproductive health including the prevalence of HIV that is so common with this population. For the youth, school-based mental health and wellness will be emphasized. Also addressing the drugs, alcohol and experimentation with tobacco products as stress relief will be addressed. Teaching inclusion science and healthcare equity and how to recognize incivility, where to go to get justice will be part of the strategic interventions of the program. With the assistance of the gay/lesbian parents and their children, we will collaboratively design customized, evidence-based programs and services to adequately and accurately address the current healthcare disparities still prevalent in the LGBTQ community.

Consider how the selected intervention addresses at least one of the CLAS standards.

One of the CLAS standards that seem to stand out to me is how an advanced practice nurse can demonstrate sensitivity towards the culture of the lesbian, gay, bisexual, transgender and queer community. Worthy of consideration for the nurse are culture and gender as key components, foundational to inform practice improvement leading to quality care (Surikova et al., 2020)

One of the challenges community nurses face is the discomfort they feel when they suddenly are faced with having to address patients’ sexual behaviors. This is particularly true with the LGBTQ community, a factor that can result in serious consequences (Landry, 2017).

Sometimes it only takes minor adjustments in a provider’s approach to make a significant difference in the life of patients to improve health outcomes especially with the healthcare disparities this group faces.

There are mental, emotional, biological and psychological issues ranging from anger, guilt, shame, feelings of unworthiness, violence, fear, anxiety, suicide contemplation, safety issues etc. all needing to be addressed, not ignored. As health care professionals it is our job to make sure we do not shy away from addressing issues around their sexuality when it is called for. Part of cultural competence is being culturally sensitive to the above-mentioned needs in order to provide top quality mental and emotional healthcare for our patients.

When we demonstrate a sense of comprehension and empathy towards the patients’ culture, and when we avoid a judgmental approach toward their gender orientation, we show understanding and accommodation, thereby building the trust that is necessary for improving outcomes and eliminating disparities.

How can nurse leaders and healthcare providers be advocates and work in the best interest of their patients if they harbor a repulsive or negative attitude towards those with gender differences that is termed non-conventional? I had to deal with my own biases when I got assigned to families with two moms or two dads. At first it was awkward and challenging because I was not prepared for this and had never been in very close proximity with the LGBTQ group. But as time went on, the walls got eroded because I chose to approach it from a scientific and evidence-based standpoint. Many nurses from my organization simply could not do it for some reason and I think it is simply ignorance.

Gender flexibility orientation is something nurses must educate themselves about. Just as discrimination due to race, culture, religious beliefs, and age is wrong, discrimination because of gender orientation is equally wrong and unethical. It is a form of incivility because we are responsible for equity-based healthcare.

References

Shattuck, D. et al. (2020, Aug). Recruitment of Schools for Intervention Research to Reduce Health Disparities for Sexual and Gender Minority Students. Journal of School Nursing 36(4) 258-264.

Landry, J. (May, 2017). Delivering Culturally Sensitive Care to LGBTQI Patients. The Journal for Nurse Practitioners, 13(5):342-347

Surikova, J., Payne, A., Miller, KL., Ravaei, A., & Nolan, RP. (2020, July, 18). A cultural and gender-based approach to understanding patient adjustment to chronic heart failure. Health Qual Life Outcomes, 18 (1), pp. 238. DOI: 10.1186/s12955-020-01482-1

I NEED A COMMENT FOR THIS DISCUSSION BOARD WITH AT LEAST 2 PARAGRAPHS AND 3 SOURCES NO LATER THAN 5 YEARS.