Tag: Clinical Nursing & Patient Care

  • [Solved] Discussion P W7 Reply to Peer 1-2

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    Recent milestones in the understanding of gastric acid secretion and treatment of acid-peptic disorders include the discovery of histamine H2-receptors and development of histamine H2-receptor antagonists, identification of H+K+-ATPase as the parietal cell proton pump and development of proton pump …

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    Recent milestones in the understanding of gastric acid secretion and treatment of acid-peptic disorders include the discovery of histamine H2-receptors and development of histamine H2-receptor antagonists, identification of H+K+-ATPase as the parietal cell proton pump and development of proton pump inhibitors, and identification of Helicobacter pylori as the major cause of duodenal ulcer and development of effective eradication regimens (Schubert et al. 2008). The stimuli for acid secretions are as follows, Acetylcholine, Gastrin and Histamine. When this acid secretion combines food can digest but also it can create different issues, for example, it can facilitate digestion of protein as well as the absorption of iron, calcium, and vitamin B12. When we take medication is these secretions are necessary for absorption of certain drugs however taking too much medicine or eating the wrong foods can lead to acid-related clinical conditions. Parietal cells secrete hydrochloric acid at a concentration of approximately 160 mmol/L or pH 0.8. Acid is thought to gain access to the lumen via channels in the mucus layer created by the relatively high intraglandular hydrostatic pressures generated during secretion, approximately 17 mm Hg (Johnsson et al, 2001). The acids facilitate the ingestion of protein and absorption of iron, calcium, and vitamin B-12 as well as prevent bacterial overgrowth and enteric infection. However, if the acid levels and pepsin increase a risk of ulcers can occur. The principal of acid secretion is histamine released from ECL cells (paracrine); gastrin, released from G cells (hormonal); and ACh, released from postganglionic enteric neurons (neurocrine) (Schubert et al. 2008).

    Helicobacter pylori (H. pylori) attack the lining that protects your stomach. Many people have it and won’t have any issues with ulcers until the time is right for one to start causing issues. As the host starts showing symptoms of an ulcer, the H pylori make an enzyme called urease that makes the acid in the stomach less acidic while weakening the stomach lining, furthermore the host is at a greater risk of being hurt by acid and pepsin, strong digestive fluids. That can lead to sores or ulcers in your stomach or duodenum (2024). Helicobacter pylori is the first formally recognized bacterial carcinogen and is one of the most successful human pathogens, as over half of the world's population is colonized with this gram-negative bacterium. Unless treated, colonization usually persists lifelong. H. pylori infection represents a key factor in the etiology of various gastrointestinal diseases, ranging from chronic active gastritis without clinical symptoms to peptic ulceration, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue lymphoma (Kusters et al., 2006). In conclusion H pylori is a bacteria that is found in all of us how it develops is how it is going to affect us, by taking simple precautions such as eating food that is cleaned thoroughly and cooked in a safe way and by drinking clean and potable water from a sanitary source that will not have bacteria. Lastly, good hand hygiene is the best way to effectively protect ourselves from these bacteria.

    References

    Schubert, Mitchell L. et al (2008). Control of Gastric Acid Secretion in Health and Disease

    Gastroenterology, Volume 134, Issue 7, 1842 – 1860

    Johansson, M. ∙ Synnerstad, I. ∙ Holm, L. (2001). Acid transport through channels in the mucous layer of rat stomach Gastroenterology; 119:1297-1304

    Helicobacter pylori. Johns Hopkins Medicine. (2024, May 13). [https://www.hopkinsmedicine.org/health/conditions-and-diseases/helicobacter-pylori](https://www.hopkinsmedicine.org/health/conditions-and-diseases/helicobacter-pylori)

    Kusters, J. G., van Vliet, A. H. M., & Kuipers, E. J. (2006, July). Pathogenesis of helicobacter pylori infection. Clinical microbiology reviews. [https://pmc.ncbi.nlm.nih.gov/articles/PMC1539101/](https://pmc.ncbi.nlm.nih.gov/articles/PMC1539101/)

    – 2 years ago

  • [Solved] ROLES WEEK 7

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    – 2 years ago **files (1)** – ## Discussion7Module7ROLESINLEADERSHIP.docx **## Discussion7Module7ROLESINLEADERSHIP.docx** ![A screenshot of a web page AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/roles-week-7) ![A screenshot of a white sheet Description automatically …

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    – 2 years ago

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  • [Solved] PATHO WEEK 7

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    – 2 years ago

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  • [Solved] NUR 514 Clinical Soap note 3

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    #### **Submission Instructions:** – Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings. – You must use the template provided. Turnitin will recognize the template and not score against it. – [\ \ SoapNoterubric.docx](https:/…

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    #### **Submission Instructions:**

    – Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
    – You must use the template provided. Turnitin will recognize the template and not score against it.

    – [\
    \
    SoapNoterubric.docx](https://www.sweetstudy.com/files/soapnoterubric-docx-10201467 "SoapNoterubric.docx")
    – [\
    \
    SOAPNoteTemplate.docx](https://www.sweetstudy.com/files/soapnotetemplate-docx-10201469 "SOAPNoteTemplate.docx")

    – 2 years ago

  • [Solved] week 7.1

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    In-depth study guidance and analytical solution covering week 7.1.

