Knee Injury Case Studies In Nursing College Admission Essay Help

Written Assignment on What’s In A Number? global history essay help

QUESTIONJUL 03, 2019

Assignment: Module 09 Written Assignment – What’s In A Number? Complete the following worksheet on ABGs: What’s in A number Student worksheet Submit your completed assignment by following the directio

Assignment: Module 09 Written Assignment – What’s In A Number?

Complete the following worksheet on ABGs: What’s in A number Student worksheet

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:

Jstudent_exampleproblem_101504

Need Help? Click here for complete drop box instructions.

Role of the nurse in end-of-life decision making extended essay help biology: extended essay help biology

QUESTIONJUL 03, 2019

Your manager asked you to prepare an article for a community newsletter for a local retirement village. The editor wants you to talk about the laws, policies, and choices surrounding end-of-life healt

Your manager asked you to prepare an article for a community newsletter for a local retirement village. The editor wants you to talk about the laws, policies, and choices surrounding end-of-life health care decisions

Preparation 

Search the Capella library and the Internet for scholarly and professional peer-reviewed articles on end-of-life care. You will need at least three articles to use as support for your work on this assessment.

Directions

Write an article of 750–1,000 words (3–4 pages) that discusses the laws, policies, and choices surrounding end-of-life health care decisions. Address the following in your article: 

Describe the role of the nurse in end-of-life decision making with patients and their families.Explain the legislation that generated end-of-life health care policies. Was the legislation an outcome of a specific medical case?Identify the primary policies regarding current health care practices related to end-of-life health care decisions. How to these policies affect treatment decisions?Explain the effect of end-of-life regulations and controls on patient outcomes. What effect does this have on the nurse-patient relationship?Describe the ethical considerations that have influenced policy decisions in regard to end-of-life decisions.

Additional Requirements

Your article should meet the following requirements:

Written communication: Written communication should be free of errors that detract from the overall message.References: Cite a minimum of three resources; a majority of these should be peer-reviewed sources. Your reference list should be appropriate to the body of literature available on this topic that has been published in the past 5 years.APA format: Resources and citations should be formatted according to current APA style and formatting.Length: 750–1,000 words or 3–4 typed, double-spaced pages, excluding title page and reference page. Use Microsoft Word to complete the assessment.Font and font size: Times New Roman, 12-point.

The Patient Protection and Affordable Care Act best essay help

QUESTIONJUL 03, 2019

#1 The Patient Protection and Affordable Care Act (PPACA) was passed into legislation in March of 2010. Identify the impact of this legislation on your nursing practice by choosing two key nursing pro

#1 The Patient Protection and Affordable Care Act (PPACA) was passed into legislation in March of 2010. Identify the impact of this legislation on your nursing practice by choosing two key nursing provisions outlined in the topic material “Nursing and Health Reform.” Discuss how these two provisions have impacted, or will impact, your current practice of nursing.

Read “Nursing and Health Reform,” located on the Wound Ostomy and Continence Nurses Society website.

URL: 

http://c.ymcdn.com/sites/www.wocn.org/resource/resmgr/AdvocacyPolicy/PPACA_and_Nursing_-_Nursing_.pdf

#2 Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team. How is this advantageous to patient outcomes?

Please include in-text citations, references must be within the last 5 – 7 years.

Ways a nurse leader can negatively affect a culture admission college essay help: admission college essay help

QUESTIONJUL 03, 2019

We know that healthcare facility and even department “culture” can significantly influence employee engagement as well as their productivity and performance. Identify and discuss three ways (behaviors

We know that healthcare facility and even department “culture” can significantly influence employee engagement as well as their productivity and performance.

Identify and discuss three ways (behaviors/attitudes) nurse leaders can positively affect culture.Identify and discuss three ways (behaviors /attitudes) a nurse leader can negatively affect a culture

Transcultural Perspectives in Mental Health Nursing “essay help” site:edu: “essay help” site:edu

QUESTIONJUL 02, 2019

Transcultural Perspectives in Mental Health Nursing Read chapter 10 of the class textbook attached.  Once done, develop and post an analysis of the following cases; Case 1 : 1. Stephane, a 15-year-old

Transcultural Perspectives in Mental Health Nursing

Read chapter 10 of the class textbook attached. 

Once done, develop and post an analysis of the following cases;

Case 1 :

1. Stephane, a 15-year-old Haitian refugee who is living at a center for children of refugees has a severe cough and fever. She is curled up in a corner of the community room wrapped in a towel. She looks like she has been crying.

How can the nurse ensure culturally competent care?

List three priorities for the nurse regarding the cultural values, beliefs, and possible practices that Stephane may have.

Case 2:

2. Jacob is an 87-year-old with bipolar I disorder. He came to the United States from Poland in 1937. He was institutionalized for 2 years in a large mental health facility; currently, he lives in a community mental health center (transitional housing).

a. Identify three questions that would be important to ask Jacob on your first encounter.

b. What is the main health issue for Jacob?

What structures are needed in a community to ensure that Jacob will get the care he needs?

APA format word document, Arial 12 

For grading and in Turnitin to verify originality. 

A minimum of 3 evidence-based references besides the class textbook must be used. 

Textbook title

Transcultural   Concepts in Nursing Care

Author

Joyceen   S. Boyle; Margaret M. Andrews

A minimum of 700 words is required. Please make sure to follow the instructions as given.

Due Friday July 5th midnight.

Discussion on Envisioning Recovery college essay help near me

QUESTIONJUL 02, 2019

I need 150 words for each question and individual reference for each. Please, No Plagiarized work. MODULE 1 Q1 Identify a historical change or event that had significant impact on the development of n

I need 150 words for each question and individual reference for each. Please, No Plagiarized work.

MODULE 1

Q1

Identify a historical change or event that had significant impact on the development of nursing theory. Discuss the effect of the change/event on nursing from that point forward, the contribution(s) to nursing that resulted, and how it relates now to successfully preparing the DNP for practice.

Q2

Provide one definition and an outline of the structure of theory. Debate the purpose of theory and your perspective on the role theory or the lack of theory in today’s nursing practice environment. What purpose (if any) does theory contribute to your area of nursing practice?

MODULE 2

Q1

Define the process of theory building. Discuss the differences in approach based on inductive versus deductive reasoning. Describe how you would build and test theory in your practice area.

Q2

Select a nursing model or theory described in your textbook. What are the key concepts and components of the example you selected, and how are they defined? Create an example describing the application to an area of nursing practice.

MODULE 3

Q1

Compare and contrast a minimum of two middle range theories and discuss potential applications in your specific area of nursing practice.

Q2

Conduct a literature search in the Cumulative Index of Nursing and Allied Health Literature (CINAHL) using the terms middle range theory, mid-range theory, and nursing. Select one of the articles where the development of the middle range theory is the major focus of the paper. Share the article citation and describe how the theory was developed.

MODULE 4

Q1

Describe a recent or current ethical issue you have faced in nursing practice or which has attained national attention. Discuss the application of ethical theories or principles to the issue. Support the application with sound reasoning.

Q2

Consider yourself in a role in which you are accountable for allocation of scarce health care resources for a given situation. Discuss how ethical principles, virtues, and values affect your decision making. Describe your process for ethical decision making. How might a resolution cause conflicts between personal values and beliefs and the perspective of the community or organization?

MODULE 5

Q1

Learning theories have implications for advanced practice nurses outside the classroom. Share an example describing the application of learning theory or theories to develop a program targeting change to a specific organizational issue, patient lifestyle, or specific unhealthy behaviors.

Q2

Health behavior change theories suggest behavior change as a “process,” not an “event.” How can you put this into action for developing an intervention for practice or research? Discuss how you would apply this in planning your DNP project.

MODULE 6

Q1

Discuss “Envisioning Recovery” as an overarching framework for practice development and focus for all health care treatment.

Q2

How can the knowledge of economic theory be utilized by advanced practice nurses? How can economic theory be applied in analysis of interventions?

MODULE 7

Q1

How can the DNP-prepared nurse apply the concepts of a complex adaptive system to individual patient care? Provide examples.

Q2

Research change theories in scholarly literature and on the Internet. Develop a scenario and describe application of a change theory from the perspective of an advanced practice nurse leader.

