To prepare:

Review this week’s Learning Resources, including the Focused SOAP Note Template.

Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:

Subjective: What details did the patient provide regarding his or her personal and medical history?

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”). 

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: Head

Onset: 3 days ago

Character: Pounding, pressure around the eyes and temples

Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia

Timing: After being on the computer all day at work

Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use; also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Include a QUESTION of what the allergy is (e.g., angioedema, anaphylaxis, etc.). This will help determine a true reaction vs. intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed.
 

Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco, and alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: Identify illnesses with possible genetic predisposition, and contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression).History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Reproductive Hx: Menstrual history (date of LMP), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period (MM/DD/YYYY).

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e.) General: Head: EENT: etc. 

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)

A.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

P. 

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. 

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Week 7 

Question 1: How can reflective practice help nurses navigate and address instances of incivility in their work environment? Use proper APA references 

Question2: give a feedback to this two post with a paragraph per post, use reference for each paragraph 

Reply to Junie:  
     Incivility in the workplace often results from rudeness, arrogance, and bullying of staff members from senior staff within the workplace, causing a hostile environment (Craft et al., 2020). Incivility evolves from job insecurities, increased diversity, and personal misunderstandings (Craft et al., 2020). My caregiver partner and I were assigned duties in the surgery ward with the chief nurse a while back. However, there was an assigned nurse at the time. So when she reported back to her post and found us, she started insulting and accusing us of being after her job. The abuse had escalated within no time, making the situation embarrassing.  This situation made me feel disrespected and agitated. The same was true for my partner because she retaliated and became aggressive towards the nurse. They became aggressive at each other to the point of physical altercation. The already nearing colleagues stopped this fight because the uncomfortable commotion was affecting the patients in the wards.

     Taskaya and Aksoy (2020) state that workplace incivility promotes significant harm to an individual’s health and those around them and even influences the productivity level of the staff. Such was the situation where most of the staff started launching their complaints against some of the colleagues who had bullying tendencies. At this point, work productivity within the wards was low, thus affecting the patients’ caregiving services and recuperating process. The most strategic way of curbing workplace incivility is introducing educational intervention activities, essential in enhancing interpersonal communication (Howard & Embree, 2020). This allows individuals to understand the existing uncivil behaviors and identify the most suitable ways of curbing such behaviors in future incidences. Furthermore, it enhances the art of following set guidelines and accepting changes made, thus respecting the authorities, remembering that all nurses are a team, and ensuring patients’ recovery is the goal. 

References
Craft, J., Schivinski, E. L., & Wright, A. (2020). The grim reality of nursing incivility. Journal for Nurses in Professional Development, 36(1), 41-43. DOI: 10.1097/NND.0000000000000599

Howard, M. S., & Embree, J. L. (2020). Educational intervention improves the communication abilities of nurses encountering workplace incivility. The Journal of Continuing Education in Nursing, 51(3), 138–144. https://doi.org/10.3928/00220124-20200216-09

Ta?kaya, S., & Aksoy, A. (2021). A bibliometric analysis of workplace incivility in nursing. Journal of Nursing Management, 29(3), 518-525. https://doi.org/10.1111/jonm.13161

Reply to Veronica: 

    Everybody may have good days or bad days. Still, when it happens at the workplace, it can create some situations that one nurse can avoid or does not show her emotions, but the other might show it up, unable to manage their feelings, which can put the healthcare team at a compromise. I witnessed the situation at the post-anesthesia care unit (PACU). In this PACU unit, nurses and CRNAs have worked together for several years and have an excellent professional team. However, it was a hectic workday, with many surgeries, and the unit needed more staff; we could not take our lunches by 3 pm. When a PACU nurse, T., was receiving a patient after surgery from the operation room (OR) to BAY #9 and was getting a report from an S., CRNA. At the end of the report, the CRNA made a general joke unrelated to the nurse, and it was not bullying, just a joke to cheer up Nurse T, but it triggered her differently. Nurse T. became agitated and screamed to the CRNA that other unit nurses got to Bay #9 in bewilderment. The situation was shocking for everybody. I felt so bad for the CRNA, the patient, and Nurse T, who was driven by negative emotions. The patient, who had just woken up after the surgery, became very confused, unknowing what was going on. The S., CRNA, is a friendly and intelligent young CRNA who got upset and felt terrible that he, somehow, unintentionally provoked this situation. Nurse T. could not hold emotions, started crying, and failed to care for her patient.  Nurse T, a single mother with two little kids trying to work more hours and pick up extra shifts, was stressed and overwhelmed by her daily life.  

    The charge nurse told Nurse T. to step back and took over the patient’s care. Nurse T. was unable to work and finish the shift. The situation negatively impacted the workplace culture and quality of patient care by delaying patient care and compromising the safety of the patient’s care. All PACU nurses, being initially understaffed that day, were more stressed, which decreased their work satisfaction. S., CRNA might have feelings of being disconnected and not making any jokes when giving reports to T, RN. The PACU manager had a meeting with Nurse T., and since then, she has been trying to manage her emotions and self-care to balance work and days off with her parents babysitting her kids. The PACU unit staff is still tight together and has an excellent team to take care of patients. However, everybody involved made some conclusions to avoid such a situation. 

    One of the strategies for a healthy work environment is that the entity should implement the Pathway for Fostering Organizational Civility Framework, which consists of several steps to create a healthier and more civil workplace culture. Clark (2019). According to Mabona et al. (2022), a healthy work environment is crucial in attaining good patient and societal outcomes and optimal entity performance. Also, nurses must improve their self-management skills to prevent or avoid workplace violence or conflict and to enhance emotional intelligence. According to Al-Hamdan et al. (2021), one study revealed that nurses’ emotional intelligence was positively and significantly correlated with nurse-to-nurse collaboration and linked to benefits for nurses by improving job satisfaction, better nursing retention, improved quality of patient care and magnified healthcare efficiency and productivity.