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    Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

  • [Solved] Replies

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    Attached – [\ \ Screenshot_20250221_191504_Chrome.jpg](https://www.sweetstudy.com/files/screenshot-20250221-191504-chrome-jpg "Screenshot_20250221_191504_Chrome.jpg") – [\ \ Screenshot_20250221_191447_Chrome.jpg](https://www.sweetstudy.com/files/screenshot-20250221-191447-chrome-jpg "Scree…

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    – [\
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    Screenshot_20250221_191447_Chrome.jpg](https://www.sweetstudy.com/files/screenshot-20250221-191447-chrome-jpg "Screenshot_20250221_191447_Chrome.jpg")

    – 2 years ago

  • [Solved] Asssigment

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    – 2 years ago **files (1)** – ## EthicalandLegalAspectofNursingPractice-.docx **## EthicalandLegalAspectofNursingPractice-.docx** Florida National University Course Reflection Guidelines ## Purpose The purpose of this assignment is to provide the student an opportunity to reflect on selected RN-BSN …

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    – 2 years ago

    **files (1)**

    – ## EthicalandLegalAspectofNursingPractice-.docx

    **## EthicalandLegalAspectofNursingPractice-.docx**

    Florida National University

    Course Reflection

    Guidelines

    ## Purpose

    The purpose of this assignment is to provide the student an opportunity to reflect on selected RN-BSN competencies acquired through the course.

    ## Course Outcomes

    This assignment provides documentation of student ability to meet the following course outcomes:

    · Identify the different legal and ethical aspects in the nursing practice (ACCN Essential V; QSEN: patient-centered care, teamwork and collaboration).

    · Analyze the legal impact of the different ethical decisions in the nursing practice (ACCN Essential V; QSEN: patient- centered care, teamwork and collaboration).

    · Understand the essential of the nursing law and ethics (ACCN Essential V; QSEN: patient-centered care, teamwork and collaboration).

    **Points**

    This assignment is worth a total of 200 points (20%).

    **Due Date**

    Submit your completed assignment under the Assignment tab by
    **Monday** 11:59 p.m. EST of
    **Week 8** as directed.

    ## Requirements

    1. The
    **Course Reflection** is worth 200 points (10%) and will be graded on quality of self-assessment, use of citations, use of Standard English grammar, sentence structure, and overall organization based on the required components as summarized in the directions and grading criteria/rubric.

    2. Follow the directions and grading criteria closely. Any questions about your essay may be posted under the Q & A forum under the Discussions tab.

    3.
    **The length of the reflection is to be within three to six pages excluding title page and reference pages.**

    4. APA format is required with both a title page and reference page. Use the required components of the review as Level 1 headers (upper and lower case, centered):

    Note: Introduction – Write an introduction but do not use “Introduction” as a heading in accordance with the rules put forth in the
    _Publication manual of the American Psychological Association_(2010, p. 63).

    a. Course Reflection

    b. Conclusion

    ## Preparing Your Reflection

    The
    _BSN Essentials_ (AACN, 2008) outline a number of healthcare policy and advocacy competencies for the BSN-prepared nurse. Reflect on the course readings, discussion threads, and applications you have completed across this course and write a reflective essay regarding the extent to which you feel you are now prepared to (choose 4):

    1. “Demonstrate the professional standards of moral, ethical, and legal conduct.

    2. Assume accountability for personal and professional behaviors.

    3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession.

    4. Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers.

    5. Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice.

    6. Reflect on one’s own beliefs and values as they relate to professional practice.

    7. Identify personal, professional, and environmental risks that impact personal and professional choices, and behaviors.

    8. Communicate to the healthcare team one’s personal bias on difficult healthcare decisions that impact one’s ability to provide care.

    9. Recognize the impact of attitudes, values, and expectations on the care of the very young, frail older adults, and other vulnerable populations.

    10. Protect patient privacy and confidentiality of patient records and other privileged communications.

    11. Access interprofessional and intra-professional resources to resolve ethical and other practice dilemmas.

    12. Act to prevent unsafe, illegal, or unethical care practices.

    13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development.

    14. Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care.” (p. 28).

    Reference:

    American Association of Colleges of Nursing [AACN]. (2008).
    _The essentials of baccalaureate education for professional nursing practice._ Washington, DC: Author.

    ## Directions and Grading Criteria

    | | | | |
    | — | — | — | — |
    | Category | Points | % | Description |
    | (Introduction – see note under requirement #4 above) | 8 | 8 | Introduces the purpose of the reflection and addresses BSN Essentials (AACN, 2008) pertinent to healthcare policy and advocacy. |
    | You Decide Reflection | 80 | 80 | Include a self-assessment regarding learning that you believe represents your skills, knowledge, and integrative abilities to meet the pertinent BSN Essential and sub-competencies (AACN, 2008) as a result of active learning throughout this course. Be sure to use examples from selected readings, threaded discussions, and/or applications to support your assertions to address each of the following sub-competencies:<br>(a) “Demonstrate the professional standards of moral, ethical, and legal conduct.<br>(b) Assume accountability for personal and professional behaviors.<br>(c) Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession.<br>(d) Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers.<br>(e) Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice.<br>(f) Reflect on one’s own beliefs and values as they relate to professional practice.<br>(g) Identify personal, professional, and environmental risks that impact personal and professional choices, and behaviors.<br>(h) Communicate to the healthcare team one’s personal bias on difficult healthcare decisions that impact one’s ability to provide care.<br>(i) Recognize the impact of attitudes, values, and expectations on the care of the very young, frail older adults, and other vulnerable populations.<br>(j) Protect patient privacy and confidentiality of patient records and other privileged communications.<br>(k) Access interprofessional and intra-professional resources to resolve ethical and other practice dilemmas.<br>(l) Act to prevent unsafe, illegal, or unethical care practices.<br>(m) Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development.<br>(n) Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care.” (p. 28). |
    | Conclusion | 4 | 4 | An effective conclusion identifies the main ideas and major conclusions from the body of your essay. Minor details are left out. Summarize the benefits of the pertinent BSN Essential and sub-competencies (AACN, 2008) <br>_pertaining to scholarship for evidence-based practice._ |
    | Clarity of writing | 6 | 6 | Use of standard English grammar and sentence structure. No spelling errors or typographical errors. Organized around the required components using appropriate headers. Writing should demonstrate original thought without an over-reliance on the works of others. |
    | APA format | 2 | 2 | All information taken from another source, even if summarized, must be appropriately cited in the manuscript and listed in the references using APA (6th ed.) format:<br>1. Document setup<br>2. Title and reference pages<br>3. Citations in the text and references. |
    | Total: | 100 | 100 | A quality essay will meet or exceed all of the above requirements. |