MODULE 8

Q1

Which science-based theories do you think are the most useful to advanced practice nurses, and why?

Q2

Explore various science-based theories. Select two theories to describe to your peers. How is each of these theories relevant to application for a DNP-prepared nurse.

Health History and Medical Information persuasive essay help: persuasive essay help

QUESTIONAUG 18, 2019

Evaluate the Health History and Medical Information for Mr. C., presented below. Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay as

Evaluate the Health History and Medical Information for Mr. C., presented below.

Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.

Health History and Medical Information

Health History

Mr. C., a 32-year-old single male, is seeking information at the outpatient center regarding possible bariatric surgery for his obesity. He currently works at a catalog telephone center. He reports that he has always been heavy, even as a small child, gaining approximately 100 pounds in the last 2-3 years. Previous medical evaluations have not indicated any metabolic diseases, but he says he has sleep apnea and high blood pressure, which he tries to control by restricting dietary sodium. Mr. C. reports increasing shortness of breath with activity, swollen ankles, and pruritus over the last 6 months.

Objective Data:

Height: 68 inches; weight 134.5 kgBP: 172/98, HR 88, RR 263+ pitting edema bilateral feet and anklesFasting blood glucose: 146 mg/dLTotal cholesterol: 250 mg/dLTriglycerides: 312 mg/dLHDL: 30 mg/dLSerum creatinine 1.8 mg/dLBUN 32 mg/dl

Critical Thinking Essay 

In 750-1,000 words, critically evaluate Mr. C.’s potential diagnosis and intervention(s). Include the following:

Describe the clinical manifestations present in Mr. C.Describe the potential health risks for obesity that are of concern for Mr. C. Discuss whether bariatric surgery is an appropriate intervention.Assess each of Mr. C.’s functional health patterns using the information given. Discuss at least five actual or potential problems can you identify from the functional health patterns and provide the rationale for each. (Functional health patterns include health-perception, health-management, nutritional, metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception/self-concept, role-relationship, sexuality/reproductive, coping-stress tolerance.)Explain the staging of end-stage renal disease (ESRD) and contributing factors to consider.Consider ESRD prevention and health promotion opportunities. Describe what type of patient education should be provided to Mr. C. for prevention of future events, health restoration, and avoidance of deterioration of renal status.Explain the type of resources available for ESRD patients for nonacute care and the type of multidisciplinary approach that would be beneficial for these patients. Consider aspects such as devices, transportation, living conditions, return-to-employment issues.

You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

Importance of the IOM “Future of Nursing” report essay help site:edu

QUESTIONJUL 02, 2019

In a formal paper of 1,000-1,250 words you will discuss the work of the Robert Wood Johnson Foundation Committee Initiative on the Future of Nursing and the Institute of Medicine research that led to

In a formal paper of 1,000-1,250 words you will discuss the work of the Robert Wood Johnson Foundation Committee Initiative on the Future of Nursing and the Institute of Medicine research that led to the IOM report, “Future of Nursing: Leading Change, Advancing Health.” Identify the importance of the IOM “Future of Nursing” report related to nursing practice, nursing education and nursing workforce development. What is the role of state-based action coalitions and how do they advance goals of the Future of Nursing: Campaign for Action?

Explore the Campaign for Action webpage (you may need to research your state’s website independently if it is not active on this site): http://campaignforaction.org/states

Review your state’s progress report by locating your state and clicking on one of the six progress icons for: education, leadership, practice, interpersonal collaboration, diversity, and data. You can also download a full progress report for your state by clicking on the box located at the bottom of the webpage.

In a paper of 1,000-1,250 words:

1. Discuss the work of the Robert Wood Johnson Foundation Committee Initiative on the Future of Nursing and the Institute of Medicine research that led to the IOM report, “Future of Nursing: Leading Change, Advancing Health.”

2. Identify the importance of the IOM “Future of Nursing” report related to nursing practice, nursing education and nursing workforce development.

3. What is the role of state-based action coalitions and how do they advance goals of the Future of Nursing: Campaign for Action?

Summarize two initiatives spearheaded by your state’s action coalition. In what ways do these initiatives advance the nursing profession? What barriers to advancement currently exist in your state? How can nursing advocates in your state overcome these barriers?

Please include a strong thesis statement, in-text citations with all factual information, a minimum of three scholarly in-text citations and references are required for this assignment. References must be within the last 5 -7 years.

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

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

What causes the amount of sputum to increase? melbourne essay help

QUESTIONJUL 02, 2019

Respond on two different days who selected a different scenario than you, in one or more of the following ways: Share insights on how the factor you selected impacts the disorder your colleague identi

Respond on two different days who selected a different scenario than you, in one or more of the following ways:

Share insights on how the factor you selected impacts the disorder your colleague identified.

Ask a probing question regarding the disorder that your colleague identified.

Suggest an alternative disorder for the scenario your colleague selected.

                                                                Main Post

Scenario 3:

Maria is a 36-year-old who presents for evaluation of a cough. She is normally a healthy young lady with no significant medical history. She takes no medications and does not smoke. She reports that she was in her usual state of good health until approximately 3 weeks ago when she developed a “really bad cold.” The cold is characterized by a profound, deep, mucus-producing cough. She denies any rhinorrhea or rhinitis—the primary problem is the cough. She develops these coughing fits that are prolonged, very deep, and productive of a lot of green sputum. She hasn’t had any fever but does have a scratchy throat. Maria has tried over-the-counter cough medicines but has not had much relief. The cough keeps her awake at night and sometimes gets so bad that she gags and dry heaves.

Acute Cough

     Coughs are the body’s way of clearing airways via forceful expiration.  Inflammation, inhaled particles, accumulated mucus, or foreign bodies stimulate a cough reflex by irritant receptor stimulation in the airway.  An acute cough is classified as lasting 2-3 weeks, and chronic cough is greater than three weeks in a non-smoker. Frequent cough causes are allergic rhinitis, upper respiratory infections, pneumonia, aspiration, pulmonary embolus, and congestive heart failure.  Due to the above-listed scenario, this cough would be diagnosed as acute cough due to timeframe, cough characteristics, and patient history (Huether & McCance, 2019).

Green Sputum

     Sputum contains immune cells and white blood cells from the lower respiratory tract that protect the airway from infections.  Sputum can be clear or colored.  Color sputum may be yellow, white, green, red or blood-tinged, or pink.  Neutrophils are white blood cells that can take on a green color.  This color sputum can be indicative of bacterial infections of the lower respiratory tract.  Pneumonia and cystic fibrosis can produce this color sputum.  To indeed rule out something benign, a sputum culture would need to be obtained and tested (Verywell Health, 2019).  At three weeks in, it would likely be premature to order cultures with limited symptoms. 

Treatment

     Due to the timeframe of cough and only accompanying symptom being green sputum, as a practitioner, I would prescribe an expectorant and schedule a follow up if symptoms persist or worsen.  Teaching should include that adverse effects of expectorants might be GI upset, headache, drowsiness, and dizziness.  Advise patient that expectorants are designed to be short-term (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Additional home treat to loosen secretions would be a humidifier, staying adequately hydrated and warm salt water gargles if sore throat should appear (Barkley, 2018).

Patient Factors- Behavior and Age

          Maria is an otherwise, healthy 36-year-old female.  Due to her age and symptom status, Maria would be treated conservatively.  Maria is a non-smoker and takes no prescribed medications.  Further investigation would be required if she was a smoker, currently on prescriptions medications, had current disease processes that may factor into the treatment plan.

References

Arcangelo,  V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.).  (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams  & Wilkins.

Barkley, T.  (2018).  Adult-gerontology primary care nurse practitioner.  West Hollywood, CA:  Barkley & Associates.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.

Verywell Health.  (2019). What causes the amount of sputum to increase?  Retrieved from https://www.verywellhealth.com/what-is-sputum-2249192

What are the weakness and strengths of this community? free college essay help: free college essay help

QUESTIONJUL 02, 2019

Discuss aspects of a health concern not being addressed despite the efforts of services and partnerships involved and describe the ultimate outcome(s) or goal(s) from Healthy People 2020 relating to

Discuss aspects of a health concern not being addressed despite the efforts of services and partnerships involved and describe the ultimate outcome(s) or goal(s) from Healthy People 2020 relating to  Skin breakdown in the elderly 

Answering the following questions may assist in data interpretation:

What similarities are apparent between the data that were gathered and the data that were generated?What differences are apparent between the data that were gathered and the data that were generated?What are the weakness and strengths of this community?In what areas is improvement needed in this community?