    ## Grading Rubric

    | | | | |
    | — | — | — | — |
    | Assignment Criteria | Meets Criteria | Partially Meets Criteria | Does Not Meet Criteria |
    | (Introduction – see note under requirement #4 above)<br>(8 pts) | Short introduction of selected BSN sub-competencies (AACN, 2008) pertinent to <br>_scholarship for evidence-based practice_. Rationale is well presented, and purpose fully developed. <br> <br>**7 – 8 points** | Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.<br>**5 – 6 points** | Little or very general introduction of selected BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.<br>**0 – 4 points** |
    | You Decide Reflection<br>(80 pts) | Excellent self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) supported with examples.<br>**70 – 80 points** | Basic self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) not supported with examples.<br>**59 – 69 points** | Little or very general self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Little or no reflection on pertinent BSN sub-competencies (AACN, 2008) or reflection not supported with examples.<br>**0 – 58 points** |
    | Conclusion<br>(4 pts) | Excellent understanding of pertinent BSN sub- competencies (AACN, 2008). Conclusions are well evidenced and fully developed.<br>**3 – 4 points** | Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.<br>**2 points** | Little understanding of pertinent BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.<br>**0 – 1 point** |
    | Clarity of writing<br>(6 pts) | Excellent use of standard English showing original thought with minimal reliance on the works of others. No spelling or grammar errors. Well organized with proper flow of meaning. <br>**5 – 6 points** | Some evidence of own expression and competent use of language. No more than three spelling or grammar errors. Well organized thoughts and concepts.<br>**3 – 4 points** | Language needs development or there is an over-reliance on the works of others. Four or more spelling and/or grammar errors. Poorly organized thoughts and concepts.<br>**0 – 2 points** |
    | APA format<br>(2 pts) | APA format correct with no more than 1-2 minor errors. <br>**2 points** | 3-5 errors in APA format and/or 1-2 citations are missing.<br>**1 point** | APA formatting contains multiple errors and/or several citations are missing.<br>**0 points** |
    | Total Points Possible = 100 points |

    ## | | | | — | — | | NUR3826 Course Reflection Guidelines.docx 08/21/19 | 2 |

    **## EthicalandLegalAspectofNursingPractice-.docx**

    Florida National University

    Course Reflection

    Guidelines

    ## Purpose

    The purpose of this assignment is to provide the student an opportunity to reflect on selected RN-BSN competencies acquired through the course.

    ## Course Outcomes

    This assignment provides documentation of student ability to meet the following course outcomes:

    · Identify the different legal and ethical aspects in the nursing practice (ACCN Essential V; QSEN: patient-centered care, teamwork and collaboration).

    · Analyze the legal impact of the different ethical decisions in the nursing practice (ACCN Essential V; QSEN: patient- centered care, teamwork and collaboration).

    · Understand the essential of the nursing law and ethics (ACCN Essential V; QSEN: patient-centered care, teamwork and collaboration).

    **Points**

    This assignment is worth a total of 200 points (20%).

    **Due Date**

    Submit your completed assignment under the Assignment tab by
    **Monday** 11:59 p.m. EST of
    **Week 8** as directed.

    ## Requirements

    1. The
    **Course Reflection** is worth 200 points (10%) and will be graded on quality of self-assessment, use of citations, use of Standard English grammar, sentence structure, and overall organization based on the required components as summarized in the directions and grading criteria/rubric.

    2. Follow the directions and grading criteria closely. Any questions about your essay may be posted under the Q & A forum under the Discussions tab.

    3.
    **The length of the reflection is to be within three to six pages excluding title page and reference pages.**

    4. APA format is required with both a title page and reference page. Use the required components of the review as Level 1 headers (upper and lower case, centered):

    Note: Introduction – Write an introduction but do not use “Introduction” as a heading in accordance with the rules put forth in the
    _Publication manual of the American Psychological Association_(2010, p. 63).

    a. Course Reflection

    b. Conclusion

    ## Preparing Your Reflection

    The
    _BSN Essentials_ (AACN, 2008) outline a number of healthcare policy and advocacy competencies for the BSN-prepared nurse. Reflect on the course readings, discussion threads, and applications you have completed across this course and write a reflective essay regarding the extent to which you feel you are now prepared to (choose 4):

    1. “Demonstrate the professional standards of moral, ethical, and legal conduct.