The assignment should be written in an APA-formatted essay. The essay should be betwee

Personal health behaviors- positive and negative. a level english language essay help

irst observe your personal health behaviors- positive and negative. Lack of Sleep, Junk food, Stress about grade, and I excercise 3-4 times a week Analyze and assess how these behaviors influence c

First observe your personal health behaviors- positive and negative.  

Lack of Sleep, Junk food, Stress about grade, and I excercise 3-4 times a week

Analyze and assess how these behaviors influence certain risk factors for unhealthy conditions.  Discuss whether they are helping mitigate risk or are they increasing risk.  Provide a detailed account that demonstrates significant critical thinking.

Write a 3-4 page paper discussing your behavioral  risks.  Identify prevention techniques you can implement to mitigate health risks.  What are specific habits you should adopt or change to improve your chance for success?  What specific strategies (ways to increase knowledge, skill, or attitude) can you use to help with habit change or adoption?  

All written submissions should reflect professionalism in grammar, spelling, writing style/format (one-inch margins, double spaced, typed in 12-point Times New Roman font), include APA 6th citations when appropriate, an appropriate title page, and be uploaded as .doc or .docx documents.

Social Determinants of Health topic area custom essay help: custom essay help

QUESTIONJUL 02, 2019

Follow the link provided below to the Healthy People 2020 Social Determinants of Health topic area, navigate around, and then comment on some general responsibilities, objectives, etc. Reflect on how

Follow the link provided below to the Healthy People 2020 Social Determinants of Health topic area, navigate around, and then comment on some general responsibilities, objectives, etc.  Reflect on how socioeconomics and culture can be social determinants that affect one’s health.  How do social determinants of health affect health disparities?

Stabilization for Trauma and Dissociation mba essay help: mba essay help

QUESTIONJUL 01, 2019

Practicum – Week 5 Journal Entry                                       Learning Objectives Students will: · Develop diagnoses for clients receiving psychotherapy* · Evaluate the efficacy of therapeuti

Practicum – Week 5 Journal Entry

                                      Learning Objectives

Students will:

· Develop diagnoses for clients receiving psychotherapy*

· Evaluate the efficacy of therapeutic approaches for clients*

· Analyze legal and ethical implications of counseling clients with psychiatric 

  disorders*

                                             The Assignment 

Select a client whom you observed or counseled that suffers from a disorder related to trauma. Then, address the following in your Practicum Journal:

· Describe the client (without violating HIPAA regulations) and identify any 

  pertinent history or medical information, including prescribed medications.

· Using the DSM-5, explain and justify your diagnosis for this client.

· Explain whether any of the therapeutic approaches in this week’s Learning 

 Resources would be effective with this client. Include expected outcomes based  

 on these therapeutic approaches. Support your approach with evidence-based  

 literature.

· Explain any legal and/or ethical implications related to counseling this client.

                                                  Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

Chapter      13, “Stabilization for Trauma and Dissociation” (pp. 469–508)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Required Media

Laureate Education (Producer). (2012a). Academic year in residence: Thompson family case study [Multimedia file]. Baltimore, MD: Author. 

Ochberg, F. (2012). Psychotherapy for chronic PTSD [Video file]. Mill Valley, CA: Psychotherapy.net.

· NOTE: PLEASE SEE AND PAY ATTENTION TO THE ATTACHED Practicum Journal  

 Template AND JOURNAL SAMPLE (TIME LOG & JOURNAL ENTRIES) FOR WRITING 

 THIS ASSIGNMENT…..ALSO FOR THE TIME LOG AND JOURNAL ENTRIES, JUST 

 MAKE UP A REASONABLE INFORMATION AND CLIENT INFORMATION IN MENTAL 

 HEALTH NURSING.

Role of professional nurses in policy evaluation. devry tutorcom essay help

QUESTIONJUL 01, 2019

In the Module 4 Discussion, you considered how professional nurses can become involved in policy-making. A critical component of any policy design is evaluation of the results. How comfortable are you

In the Module 4 Discussion, you considered how professional nurses can become involved in policy-making. A critical component of any policy design is evaluation of the results. How comfortable are you with the thought of becoming involved with such matters?

Some nurses may be hesitant to get involved with policy evaluation. The preference may be to focus on the care and well-being of their patients; some nurses may feel ill-equipped to enter the realm of policy and political activities. However, as you have examined previously, who better to advocate for patients and effective programs and polices than nurses? Already patient advocates in interactions with doctors and leadership, why not with government and regulatory agencies?

In this Discussion, you will reflect on the role of professional nurses in policy evaluation.

To Prepare:

In the Module 4 Discussion, you considered how professional nurses can become involved in policy-making.Review the Resources and reflect on the role of professional nurses in policy evaluation.

Post an explanation of at least two opportunities that currently exist for RNs and APRNs to actively participate in policy review. Explain some of the challenges that these opportunities may present and describe how you might overcome these challenges. Finally, recommend two strategies you might make to better advocate for or communicate the existence of these opportunities. Be specific and provide examples.

4 to 4 References

Review on the Work Environment Assessment my essay help uk: my essay help uk

QUESTIONJUL 01, 2019

To Prepare: Review the Resources and examine the Clark Healthy Workplace Inventory, found on page 20 of Clark (2015). Review the Work Environment Assessment Template. Select and review one or more

To Prepare:

Review the Resources and examine the Clark Healthy Workplace Inventory, found on page 20 of Clark (2015).Review the Work Environment Assessment Template.Select and review one or more of the following articles found in the Resources:Clark, Olender, Cardoni, and Kenski (2011)Clark (2018)Clark (2015)Griffin and Clark (2014)

The Assignment (3-6 pages total):

Part 1: Work Environment Assessment (1-2 pages)

Review the Work Environment Assessment Template you completed for this Module’s Discussion.Describe the results of the Work Environment Assessment you completed on your workplace.Identify two things that surprised you about the results and one idea you believed prior to conducting the Assessment that was confirmed.Explain what the results of the Assessment suggest about the health and civility of your workplace.

Part 2: Reviewing the Literature (1-2 pages)

Briefly describe the theory or concept presented in the article(s) you selected.Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment.Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples.

Part 3: Evidence-Based Strategies to Create High-Performance Interprofessional Teams (1–2 pages)

Recommend at least two strategies, supported in the literature, that can be implemented to address any shortcomings revealed in your Work Environment Assessment.Recommend at least two strategies that can be implemented to bolster successful practices revealed in your Work Environment Assessment.

Planning Phase of the Nursing Process ccusa autobiographical essay help

QUESTIONJUL 01, 2019

1. Mrs. Elle, 80 years of age, is a female patient who is diagnosed with end-stage cancer of the small intestine. She is currently receiving comfort measures only in hospice. She has gangrene of her r

1. Mrs. Elle, 80 years of age, is a female patient who is diagnosed with end-stage cancer of the small intestine. She is currently receiving comfort measures only in hospice. She has gangrene of her right foot and has a history of diabetes controlled with oral agents. She is confused and the physician has determined that she is unable to make her own informed decisions. The hospice nurse, not realizing that the weekly order for CBC and renal profile had been discontinued, obtained the labs and sent them to the nearby laboratory for processing. The abnormal lab results obtained later that day revealed that the patient needed a blood transfusion. The hospice nurse updated the patient’s medical power of attorney who was distressed at the report. The patient’s wishes were to die peacefully and to not have to undergo an amputation of her right foot. But if the patient receives the blood transfusion, she may live long enough to need the amputation. The patient’s physician had previously informed the medical power of attorney that the patient would most likely not be able to survive the amputation. The patient’s medical power of attorney had made the request to cease all labs so that the patient would receive comfort measures until she died. The patient has no complaint of shortness of breath or discomfort. 