    2. Assume accountability for personal and professional behaviors.

    3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession.

    4. Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers.

    5. Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice.

    6. Reflect on one’s own beliefs and values as they relate to professional practice.

    7. Identify personal, professional, and environmental risks that impact personal and professional choices, and behaviors.

    8. Communicate to the healthcare team one’s personal bias on difficult healthcare decisions that impact one’s ability to provide care.

    9. Recognize the impact of attitudes, values, and expectations on the care of the very young, frail older adults, and other vulnerable populations.

    10. Protect patient privacy and confidentiality of patient records and other privileged communications.

    11. Access interprofessional and intra-professional resources to resolve ethical and other practice dilemmas.

    12. Act to prevent unsafe, illegal, or unethical care practices.

    13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development.

    14. Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care.” (p. 28).

    Reference:

    American Association of Colleges of Nursing [AACN]. (2008).
    _The essentials of baccalaureate education for professional nursing practice._ Washington, DC: Author.

    ## Directions and Grading Criteria

    | | | | |
    | — | — | — | — |
    | Category | Points | % | Description |
    | (Introduction – see note under requirement #4 above) | 8 | 8 | Introduces the purpose of the reflection and addresses BSN Essentials (AACN, 2008) pertinent to healthcare policy and advocacy. |
    | You Decide Reflection | 80 | 80 | Include a self-assessment regarding learning that you believe represents your skills, knowledge, and integrative abilities to meet the pertinent BSN Essential and sub-competencies (AACN, 2008) as a result of active learning throughout this course. Be sure to use examples from selected readings, threaded discussions, and/or applications to support your assertions to address each of the following sub-competencies:<br>(a) “Demonstrate the professional standards of moral, ethical, and legal conduct.<br>(b) Assume accountability for personal and professional behaviors.<br>(c) Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession.<br>(d) Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers.<br>(e) Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice.<br>(f) Reflect on one’s own beliefs and values as they relate to professional practice.<br>(g) Identify personal, professional, and environmental risks that impact personal and professional choices, and behaviors.<br>(h) Communicate to the healthcare team one’s personal bias on difficult healthcare decisions that impact one’s ability to provide care.<br>(i) Recognize the impact of attitudes, values, and expectations on the care of the very young, frail older adults, and other vulnerable populations.<br>(j) Protect patient privacy and confidentiality of patient records and other privileged communications.<br>(k) Access interprofessional and intra-professional resources to resolve ethical and other practice dilemmas.<br>(l) Act to prevent unsafe, illegal, or unethical care practices.<br>(m) Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development.<br>(n) Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care.” (p. 28). |
    | Conclusion | 4 | 4 | An effective conclusion identifies the main ideas and major conclusions from the body of your essay. Minor details are left out. Summarize the benefits of the pertinent BSN Essential and sub-competencies (AACN, 2008) <br>_pertaining to scholarship for evidence-based practice._ |
    | Clarity of writing | 6 | 6 | Use of standard English grammar and sentence structure. No spelling errors or typographical errors. Organized around the required components using appropriate headers. Writing should demonstrate original thought without an over-reliance on the works of others. |
    | APA format | 2 | 2 | All information taken from another source, even if summarized, must be appropriately cited in the manuscript and listed in the references using APA (6th ed.) format:<br>1. Document setup<br>2. Title and reference pages<br>3. Citations in the text and references. |
    | Total: | 100 | 100 | A quality essay will meet or exceed all of the above requirements. |

    ## Grading Rubric

    | | | | |
    | — | — | — | — |
    | Assignment Criteria | Meets Criteria | Partially Meets Criteria | Does Not Meet Criteria |
    | (Introduction – see note under requirement #4 above)<br>(8 pts) | Short introduction of selected BSN sub-competencies (AACN, 2008) pertinent to <br>_scholarship for evidence-based practice_. Rationale is well presented, and purpose fully developed. <br> <br>**7 – 8 points** | Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.<br>**5 – 6 points** | Little or very general introduction of selected BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.<br>**0 – 4 points** |
    | You Decide Reflection<br>(80 pts) | Excellent self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) supported with examples.<br>**70 – 80 points** | Basic self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) not supported with examples.<br>**59 – 69 points** | Little or very general self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Little or no reflection on pertinent BSN sub-competencies (AACN, 2008) or reflection not supported with examples.<br>**0 – 58 points** |
    | Conclusion<br>(4 pts) | Excellent understanding of pertinent BSN sub- competencies (AACN, 2008). Conclusions are well evidenced and fully developed.<br>**3 – 4 points** | Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.<br>**2 points** | Little understanding of pertinent BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.<br>**0 – 1 point** |
    | Clarity of writing<br>(6 pts) | Excellent use of standard English showing original thought with minimal reliance on the works of others. No spelling or grammar errors. Well organized with proper flow of meaning. <br>**5 – 6 points** | Some evidence of own expression and competent use of language. No more than three spelling or grammar errors. Well organized thoughts and concepts.<br>**3 – 4 points** | Language needs development or there is an over-reliance on the works of others. Four or more spelling and/or grammar errors. Poorly organized thoughts and concepts.<br>**0 – 2 points** |
    | APA format<br>(2 pts) | APA format correct with no more than 1-2 minor errors. <br>**2 points** | 3-5 errors in APA format and/or 1-2 citations are missing.<br>**1 point** | APA formatting contains multiple errors and/or several citations are missing.<br>**0 points** |
    | Total Points Possible = 100 points |

    ## | | | | — | — | | NUR3826 Course Reflection Guidelines.docx 08/21/19 | 2 |

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    Assignment Prompt & Instructions

    – 2 years ago

    **files (1)**

    – ## CourseReflectionNUR4636-8wks1.docx

    **## CourseReflectionNUR4636-8wks1.docx**

    Florida National University NUR4636

    Course Reflection

    Guidelines

    ## Purpose

    The purpose of this assignment is to provide the student an opportunity to reflect on selected RN-BSN competencies acquired through the NUR4636 course.