What ethical dilemma exists?Who are the stakeholders and what gains or losses do each have?What strategies should the hospice nurse take to resolve the ethical dilemma?

2. The nurse receives a 12-year-old girl from the operating room after an emergent appendectomy due to ruptured appendix. Upon arrival to the postanesthesia care unit, the patient is drowsy, but arousable to voice; she was extubated in the operating room and is receiving oxygen by facemask at 40%. She has two peripheral IVs in her left arm that are infusing Lactated Ringers solution at 100 mL/hr. A nasogastric tube is attached to low constant suction, and a small amount of aspirate is noted. She has a urinary catheter that is draining clear, yellow urine. Her abdominal dressing is dry and intact. Upon arousal, she complains of abdominal pain.  

What NANDA-approved nursing diagnoses may be relevant to this patient?Once the nursing diagnoses are determined, what steps does the nurse take to complete the Planning Phase of the Nursing Process?What is the difference between nursing diagnoses and collaborative problems?

Leadership and Professional Development course medical school essay help

QUESTIONJUL 01, 2019

After reading The Essentials of Baccalaureate Education for Professional Nursing Practice (http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf) and reviewing the Leadership Qualities Ass

After reading The Essentials of Baccalaureate Education for Professional Nursing Practice (http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf) and reviewing the Leadership Qualities Assessment results from Leadership, Management, and Professional Development course, write a 3-4 Professional Practice Plan which details the following:

The areas in which you feel confident.The areas you know you need more knowledge/skills practice.Which ATI Skills and Review modules you will review to increase your knowledge.Which ATI Practice Assessments you will complete improving your critical Thinking/analysis and practice skills.Minimum of five practice goals you set for yourself to achieve during the clinical component of this course

The Essentials of Baccalaureate Education essay help: essay help

QUESTIONJUL 11, 2019

After reading The Essentials of Baccalaureate Education for Professional Nursing Practice (http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf) and reviewing the Leadership Qualities Ass

After reading The Essentials of Baccalaureate Education for Professional Nursing Practice (http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf) and reviewing the Leadership Qualities Assessment results from Leadership, Management, and Professional Development course, write a 3-4 Professional Practice Plan which details the following:

The areas in which you feel confident.The areas you know you need more knowledge/skills practice.Which ATI Skills and Review modules you will review to increase your knowledge.Which ATI Practice Assessments you will complete improving your critical Thinking/analysis and practice skills.Minimum of five practice  smart goals you set for yourself to achieve during the clinical component of this course.

Ways nurse leaders can positively affect culture. personal essay help

QUESTIONJUL 01, 2019

We know that healthcare facility and even department “culture” can significantly influence employee engagement as well as their productivity and performance. Identify and discuss three ways (behaviors

We know that healthcare facility and even department “culture” can significantly influence employee engagement as well as their productivity and performance.

Identify and discuss three ways (behaviors/attitudes) nurse leaders can positively affect culture.Identify and discuss three ways (behaviors /attitudes) a nurse leader can negatively affect a culture

Assignment on What Would You Do Differently essay help services: essay help services

QUESTIONJUL 01, 2019

Written Assignment – What Would You Do Differently Points/Grading Rubric: Criteria Points Discuss what lead to errors in the video you watched for this assignment Discuss what lead to errors in the ar

Written Assignment – What Would You Do Differently

Points/Grading Rubric:

Criteria

Points

Discuss what lead to errors in the video you watched for this assignment

Discuss what lead to errors in the article you read for this assignment

Reflect on how you will practice nursing differently based upon what you have learned. 

Grammar, APA and Organization

Your written assignment this week is to reflect on a video and an article. In each tragic case discuss what lead to error in the system. In a paragraph or two reflect on how you might practice differently based on what you have learned in this module.

Video Example

Article Example

Radiology Emergency Surgical Dental Pharmacy law essay help: law essay help

QUESTIONJUN 30, 2019

Select at least three (3) of the following information systems: Radiology Emergency Surgical Dental PharmacyCreate a 10- to 15-slide Microsoft® PowerPoint® presentation in which you define and des

Select at least three (3) of the following information systems:

RadiologyEmergencySurgicalDentalPharmacy

Create a 10- to 15-slide Microsoft® PowerPoint® presentation in which you define and describe each information system, including a discussion of its purpose and use.

Write a 1-page handout to accompany your presentation, and include speaker notes within the presentation. This should be a high level overview of the presentation.

Cite at least two (2) outside sources according to APA guidelines. For additional information on how to properly cite your sources, access the Reference and Citation Generator in the Center for Writing Excellence.

Submit your assignment via a Microsoft Word document.

Comprehensive Client Family Assessment history essay help

Learning Objectives Students will:  •Assess clients presenting for psychotherapy • Develop genograms for clients presenting for psychotherapy                                                           

Learning Objectives Students will:  •Assess clients presenting for psychotherapy • Develop genograms for clients presenting for psychotherapy 

                                                                                                                                                                                  To prepare: • Select a client whom you have observed or counseled at your practicum site. • Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.  

The Assignment 

Part 1: Comprehensive Client Family Assessment With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations):  •Demographic information  •Presenting problem  •History or present illness  •Past psychiatric history   •Medical history • Substance use history  •Developmental history  •Family psychiatric history   •Psychosocial history  •History of abuse/trauma  •Review of systems   •Physical assessment  •Mental status exam  •Differential diagnosis  •Case formulation  •Treatment plan 

Part 2: Family Genogram Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents). 

Required Readings: 

(1) Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

ATTACHED WITH THIS HOMEWORK IS A SAMPLE OF THIS ASSIGNMENT AND REMEMBER IT HAS TWO PARTS.

Benchmark Capstone Change Proposal writing essay help: writing essay help

QUESTIONJUL 22, 2019

Benchmark Capstone Change Proposal In  this assignment, students will pull together the change proposal project  components they have been working on throughout the course to create a  proposal inclus

Benchmark Capstone Change Proposal

In  this assignment, students will pull together the change proposal project  components they have been working on throughout the course to create a  proposal inclusive of sections for each content focus area in the  course. At the conclusion of this project, the student will be able to  apply evidence-based research steps and processes required as the  foundation to address a clinically oriented problem or issue in future  practice.

Students will develop a 1,250-1,500 word (word count does not include references)  paper that includes the following information as it applies to the  problem, issue, suggestion, initiative, or educational need profiled in  the capstone change proposal:

BackgroundProblem statementPurpose of the change proposalPICOTLiterature search strategy employedEvaluation of the literatureApplicable change or nursing theory utilizedProposed implementation plan with outcome measuresIdentification of potential barriers to plan implementation, and a discussion of how these could be overcomeAppendix section, if tables, graphs, surveys, educational materials, etc. are created (I am not sure what an appendix section is but if you know please add something. I do know it should come AFTER the references)

All reference resources are attached. Please use the Literature Review paper as just a REFERENCE.

Prepare this assignment according to APA Style Guidelines. An abstract is not required.

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

Protocol driven palliative care consultation essay help from professional writers

Hi, I need the attached table to be filled out based on the article i provided. PLEASE answer all questions very carefully, be concise and make sure your answer perfectly cover the question. I had pro

Protocol driven palliative care consultation: Outcomes of the ENABLE CHF-PC pilot study Rachel Wells, MSN, RN a*, Deborah Ejem, Ph.D. a, J. Nicholas Dionne-Odom, Ph.D., RN a, Gulcan Bagcivan, Ph.D., RN a, Konda Keebler, MS, RN a, Jennifer Frost, MSN, RN a, Andres Azuero, Ph.D. a, Alan Kono, MD b, Keith M. Swetz, MD, MA c,d , Marie Bakitas, DNSc a,c aSchool of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USAbCardiology, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine at Dartmouth, Heart and Vascular Center DHMC, 1 Medical Center Drive, Lebanon, NH 03756, USAcDepartment of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB Center for Palliative & Supportive Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-0012, USA dBirmingham Veterans Affairs Medical Center, Birmingham, AL, USA ARTICLE INFO Article history:

Received 19 January 2018 Received in revised form 12 June 2018 Accepted 14 June 2018 Available online 22 August 2018 ABSTRACT Background:Little has been reported about protocol-driven outpatient palliative care consultation (OPCC) for advanced heart failure (HF).