    ## Course Outcomes

    This assignment provides documentation of student ability to meet the following course outcomes:

    · The students will be able to recognize the different level of prevention and apply them in the community (ACCN Essential I, II, IV, V, VII; QSEN: safety, evidence-based practice, teamwork and collaboration, quality improvement, informatics, and patient-centered care).

    · This course will enable the student to place in practice methods of health prevention, promotion and restoration in the communities (ACCN Essential I, II, IV, V, VII; QSEN: safety, evidence-based practice, and teamwork and collaboration, quality improvement, informatics, and patient.

    · The students will be able to educate the communities about the different ways to prevent illness and promote health (ACCN Essential I, II, IV, V, VII; QSEN: safety, evidence-based practice, teamwork, and collaboration, quality improvement, informatics, and patient-centered care).

    · The student will understand the different tools available to put in place and in the hands of the communities in order to keep them healthy (ACCN Essential I, II, IV, V, VII; QSEN: safety, evidence-based practice, teamwork and collaboration, quality improvement, informatics, and patient-centered care).

    **Points**

    This assignment is worth a total of 100 points (10%).

    **Due Date**

    Submit your completed assignment under the Assignment tab by Monday at 11:59 p.m. EST of
    **Week 8** as directed.

    ## Requirements

    1. The
    **Course Reflection** is worth 100 points (10%) and will be graded on quality of self-assessment, use of citations, use of Standard English grammar, sentence structure, and overall organization based on the required components as summarized in the directions and grading criteria/rubric.

    2. Follow the directions and grading criteria closely. Any questions about your essay may be posted under the Q & A forum under the Discussions tab.

    3.
    **The length of the reflection is to be within three to six pages excluding title page and reference pages.**

    4. APA format is required with both a title page and reference page. Use the required components according
    **to APA 7th Edition formatting**.

    ## Preparing Your Reflection

    The
    _BSN Essentials_ (AACN, 2008) outline a number of healthcare policy and advocacy competencies for the BSN-prepared nurse. Reflect on the
    **NUR4636** course readings, discussion threads, and applications you have completed across this course and write a reflective essay regarding the extent to which you feel you are now prepared to
    **(choose 4):**

    1. “Demonstrate basic knowledge of healthcare policy, finance, and regulatory environments, including local, state, national, and global healthcare trends.

    2. Describe how health care is organized and financed, including the implications of business principles, such as patient and system cost factors.

    3. Compare the benefits and limitations of the major forms of reimbursement on the delivery of healthcare services.

    4. Examine legislative and regulatory processes relevant to the provision of health care.

    5. Describe state and national statutes, rules, and regulations that authorize and define professional nursing practice.

    6. Explore the impact of sociocultural, economic, legal, and political factors influencing healthcare delivery and practice.

    7. Examine the roles and responsibilities of the regulatory agencies and their effect on patient care quality, workplace safety, and the scope of nursing and other health professionals’ practice.

    8. Discuss the implications of healthcare policy on issues of access, equity, affordability, and social justice in healthcare delivery.

    9. Use an ethical framework to evaluate the impact of social policies on health care, especially for vulnerable populations.

    10. Articulate, through a nursing perspective, issues concerning healthcare delivery to decision makers within healthcare organizations and other policy arenas.

    11. Participate as a nursing professional in political processes and grassroots legislative efforts to influence healthcare policy.

    12. Advocate for consumers and the nursing profession.

    13. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations.

    14. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems.

    15. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations.

    16. Use behavioral change techniques to promote health and manage illness.

    17. Use evidence based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan.

    18. Use information and communication technologies in preventive care.

    19. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions.

    20. Assess the health, healthcare, and emergency preparedness needs of a defined population.

    21. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations.

    22. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and the prevention of illness, injury, disability, and premature death.

    23. Participate in clinical prevention and population focused interventions with attention to effectiveness, efficiency, cost-effectiveness, and equity.

    24. Advocate for social justice, including a commitment to the health of vulnerable populations and the elimination of health disparities.

    25. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease.” (pp. 20-21, 24-25).

    Reference:

    American Association of Colleges of Nursing [AACN]. (2008).
    _The essentials of baccalaureate education for professional nursing practice._ Washington, DC: Author.