Objectives:To describe evaluation practices and treatment recommendations made during protocol-driven OPCCs for advanced HF.

Methods:We performed content analysis of OPCCs completed as part of ENABLE CHF-PC, an early palliative care HF intervention, conducted at sites in the Northeast and Southeast. T-tests, Fisher’s exact, and Chi- square tests were used to evaluate sociodemographic, outcome measures, and site content differences.

Results:Of 61 ENABLE CHF-PC participants, 39 (64%) had an OPCC (Northeast,n= 27; Southeast,n= 12). Social and medical history assessed most were close relationships (n= 35, 90%), family support (n= 33, 85%), advance directive status (n= 33, 85%), functional status (n= 30, 77%); and symptoms were mood (n= 35, 90%), breathlessness (n= 28, 72%), and chest pain (n= 24, 62%). Treatment recommendations focused on care coordination (n= 13, 33%) and specialty referrals (n= 12, 31%). Between-site OPCC differences included assessment of family support (Northeast vs. Southeast: 100% vs. 50%), code status (96% vs. 58%), goals of care discussions (89% vs. 41.7%), and prognosis understanding (85% vs. 33%).

Conclusion:OPCCs for HF focused on evaluating medical and social history, along with goals of care and code status discussions. Symptom evaluation commonly included mood disorders, pain, dyspnea, and fatigue.

Notable regional differences were found in topics evaluated and OPCC completion rates.

© 2018 Elsevier Inc. All rights reserved. Keywords:

Outpatient supportive care Heart failure Content analysis Introduction Advanced heart failure (HF) as defined by New York Heart Associ- ation (NYHA) Stage III-IV 1or American College of Cardiology/Ameri- can Heart Association (ACC/AHA) Class C-D 2is characterized by high symptom burden, complex treatments, poor quality of life, and unpredictable trajectory. 3HF affects 6.5 million American adults, with a 46% increase anticipated over the next 15 years. 4Whilefive- year survival after HF diagnosis has improved from 54% to 61%, HF remains a top cause of hospitalization and mortality. 5 Given this burden, there has been a call for collaboration between palliative care and cardiology in HF management. 6,7 Recent guidelines by cardiovascular professional organizations have called for palliative care integration into longitudinal HF care including access to pallia- tive care in the ambulatory setting. 8Palliative care (PC) focuses on relief of suffering through symptom and pain management, establish- ing goals of care, and holistic care coordination. 9Despite evidence supporting its benefits 10,11 PC initiation often occurs late, 12if at all, 13 with consultations occurring primarily during hospitalizations. While rates of inpatient palliative care use for HF vary from 2% to 33%, 14 16 there is limited evidence describing the frequency of outpatient PC for HF. Additionally, literature describing the features of these outpa- tient palliative care visits is sparse, especially when symptoms are not the primary motivation for consultation. Prior studies were Abbreviations:OPCC, outpatient palliative care consultation; HF, heart failure; ENABLE CHF-PC, Educate, Nurture, Advise Before Life Ends: Comprehensive Heartcare for Patients and Caregivers single-arm pilot study; PC, palliative care * Corresponding author.

E-mail address:[email protected](R. Wells).

https://doi.org/10.1016/j.hrtlng.2018.06.012 0147-9563 © 2018 Elsevier Inc. All rights reserved. Heart & Lung 47 (2018) 533 538 Contents lists available atScienceDirect Heart & Lung journal homepage:www.heartandlung.com frequently retrospective using a single site, 10,17 focusing on feasibil- ity, model development, or patient-reported outcomes of symptom- driven consultation. Other studies focused on patient and provider perspectives concerning the need for outpatient palliative care con- sultations for HF patients. 18,19 The study by Evangelista 10 demon- strated a reduction in symptom burden and depression and improvement in quality of life in HF patients receiving outpatient pal- liative care services. Rogers et al 20 found similar outcomes in their randomized controlled trial. Studies by Bekelman et al., 17 Smith et al., 21Rabow et al., 22and Gandesbery et al. 23found outpatient palli- ative care consultation services to be feasible and acceptable to HF patients. Additionally, recent reviews of palliative care identify unad- dressed palliative care needs especially concerning symptom burden in the HF population. 24 Furthermore, this care gap is particularly prevalent in diverse, underserved populations. 25To our knowledge, no studies to date have explored protocol- or trigger-driven outpa- tient palliative care consultations for HF patients. Given limited data, we sought to describe the assessments and treatment recommenda- tions made in protocol-driven OPCCs for advanced HF patients using PC clinic notes from an early PC pilot study. 26Secondary outcomes included comparison of baseline measures and demographic infor- mation between those who did and did not complete OPCC and regional variation in OPCC content. Methods Study design From April 1, 2014 to December 31, 2015, we enrolled 61 patients diagnosed with advanced HF and 48 family caregivers in a two-site, single-arm pilot study to determine the feasibility of ENABLE CHF-PC ( Educate, Nurture, Before Life Ends: Comprehen- sive Heart care for Patients and Caregivers), an intervention to deliver early concurrent PC. 26 Palliative care services aim to reduce distress and burden and improve quality of life. 27 Early palliative care occurs closer to the point of diagnosis and earlier in the disease trajectory at the same time as the patient receives traditional disease-related care. Both sites were cardiology clinics at larger academic medical centers. Darthmouth-Hitchcock Medi- cal Center (DHMC) in Lebanon, NH has a long-standing, embedded palliative care clinic located in close physical proximity to the car- diology clinic whereas the University of Alabama at Birmingham (UAB) Health System in Birmingham, AL has two palliative care clinic locations without an embedded care model. The study was approved by the Institutional Review Boards of UAB and DHMC.

All patient and caregiver participants provided written informed consent. Fig. 1.Parent ENABLE: CHF-PC study schema. 534R. Wells et al. / Heart & Lung 47 (2018) 533 538 Sample Patients with advanced HF were identified and approached by study coordinators and recruitment staff. Patients were eligible if they presented with advanced HF as defined by NYHA Class III/IV or AHA/ACC Stage C/D HF. In addition to an advanced HF diagnosis, patient eligibility criteria were: (1) age 50, (2) English-speaking, and (3) access to telephone service (land-based or reliable cellular).

Patients were ineligible if they had prior heart transplant or mechani- cal circulatory support implantation, non-correctable hearing loss, dementia or significant confusion (Callahan score of 3), 28 and a DSM-IV Axis I diagnosis or active substance use disorder. Family care- givers approached by study staff were identified by the eligible patients as“someone who knows you well and is involved with your medical care.”Trained community-based recruitment staff reviewed informed consent and study documents with eligible patients prior to study enrollment at local cardiology clinics. ENABLE: CHF-PC intervention The ENABLE CHF-PC intervention schema is provided inFig. 1. The parent ENABLE CHF-PC study was a single arm, two-site feasibility study exploring recruitment and retention of rural, racially-diverse patient-caregiver dyads and longitudinal patient-reported outcomes of symptom burden, depression/anxiety, quality of life, and caregiver burden. 26Main results of the parent study have been described previ- ously. 26The parent study ENABLE CHF-PC intervention included an in-person OPCC and 6 weekly telephone sessions to review theChart- ing Your Coursecurriculum. Implemented by nurses with specialty training in PC, the curriculum (based on the Chronic Care Model) 29 promoted patient self-management and decision support to encour- age, activate, and empower patients about their health outcomes. In addition to the weekly telephone sessions, patients were sched- uled for a single, in-person outpatient palliative care consultation at the palliative care outpatient clinic either at UAB or DHMC. This OPCC, the focus of this study, is highlighted by a box in the study schema (Fig. 1). With each ENABLE CHF-PC triggered OPCC, both sites followed site-specific standard practice for initial consultation using an established palliative care service. Modeled from the National Con- sensus Project guidelines, 30 a comprehensive outpatient palliative care consultation includes discussions or evaluations of illness under- standing, decision-making preferences, goals of care, physical/psy- cho-emotional symptoms, spirituality, advance care planning, and care coordination. Patients received standard heart failure-related medical care throughout the intervention process. Any additional PC visits were initiated by patient or clinician (PC or HF) request. Data collection Participants completed baseline questionnaires as part of the parent study26prior to the OPCC including: demographics, chronic illness care (Patient Assessment of Chronic Illness Care), 31 global health (Patient- Reported Outcomes Measurement System, Global Health Scale, Short Form version 1.0), 32anxiety/depression (Hospital Anxiety and Depression Scale), 33 and patient-reported healthcare utilization (investigator- designed survey of recent hospital days). Initial OPCC notes in the elec- tronic health record were printed and de-identified. OPCC content was assessed using modifications to a previously established coding scheme. 17 Data analysis Using an a priori coding scheme based on work by Bekelman et al. 17, we assessed the OPCC notes for evaluation of general health, social his- tory, and symptoms, general provider- and symptom-specifictreatment recommendations, and advance care planning recommendations. The previously established coding scheme 17was developed through retro- spective review of the content of palliative care clinic notes with a focus on provider-addressed topics and treatment actions. The coding scheme by Bekelman et al. was divided into evaluation, treatment, advance care planning, and care coordination categories. All staff (R.W., K.K., J.F.) were trained prior to the study by coding 2 non-study outpatient palliative care clinic notes and noting any cod- ing discrepancies. Discrepancies were adjudicated by the parent study principal investigator (M.B.), a palliative care expert, until con- sensus was reached. For auditing, six random OPCCs notes (two from each coder) were coded by an external coder (G.B.). Agreement per- centages were calculated for 72 total codes and ranged 0.5 1.0, with all disagreement being re-discussed until consensus was reached.

Descriptive statistics were computed for patient demographics and the OPCC codes. Demographic differences, consult/no consult, and between-site differences were calculated using t-tests, Chi-square, or Fisher’s exact tests. All quantitative analyses were performed using SPSS version 24. Table 1 Characteristics of the patients who received (n= 39) and did not receive (n= 22) an OPCC.

No OPCC OPCC P Effect size n%n% Site .0006 .97 Dartmouth 5 22.7 27 69.2 UAB 17 77.3 12 30.8 Age, M (SD) 69.1 8.7 71.5 11.7 .4015 .23 Gender .7911 .07 Female 10 45.5 20 51.3 Male 13 54.5 19 48.7 Hispanic/Latino .2772 .29 No 21 95.5 37 94.9 Race .6873 .11 White 17 77.3 32 82.1 Black 5 22.7 7 17.9 Religion .1051 .44 Protestant 18 81.8 22 56.4 Attend religious services .0198 .64 Regularly 13 59.1 16 41 Ever prayed for your own health .0175 .65 Yes 20 90.9 24 61.5 If yes, ever prayed in past month 18 90 19 79.2 .428 .24 Marital Status .1423 .4 Married or living with partner 14 63.6 24 61.5 Work status .1095 .43 Retired/Homemaker 8 36.4 26 66.7 Disability 9 40.9 9 23.1 Education .3566 .25 High school graduate or GED 13 59.1 13 33.3 Medical insurance .7346 .09 Medicare/Medicaid 6 27.3 8 20.5 Medicare + Private 14 63.6 25 64.1 Smoking habits .0807 .47 Never smoked 7 31.8 22 56.4 Ever used other tobacco products 1 0 No 18 81.8 30 76.9 Alcoholic drinks per week .8904 .04 None 19 86.4 30 76.9 Days in hospital, last 3 months, M (SD) 4.14 6.71 4.45 10.23 .8991 .03 Days in ICU, last 3 months, M (SD) .64 2.15 .84 3.48 .8029 .07 Times at ED, last 3 months, M (SD) .77 1.23 .66 1.19 .7237 .09 Seen by Palliative Care, last 3 months 0 0 10 25.6 .0059 .76 Completed an advanced directive .0279 .6 Yes 9 40.9 27 69.2 Do-not-resuscitate Order .3258 .26 Yes 5 22.7 16 41 Notes:P-values from t-test, Chi-squared, or Fisher’s exact tests, as appropriate; Effect size: Cohen’s d or d-equivalent (small: d»0.2, medium d»0.5, large d»0.8); OPCC = outpatient palliative care consultation, M = mean, SD = standard deviation, GED = General Educational Development, ICU = intensive care unit, ED = emergency department. R. Wells et al. / Heart & Lung 47 (2018) 533 538535 Results Of the 61 patients enrolled, 39 completed OPCC (n DHMC = 27, n UAB = 12). Reasons for non-completion included decline/no-show (n= 14, 64%), study withdrawal prior to completing the OPCC (n=6, 27%), and death (n= 2, 9%). Patients who withdrew from the parent study prior to the completion of an OPCC provided the following rea- sons: (1) overwhelmed, (2) not interested, (3) study not meeting needs, or (4) passive withdrawal (lost to contact).Table 1details par- ticipant characteristics. Patients who received OPCCs were mostly white (n= 32, 82%), married (n= 24, 62%), retired (n= 26, 67%), and female (n= 20, 51%). Patients recruited from DHMC were more likely to complete OPCC (n= 27, 69%,p= .0006). Additionally, patients receiving OPCCs were more likely to attend religious services (n= 16, 41%,p= .0198), have prayed for their own health (n= 24, 62%, p= .0175), have completed advance directives (n= 27, 69%,p= .0279), and received PC services in the preceding 3 months (n= 10, 26%, p= 0.0059).Table 2shows baseline patient-reported outcome (PROs) measures. Baseline patient-reported measures of activation, global health, anxiety, and depression measures did not differ between those who did or did not receive an OPCC. OPCC clinic notes characteristics General health, social history, and symptom evaluation Table 3shows the assessment and treatment code frequencies.

The areas most frequently assessed in general health and social his- tory were history of close relationships (n= 35, 90%), advance direc- tive/code status (n= 33, 85%), family support (n= 33, 85%), and functional status (n= 30, 77%). Symptoms most frequently evaluated were mood (n= 35, 90%), breathlessness (n= 28, 72%), and chest pain (n= 24, 62%).

Between-site differences (DHMC vs. UAB) included assessment of caregiver support (n= 27 vs.n=6,p= .001),financial status (n= 7 vs.

n=0,p= .05), code status (n= 26 vs.n=7,p= .002), and prognostic understanding (n= 23 vs.n=4,p= .001). Treatment recommendations and advance care planning OPCC recommendations focused on care coordination (n= 13, 33%), specialty referrals (n= 12, 31%), counseling (n= 8, 21%), and ini- tiation of new medication(s) (n= 8, 21%). The most frequent advance care planning actions were code status discussions (n= 16, 41%), goals of care discussions (n= 22, 28%), and code status documentation (n= 14, 36%). No statistically significant differences in treatment recommenda- tions were found between sites; however, OPCCs performed at DHMC were more likely to include the topic of illness trajectory during advance care planning discussions (n DHMC = 8 vs. n UAB =0,p= .034). Discussion We examined OPCC notes at 2 geographically- and culturally-dis- tinct sites for patients enrolled in an early PC pilot study. The primary focus of the study was to identify commonalities and differences in the content of protocol-driven consultations. Medical and social his- tory, along with goals of care and code status discussions were fre- quently explored. The OPCCs addressed and treated common symptoms of mood disorders, pain, dyspnea, and fatigue as well as providing care coordination and referral to specialty services.

We found differences by site for general health and social assessment and discussion of illness trajectory in the context of advance care planning.

This study demonstrated that HF patients had significant symp- tom burden and unaddressed goals of care needs, consistent with extant literature. 10,17 25 Additionally, it appeared that protocol- driven consultations for HF patients focused on social issues (espe- cially caregiver dynamics), as well as symptoms. Such focus is not sur- prising given the early nature of OPCC herein, as well as the likelihood that each visit was an introductory encounter for rapport building. The sites differed in OPCC completion. While the procedure to connect patients to the outpatient PC clinic was consistent between sites, the physical location of the clinic differed with the DHMC out- patient clinic geographically co-located. The physical proximity of the clinic and familiarity with the location potentially contributed to patients’likelihood to keep the scheduled appointment. The embedd- edness of the DHMC clinic within the larger healthcare system might have also contributed to disparate rates of OPCCs through additional reminders by outside providers at non-OPCC appointments. However, another consideration for OPCC completion rate differences includes cultural and racial differences between sites. Specifically, UAB serves a more diverse, more religious 34patient population as indicated by the more racially-heterogeneous sample in the parent study. 26 The limited number of utilization trend studies examining disparities in outpatient palliative care indicate lower rates of palliative care and Table 2 Baseline measures patients who received (n= 39) and did not receive (n= 22) an OPCC.