    ## Directions and Grading Criteria

    | | | | |
    | — | — | — | — |
    | Category | Points | % | Description |
    | (Introduction – see note under requirement #4 above) | 8 | 8 | Introduces the purpose of the reflection and addresses BSN Essentials (AACN, 2008) pertinent to healthcare policy and advocacy. |
    | You Decide Reflection | 80 | 80 | Include a self-assessment regarding learning that you believe represents your skills, knowledge, and integrative abilities to meet the pertinent BSN Essential and sub-competencies (AACN, 2008) as a result of active learning throughout this course. Be sure to use examples from selected readings, threaded discussions, and/or applications to support your assertions to address each of the following sub-competencies:<br>(a) “Demonstrate basic knowledge of healthcare policy, finance, and regulatory environments, including local, state, national, and global healthcare trends.<br>(b) Describe how health care is organized and financed, including the implications of business principles, such as patient and system cost factors.<br>(c) Compare the benefits and limitations of the major forms of reimbursement on the delivery of healthcare services.<br>(d) Examine legislative and regulatory processes relevant to the provision of health care.<br>(e) Describe state and national statutes, rules, and regulations that authorize and define professional nursing practice.<br>(f) Explore the impact of sociocultural, economic, legal, and political factors influencing healthcare delivery and practice.<br>(g) Examine the roles and responsibilities of the regulatory agencies and their effect on patient care quality, workplace safety, and the scope of nursing and other health professionals’ practice.<br>(h) Discuss the implications of healthcare policy on issues of access, equity, affordability, and social justice in healthcare delivery.<br>(i) Use an ethical framework to evaluate the impact of social policies on health care, especially for vulnerable populations.<br>(j) Articulate, through a nursing perspective, issues concerning healthcare delivery to decision makers within healthcare organizations and other policy arenas.<br>(k) Participate as a nursing professional in political processes and grassroots legislative efforts to influence healthcare policy.<br>(l) Advocate for consumers and the nursing profession.<br>(m) Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations.<br>(n) Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems.<br>(o) Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations.<br>(p) Use behavioral change techniques to promote health and manage illness.<br>(q) Use evidence based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan.<br>(r) Use information and communication technologies in preventive care.<br>(s) Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions.<br>(t) Assess the health, healthcare, and emergency preparedness needs of a defined population.<br>(u) Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations.<br>(v) Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and the prevention of illness, injury, disability, and premature death.<br>(w) Participate in clinical prevention and population focused interventions with attention to effectiveness, efficiency, cost-effectiveness, and equity.<br>(x) Advocate for social justice, including a commitment to the health of vulnerable populations and the elimination of health disparities.<br>(y) Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease.” (pp. 20-21, 24-25). |
    | Conclusion | 4 | 4 | An effective conclusion identifies the main ideas and major conclusions from the body of your essay. Minor details are left out. Summarize the benefits of the pertinent BSN Essential and sub-competencies (AACN, 2008) <br>_pertaining to scholarship for evidence-based practice._ |
    | Clarity of writing | 6 | 6 | Use of standard English grammar and sentence structure. No spelling errors or typographical errors. Organized around the required components using appropriate headers. Writing should demonstrate original thought without an over-reliance on the works of others. |
    | APA format | 2 | 2 | All information taken from another source, even if summarized, must be appropriately cited in the manuscript and listed in the references using APA (6th ed.) format:<br>1. Document setup<br>2. Title and reference pages<br>3. Citations in the text and references. |
    | Total: | 100 | 100 | A quality essay will meet or exceed all of the above requirements. |

    ## Grading Rubric

    | | | | |
    | — | — | — | — |
    | Assignment Criteria | Meets Criteria | Partially Meets Criteria | Does Not Meet Criteria |
    | (Introduction – see note under requirement #4 above)<br>(8 pts) | Short introduction of selected BSN sub-competencies (AACN, 2008) pertinent to <br>_scholarship for evidence-based practice_. Rationale is well presented, and purpose fully developed. <br> <br>**7 – 8 points** | Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.<br>**5 – 6 points** | Little or very general introduction of selected BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.<br>**0 – 4 points** |
    | You Decide Reflection<br>(80 pts) | Excellent self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) supported with examples.<br>**70 – 80 points** | Basic self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) not supported with examples.<br>**59 – 69 points** | Little or very general self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Little or no reflection on pertinent BSN sub-competencies (AACN, 2008) or reflection not supported with examples.<br>**0 – 58 points** |
    | Conclusion<br>(4 pts) | Excellent understanding of pertinent BSN sub- competencies (AACN, 2008). Conclusions are well evidenced and fully developed.<br>**3 – 4 points** | Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.<br>**2 points** | Little understanding of pertinent BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.<br>**0 – 1 point** |
    | Clarity of writing<br>(6 pts) | Excellent use of standard English showing original thought with minimal reliance on the works of others. No spelling or grammar errors. Well organized with proper flow of meaning. <br>**5 – 6 points** | Some evidence of own expression and competent use of language. No more than three spelling or grammar errors. Well organized thoughts and concepts.<br>**3 – 4 points** | Language needs development or there is an over-reliance on the works of others. Four or more spelling and/or grammar errors. Poorly organized thoughts and concepts.<br>**0 – 2 points** |
    | APA format<br>(2 pts) | APA format correct with no more than 1-2 minor errors. <br>**2 points** | 3-5 errors in APA format and/or 1-2 citations are missing.<br>**1 point** | APA formatting contains multiple errors and/or several citations are missing.<br>**0 points** |
    | Total Points Possible = 100 points |

    ## | | | | — | — | | NUR4636 Course Reflection Guidelines.docx 08/21/19 | 2 |

    **## CourseReflectionNUR4636-8wks1.docx**

    Florida National University NUR4636

    Course Reflection

    Guidelines

    ## Purpose

    The purpose of this assignment is to provide the student an opportunity to reflect on selected RN-BSN competencies acquired through the NUR4636 course.