No OPCC OPCC P Effect size M (SD) M (SD) PROMIS, short form v.1.0 Global physical health T score 37.49 (8.31) 40.25 (8.28) .2166 .33 Global mental health T score 44.82 (8.5) 45.8 (8.27) .6613 .12 PACIC Patient activation 2.97 (1.07) 3.28 (1.24) .326 .26 Decision support 3.5 (1.02) 3.75 (0.97) .3427 .25 Goal setting 2.68 (1.09) 3.12 (0.96) .1109 .43 Problem solving 3.31 (1.36) 3.73 (0.94) .2029 .38 Care coordination 2.3 (1.13) 2.51 (1.03) .4683 .2 PACIC summary score 2.88 (0.99) 3.21 (0.78) .1566 .38 HADS Anxiety5.68 (3.48) 5.74 (3.54) .9477 .02 Depression 4.05 (4.05) 4.41 (3.9) .7306 .09 Notes:P-values from t-tests, Effect size: Cohen’s d (small: d»0.2, medium d»0.5, large d»0.8), OPCC = outpatient palliative care consultation, PROMIS = Patient-Reported Outcome Measurement System, v. = version, PACIC = Patient Assessment of Chronic Illness Care, HADS = Hospital Anxiety and Depression Scale. With PROMIS, higher scores indicate better functioning. PACIC scores range from 1 to 5. Higher PACIC scores indicate better self-management and support of chronic condition. HADS scale scoresrange from 0 to 21. Higher HADS scores indicate more severe symptoms. 536R. Wells et al. / Heart & Lung 47 (2018) 533 538 hospice use in African American and Hispanic patients. 35A review of racial disparities in palliative identified the following potential bar- riers: palliative care knowledge, cultural beliefs, or treatment prefer- ences. 24,25 Future work should include more in-depth examination of site-specific barriers to OPCC completion. OPCC characteristics differed between sites. Differences in assessing family support, code status determination, goals of care discussions and prognosis understanding prompted us to do a side-by-side com- parison of actual notes including assessing for clinic and provider dif- ferences. One pronounced difference in the clinical note was use of a standardized template. We identified that the note templates between the sites had different standardized components, consistent with prac- tice variation. Noted differences in OPCC content may have been related to documentation prompting. We conjecture that using a stan- dardized template based from the eight domains described by the National Consensus Project 30may help facilitate uniform assessment and documentation. The use of different templates at the two sites also highlighted future research design implications including the need for protocol training for all clinicians included in study and the use of fidelity checklists throughout the study process to ensure consistent delivery of palliative care components. Overall, this study highlighted the need for early outpatient pallia- tive care in advanced HF patients to address symptoms, goals of care, and advance care planning needs found in these OPCCs. Limitations Our study has several limitations. First, the sample size is small.

Additionally, the sample population was fairly homogenous and does not reflect the general population with HF. This homogeneity limits generalizability, especially for minority populations disproportionally affected by HF who stand to benefit the most from OPCC. We also evaluated initial protocol-driven consultation notes, which might not explore all aspects of PC given timing limited to a single introductory instance. Conclusion Through this analysis, it appears that early triggered OPCCs dif- fered from clinically-driven consultations for patients with advanced HF. Ourfindings support the need to introduce PC into HF care con- currently to establish rapport. Earlier introduction of palliative care allows for rapport building as evidenced by the OPCC focus on social issues and dynamics. By establishing care before medical crisis or overwhelming symptom burden, patients and their caregivers are exposed to specialty palliative care providers and can establish thera- peutic relationships without the common misconception of PC serv- ices as only end of life services. 36 By establishing palliative care introductions earlier, HF patients might be more likely to utilize palli- ative care services throughout the duration of their disease to demon- strated benefit. 10,16,17,20 24 Although not symptom-driven, triggered OPCCs frequently addressed symptoms that resulted in earlier assess- ment and intervention. Additionally, while it is unclear if between- site differences are related to varied OPCC documentation templates versus actual clinical practices, the inclusion of clinical templates could facilitate the completion of an initial comprehensive evaluation.

Next steps include longitudinal studies evaluating multiple PC con- sultation notes as well as studies evaluating the impact of timing of PC consultation on patient outcomes. Declarations Ethics approval and consent to participate The study protocol was approved by the institutional review boards of Dartmouth College (Lebanon, New Hampshire) and the Uni- versity of Alabama at Birmingham (Birmingham, Alabama). All patients provided written informed consent. Competing interests The authors declare that they have no competing interests. Table 3 Assessment and treatment code frequencies in OPCC clinic notes.

Code N % Distribution of general health and social history evaluation Hospice 1 3 Specific medication review 1 3 Education 2 5 Cultural background 5 13 Financial status 7 18 Surrogate identified 10 26 Decisional capacity 11 28 Work history 25 64 Spirituality/Well-Being 26 67 Prognosis Understanding 27 69 Goals of care 29 74 Living arrangements 29 74 Substance abuse 29 74 Functional status 30 77 Advance directive status 33 85 Caregiver/Family support 33 85 Marital/Partner status 35 90 Distribution of symptom evaluation Dry mouth 1 3 Diarrhea 5 13 Constipation 6 15 Sleep problem 8 21 Grief & Bereavement 8 21 Edema/Ascites 9 23 Anorexia 9 23 Nausea/ Vomiting 10 26 Weight Loss/Dietary concerns 11 28 Cognitive/ Mental status 13 33 General pain 19 49 Fatigue 22 56 Chest pain 24 62 Breathlessness 28 72 Mood 35 90 Distribution of general health provider recommendations Medication increase 1 3 Non-cardiac Advanced therapeutics 1 3 Depression 1 3 Pain agreement 1 3 Medication- no changes 3 8 Cardiac advanced therapeutics 3 8 Family communication 3 8 Help with decision-making 3 8 Medication initiation 8 21 Counseling 8 21 Consult/ Referral 12 31 Care coordination 13 33 Distribution of symptom specific treatment Chest pain 1 3 Sleep problem 1 3 Depression 1 3 Fatigue 2 5 Breathlessness 2 5 General pain 3 8 Distribution of advance care planning actions Prognosis discussion 3 8 Hospice discussion 3 8 DNR discussion- full code specifics 4 10 Identify surrogate 7 18 Illness trajectory discussion 8 21 DNR discussion- without full code specifics 10 26 Goals of care discussion 11 28 General DNR discussion 16 41R. Wells et al. / Heart & Lung 47 (2018) 533 538537 Acknowledgments We would like to thank all of the clinicians and staff of Dart- mouth-Hitchcock Medical Center in the Department of Cardiology (especially Kathleen MacKay, RN, Virginia Beggs, MSN) and Depart- ment of Palliative Medicine (Lisa Stephens, MS, APRN, Amelia Cull- inan, MD) staff, UAB School of Nursing members (Connie White- Williams, PhD, RN, Amanda Erba, BSN, RN), Salpy Pamboukian, MD, Jose Tallaj, MD, UAB Department of Cardiology (especially Renzo Loy- aga-Rendon, MD and Deepak Acharya, MD), Elizabeth Kvale, MD and UAB Division of Geriatrics, Gerontology, and Palliative Care (espe- cially Rodney Tucker, MD, Cathy Casey, MSN) for supporting the study. We would also like to thank Julie Schach, James Mapson, Cyn- thia D Johnson, Cynthia Y Johnson, and Lori-Jane Higgins for assisting with recruitment and data collection. Most of all, we thank all patients for contributing their time and feedback. Funding This work was supported by a Pilot/Exploratory grant from the National Palliative Care Research Center. Dr. Dionne-Odom has received support from the NIH/National Institute of Nursing Research (1K99NR015903), the NIH/National Cancer Institute (2R25CA047888- 24), the National Palliative Care Research Center, and the American Cancer Society (RSG PCSM 124668). Rachel Wells, MSN, RN receives support from the Robert Wood Johnson Foundation Future of Nursing Scholars program. Dr. Deborah Ejem receives support from NIH/ National Institute of Nursing Research (3R01NR013665-02S1). Supplementary materials Supplementary material associated with this article can be found, in the online version, atdoi:10.1016/j.hrtlng.2018.06.012 . References 1.New York Heart Association: Criteria Committee.Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Ninth ed. Boston, MA: Lippincott Williams and Wilkins; 1994.

2. American Heart Association. Classes of heart failure; 2018. Retrieved from; 2018.

http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/ Classes-of-Heart-Failure_UCM_306328_Article.jsp#.Wvhqa02Wxjo . 3. Bekelman DB, Rumsfeld JS, Havranek EP, et al. Symptom Burden, Depression, and Spiritual Well-Being: A Comparison of Heart Failure and Advanced Cancer Patients.

J Gener Intern Med. 2009;24:592–598.http://dx.doi.org/10.1007/s11606-009- 0931-y.

4. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics-2017 update: A report from the American Heart Association.Circulation. 2017;135:

e146–e603.http://dx.doi.org/10.1161/cir.0000000000000485.

5. Jhund PS, MacIntyre K, Simpson CR, et al. Long-term trends infirst hospitalization for heart failure and subsequent survival between 1986 and 2003. A population study of 5.1 million people.Circulation. 2009;119:515–523.http://dx.doi.org/ 10.1161/CIRCULATIONAHA.108.812172.

6. Hunt SA. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines.J Am Coll Cardiol.

2005;46:e1–82.http://dx.doi.org/10.1016/j.jacc.2005.08.022.

7. Whellan DJ, Goodlin SJ, Dickinson MG, et al. End-of-life care in patients with heart fail- ure.JCardFail. 2014;20:121–134.http://dx.doi.org/10.1016/j.cardfail.2013.12.003.

8. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure.J Am Coll Cardiol 2017.http://dx.doi.org/10.1016/j.jacc.2017.04.025. (epub ahead of print)..

9. Center to Advance Palliative Care (n.d.). About palliative care. Retrieved from https://www.capc.org/about/palliative-care/ . 10. Evangelista LS, Lombardo D, Malik S, Ballard-Hernandez J, Motie M, Liao S. Examin- ing the effects of an outpatient palliative care consultation on symptom burden, depression, and quality of life in patients with symptomatic heart failure.J Card Fail. 2012;18:894–899.http://dx.doi.org/10.1016/j.cardfail.2012.10.019. 11.Kavalieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes: A systematic review and meta-analysis.JAMA.

2016;316(20):2104–2114.

12. Bakitas M, Macmartin M, Trzepkowski K, et al. Palliative care consultations for heart failure patients: How many, when, and why.J Card Fail. 2013;19:193–201.

http://dx.doi.org/10.1016/j.cardfail.2013.01.011.

13. Robinson MR, Al-Kindi SG, Oliveira GH. Trends in palliative care use in elderly men and women with severe heart failure in the United States.J Am Med Assoc Cardiol- ogy. 2017;2:344.http://dx.doi.org/10.1001/jamacardio.2016.4517.

14. Beernaert K, Cohen J, Deliens L, et al. Referral to palliative care in COPD and other chronic diseases: a population-based study.Respir Med2013107.http://dx.doi.org/ 10.1016/j.rmed.2013.06.003.

15. Greener DT, Quill T, Amir O, Szydlowski J, Gramling RE. Palliative care referral among patients hospitalized with advanced heart failure.J Palliat Med.

2014;17:1115–1120.http://dx.doi.org/10.1089/jpm.2013.0658.

16. Wiskar K, Celi LA, Walley KR, Fruhstorfer C, Rush B. Inpatient palliative care referral and 9-month hospital readmission in patients with congestive heart failure: a linked nationwide analysis.J Intern Med. 2017;282:445–451.http://dx.doi.org/ 10.1111/joim.12657.

17.Bekelman DB, Nowels CT, Allen LA, Shakar S, Kutner JS, Matlock DD. Outpatient palliative care for chronic heart failure: a case series.J Palliat Med. 2011;14:

815–821.

18. Lem AA, Schwartz M. African American heart failure patients’ perspective on palli- ative care in the outpatient setting.J Hosp Palliat Nurs. 2014;16:536–542.http:// dx.doi.org/10.1097/NJH.0000000000000103.

19. Ziehm J, Farin E, Seibel K, Becker G, K€ oberich S. Health care professionals’ attitudes regarding palliative care for patients with chronic heart failure: An interview study.BMC Palliat Care201615.http://dx.doi.org/10.1186/s12904-016-0149-9.

20. Rogers JG, Patel CB, Mentz RJ, et al. Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial.J Am Coll Cardiol. 2017;70:331–341.http:// dx.doi.org/10.1016/j.jacc.2017.05.030.

21. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics.J Palliat Med. 2013;16:661–668.http://dx.doi.org/10.1089/ jpm.2012.0469.

22. Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation.Archives of Intern Med. 2004;164:83–91.http://dx.doi.org/10.1001/archinte.164.1.83.

23. Gandesbery B, Dobbie K, Gorodeski EZ. Outpatient palliative cardiology service embedded within a heart failure clinic: Experiences with an emerging model of care.Am J Hosp Palliat Care. 2018;35:635–639.http://dx.doi.org/10.1177/ 1049909117729478.

24. Gelfman LP, Bakitas M, Warner Stevenson L, Kirkpatrick JN, Goldstein NE. The state of the science on integrating palliative care in heart failure.J Palliat Med.

2017;20:592–603.http://dx.doi.org/10.1089/jpm.2017.0178.

25. Johnson KS. Racial and ethnic disparities in palliative care.J Palliat Med.

2013;16:1329–1334.http://dx.doi.org/10.1089/jpm.2013.9468.

26. Bakitas M, Dionne-Odom JN, Pamboukian SV, et al. Engaging patient and families to create a feasible clinical trial integrating palliative and heart failure care: results of the ENABLE CHF-PC pilot clinical trial.BMC Palliat Care2017.http://dx.doi.org/ 10.1186/s12904-017-0226-8.

27. World Health Organization. WHO Definition of Palliative Care; 2010. Retrieved from; 2010.http://www.who.int/cancer/palliative/definition/en/ . 28.Callahan C, Unverzagt F, Hui S, Perkins A, Hendrie H. Six-item screener to identify cognitive impairment among potential research subjects.Med Care. 2002;40:

771–778.

29.Wagner EH, Austin BT, C. D, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action.Health Aff. 2001;20:64–78.

30. National Consensus Project. Clinical practice guideslines for quality palliative care.

[Adobe Digital portable document version]; 2009. Retrieved from; 2009.http:// www.nationalconsensusproject.org/Guideline.pdf . 31.Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Develop- ment and validation of the patient assessment of chronic illness care (PACIC).Med Care. 2005;43:436–444.

32. Hays RD, Bjorner JB, Revicki DA, Spritzer KL, Cella D. Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items.Qual Life Res. 2009;18:873–880.http:// dx.doi.org/10.1007/s11136-009-9496-9.

33.Zigmond AS, Snaith RP. The hospital anxiety and depression scale.Acta Psychiatrica Scandinavica. 1983;67:361–370.

34. Pew Research Center. America’s changing religious landscape; 2015. Retrieved from; 2015.http://www.pewforum.org/2015/05/12/americas-changing-religious- landscape/ . 35. Chuang E, Hope AA, Allyn K, Szalkiewicz E, Gary B, Gong MN. Gaps in provision of primary and specialty palliative care in the acute care setting by race and ethnicity.

J Pain Symptom Manag. 2017;54:645–653.http://dx.doi.org/10.1016/j.jpainsym- man.2017.05.001. e641.

36. Kavalieratos D, Mitchell EM, Carey TS, et al.“Not the ‘grim reaper service”:an assessment of provider knowledge, attitudes, and perceptions regarding palliative care referral barriers in heart failure.J Am Heart Assoc. 2014;3 e000544.http://dx.

doi.org/10.1161/jaha.113.000544. 538R. Wells et al. / Heart & Lung 47 (2018) 533 538