    ## Course Outcomes

    This assignment provides documentation of student ability to meet the following course outcomes:

    · The students will be able to recognize the different level of prevention and apply them in the community (ACCN Essential I, II, IV, V, VII; QSEN: safety, evidence-based practice, teamwork and collaboration, quality improvement, informatics, and patient-centered care).

    · This course will enable the student to place in practice methods of health prevention, promotion and restoration in the communities (ACCN Essential I, II, IV, V, VII; QSEN: safety, evidence-based practice, and teamwork and collaboration, quality improvement, informatics, and patient.

    · The students will be able to educate the communities about the different ways to prevent illness and promote health (ACCN Essential I, II, IV, V, VII; QSEN: safety, evidence-based practice, teamwork, and collaboration, quality improvement, informatics, and patient-centered care).

    · The student will understand the different tools available to put in place and in the hands of the communities in order to keep them healthy (ACCN Essential I, II, IV, V, VII; QSEN: safety, evidence-based practice, teamwork and collaboration, quality improvement, informatics, and patient-centered care).

    **Points**

    This assignment is worth a total of 100 points (10%).

    **Due Date**

    Submit your completed assignment under the Assignment tab by Monday at 11:59 p.m. EST of
    **Week 8** as directed.

    ## Requirements

    1. The
    **Course Reflection** is worth 100 points (10%) and will be graded on quality of self-assessment, use of citations, use of Standard English grammar, sentence structure, and overall organization based on the required components as summarized in the directions and grading criteria/rubric.

    2. Follow the directions and grading criteria closely. Any questions about your essay may be posted under the Q & A forum under the Discussions tab.

    3.
    **The length of the reflection is to be within three to six pages excluding title page and reference pages.**

    4. APA format is required with both a title page and reference page. Use the required components according
    **to APA 7th Edition formatting**.

    ## Preparing Your Reflection

    The
    _BSN Essentials_ (AACN, 2008) outline a number of healthcare policy and advocacy competencies for the BSN-prepared nurse. Reflect on the
    **NUR4636** course readings, discussion threads, and applications you have completed across this course and write a reflective essay regarding the extent to which you feel you are now prepared to
    **(choose 4):**

    1. “Demonstrate basic knowledge of healthcare policy, finance, and regulatory environments, including local, state, national, and global healthcare trends.

    2. Describe how health care is organized and financed, including the implications of business principles, such as patient and system cost factors.

    3. Compare the benefits and limitations of the major forms of reimbursement on the delivery of healthcare services.

    4. Examine legislative and regulatory processes relevant to the provision of health care.

    5. Describe state and national statutes, rules, and regulations that authorize and define professional nursing practice.

    6. Explore the impact of sociocultural, economic, legal, and political factors influencing healthcare delivery and practice.

    7. Examine the roles and responsibilities of the regulatory agencies and their effect on patient care quality, workplace safety, and the scope of nursing and other health professionals’ practice.

    8. Discuss the implications of healthcare policy on issues of access, equity, affordability, and social justice in healthcare delivery.

    9. Use an ethical framework to evaluate the impact of social policies on health care, especially for vulnerable populations.

    10. Articulate, through a nursing perspective, issues concerning healthcare delivery to decision makers within healthcare organizations and other policy arenas.

    11. Participate as a nursing professional in political processes and grassroots legislative efforts to influence healthcare policy.

    12. Advocate for consumers and the nursing profession.

    13. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations.

    14. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems.

    15. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations.

    16. Use behavioral change techniques to promote health and manage illness.

    17. Use evidence based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan.

    18. Use information and communication technologies in preventive care.

    19. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions.

    20. Assess the health, healthcare, and emergency preparedness needs of a defined population.

    21. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations.

    22. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and the prevention of illness, injury, disability, and premature death.

    23. Participate in clinical prevention and population focused interventions with attention to effectiveness, efficiency, cost-effectiveness, and equity.

    24. Advocate for social justice, including a commitment to the health of vulnerable populations and the elimination of health disparities.

    25. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease.” (pp. 20-21, 24-25).

    Reference:

    American Association of Colleges of Nursing [AACN]. (2008).
    _The essentials of baccalaureate education for professional nursing practice._ Washington, DC: Author.

    ## Directions and Grading Criteria

    | | | | |
    | — | — | — | — |
    | Category | Points | % | Description |
    | (Introduction – see note under requirement #4 above) | 8 | 8 | Introduces the purpose of the reflection and addresses BSN Essentials (AACN, 2008) pertinent to healthcare policy and advocacy. |
    | You Decide Reflection | 80 | 80 | Include a self-assessment regarding learning that you believe represents your skills, knowledge, and integrative abilities to meet the pertinent BSN Essential and sub-competencies (AACN, 2008) as a result of active learning throughout this course. Be sure to use examples from selected readings, threaded discussions, and/or applications to support your assertions to address each of the following sub-competencies:<br>(a) “Demonstrate basic knowledge of healthcare policy, finance, and regulatory environments, including local, state, national, and global healthcare trends.<br>(b) Describe how health care is organized and financed, including the implications of business principles, such as patient and system cost factors.<br>(c) Compare the benefits and limitations of the major forms of reimbursement on the delivery of healthcare services.<br>(d) Examine legislative and regulatory processes relevant to the provision of health care.<br>(e) Describe state and national statutes, rules, and regulations that authorize and define professional nursing practice.<br>(f) Explore the impact of sociocultural, economic, legal, and political factors influencing healthcare delivery and practice.<br>(g) Examine the roles and responsibilities of the regulatory agencies and their effect on patient care quality, workplace safety, and the scope of nursing and other health professionals’ practice.<br>(h) Discuss the implications of healthcare policy on issues of access, equity, affordability, and social justice in healthcare delivery.<br>(i) Use an ethical framework to evaluate the impact of social policies on health care, especially for vulnerable populations.<br>(j) Articulate, through a nursing perspective, issues concerning healthcare delivery to decision makers within healthcare organizations and other policy arenas.<br>(k) Participate as a nursing professional in political processes and grassroots legislative efforts to influence healthcare policy.<br>(l) Advocate for consumers and the nursing profession.<br>(m) Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations.<br>(n) Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems.<br>(o) Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations.<br>(p) Use behavioral change techniques to promote health and manage illness.<br>(q) Use evidence based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan.<br>(r) Use information and communication technologies in preventive care.<br>(s) Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions.<br>(t) Assess the health, healthcare, and emergency preparedness needs of a defined population.<br>(u) Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations.<br>(v) Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and the prevention of illness, injury, disability, and premature death.<br>(w) Participate in clinical prevention and population focused interventions with attention to effectiveness, efficiency, cost-effectiveness, and equity.<br>(x) Advocate for social justice, including a commitment to the health of vulnerable populations and the elimination of health disparities.<br>(y) Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease.” (pp. 20-21, 24-25). |
    | Conclusion | 4 | 4 | An effective conclusion identifies the main ideas and major conclusions from the body of your essay. Minor details are left out. Summarize the benefits of the pertinent BSN Essential and sub-competencies (AACN, 2008) <br>_pertaining to scholarship for evidence-based practice._ |
    | Clarity of writing | 6 | 6 | Use of standard English grammar and sentence structure. No spelling errors or typographical errors. Organized around the required components using appropriate headers. Writing should demonstrate original thought without an over-reliance on the works of others. |
    | APA format | 2 | 2 | All information taken from another source, even if summarized, must be appropriately cited in the manuscript and listed in the references using APA (6th ed.) format:<br>1. Document setup<br>2. Title and reference pages<br>3. Citations in the text and references. |
    | Total: | 100 | 100 | A quality essay will meet or exceed all of the above requirements. |

    ## Grading Rubric

    | | | | |
    | — | — | — | — |
    | Assignment Criteria | Meets Criteria | Partially Meets Criteria | Does Not Meet Criteria |
    | (Introduction – see note under requirement #4 above)<br>(8 pts) | Short introduction of selected BSN sub-competencies (AACN, 2008) pertinent to <br>_scholarship for evidence-based practice_. Rationale is well presented, and purpose fully developed. <br> <br>**7 – 8 points** | Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.<br>**5 – 6 points** | Little or very general introduction of selected BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.<br>**0 – 4 points** |
    | You Decide Reflection<br>(80 pts) | Excellent self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) supported with examples.<br>**70 – 80 points** | Basic self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) not supported with examples.<br>**59 – 69 points** | Little or very general self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Little or no reflection on pertinent BSN sub-competencies (AACN, 2008) or reflection not supported with examples.<br>**0 – 58 points** |
    | Conclusion<br>(4 pts) | Excellent understanding of pertinent BSN sub- competencies (AACN, 2008). Conclusions are well evidenced and fully developed.<br>**3 – 4 points** | Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.<br>**2 points** | Little understanding of pertinent BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.<br>**0 – 1 point** |
    | Clarity of writing<br>(6 pts) | Excellent use of standard English showing original thought with minimal reliance on the works of others. No spelling or grammar errors. Well organized with proper flow of meaning. <br>**5 – 6 points** | Some evidence of own expression and competent use of language. No more than three spelling or grammar errors. Well organized thoughts and concepts.<br>**3 – 4 points** | Language needs development or there is an over-reliance on the works of others. Four or more spelling and/or grammar errors. Poorly organized thoughts and concepts.<br>**0 – 2 points** |
    | APA format<br>(2 pts) | APA format correct with no more than 1-2 minor errors. <br>**2 points** | 3-5 errors in APA format and/or 1-2 citations are missing.<br>**1 point** | APA formatting contains multiple errors and/or several citations are missing.<br>**0 points** |
    | Total Points Possible = 100 points |

    ## | | | | — | — | | NUR4636 Course Reflection Guidelines.docx 08/21/19 | 2 |

  • [Solved] nursing

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  • [Solved] soap note

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    **Problem-Focused SOAP Note Format** **Demographic Data** – Age and gender (must be HIPAA compliant) **Subjective** – Chief Complaint (CC): A short statement about why they are there – History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are th…

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    **Problem-Focused SOAP Note Format**

    **Demographic Data**

    – Age and gender (must be HIPAA compliant)

    **Subjective**

    – Chief Complaint (CC): A short statement about why they are there
    – History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
    – Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
    – Family Hx: any history of CA, DM, HTN, MI, CVA?
    – Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
    – Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

    **Objective**

    – Vital Signs
    – Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

    **Assessment (the diagnosis)**

    – At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
    – Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

    **Plan**

    – Dx Plan (lab, x-ray)
    – Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
    – Pt. Education, including specific medication teaching points
    – Referral/Follow-up
    – Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

    **Reference**

    – Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

    – 2 years ago