Please respond to the discussion prompt.
Read the following article Informatics Competencies for Nursing and Healthcare Leaders  Download Informatics Competencies for Nursing and Healthcare Leadersand discuss the different informatics competencies needed for nurses entering into practice, experienced nurses, informatics nurses, and nurse specialists. Next, discuss how the use of health information (HI) technology has influenced your current nursing practice.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. This is required. In addition, you may also provide an example case, either from personal experience or from the media, which illustrates and supports your ideas.  All sources must be referenced and cited using correct APA 7 (including a link to the source).
In all posts referencing personal experiences, please be sure to respect and maintain patient and colleague confidentiality.

Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year old male.
A 23-year old female complains of severe left lower abdominal/pelvic pain for 6 hours. States her last menstrual period was “about 3 or 4 weeks ago”. She is sexually active and denies using any contraceptive method.
A 19-year old male complains of “burning sometimes, when I pee”. Is sexually active and denies using any contraceptive method.
A 32-year old male complains of severe pain to the left flank pain for approx. 2 hours. Was playing volleyball at the beach when it occurred. Admits to drinking 5-6 cans of beer throughout the day and denies other fluid intake.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
In your peer replies, please reply to at least one peer who chose a different case study.
APA 7 please

Please respond to the discussion prompt.
Read the following article Informatics Competencies for Nursing and Healthcare Leaders  Download Informatics Competencies for Nursing and Healthcare Leadersand discuss the different informatics competencies needed for nurses entering into practice, experienced nurses, informatics nurses, and nurse specialists. Next, discuss how the use of health information (HI) technology has influenced your current nursing practice.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. This is required. In addition, you may also provide an example case, either from personal experience or from the media, which illustrates and supports your ideas.  All sources must be referenced and cited using correct APA 7 (including a link to the source).
In all posts referencing personal experiences, please be sure to respect and maintain patient and colleague confidentiality.

Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year old male.
A 23-year old female complains of severe left lower abdominal/pelvic pain for 6 hours. States her last menstrual period was “about 3 or 4 weeks ago”. She is sexually active and denies using any contraceptive method.
A 19-year old male complains of “burning sometimes, when I pee”. Is sexually active and denies using any contraceptive method.
A 32-year old male complains of severe pain to the left flank pain for approx. 2 hours. Was playing volleyball at the beach when it occurred. Admits to drinking 5-6 cans of beer throughout the day and denies other fluid intake.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
In your peer replies, please reply to at least one peer who chose a different case study.
APA 7 please

The topic is Pressure sore in spinal injured patients in the community.  The assignment writing is based on an innovation for the proposed topic.
What I want to achieve is to justify why the proposed innovation is relevant and support it with evidence .
The proposed innovation is “Provision of beds with integrated pressure mapping system ”
Discuss this under
1, Current practice
Itemise and discuss the current practices providing citation  and highlighting pros and cons of these practices.
2, Best practice
Please highlight the best practice in preventing and managing pressure sores citing recommendations and references by different people across jurisdictions
3, Proposed innovation
The aim, objective and relevance of the innovation should be itemised and discussed.
4, Trans professional implications of the
innovation.
What are the implications to the professional delivery by professionals,  the implication of Cross professional synergy in relation to this innovation,  and the impact it would have on working relationship between professionals and service deliver to the patients.
5, Implications for person centered care
How does it impact person centered care and the implication for the service users experience .
6, Implications for personal practice
How does this innovation impact you in your professional practice?

The topic is Pressure sore in spinal injured patients in the community.  The assignment writing is based on an innovation for the proposed topic.
What I want to achieve is to justify why the proposed innovation is relevant and support it with evidence .
The proposed innovation is “Provision of beds with integrated pressure mapping system ”
Discuss this under
1, Current practice
Itemise and discuss the current practices providing citation  and highlighting pros and cons of these practices.
2, Best practice
Please highlight the best practice in preventing and managing pressure sores citing recommendations and references by different people across jurisdictions
3, Proposed innovation
The aim, objective and relevance of the innovation should be itemised and discussed.
4, Trans professional implications of the
innovation.
What are the implications to the professional delivery by professionals,  the implication of Cross professional synergy in relation to this innovation,  and the impact it would have on working relationship between professionals and service deliver to the patients.
5, Implications for person centered care
How does it impact person centered care and the implication for the service users experience .
6, Implications for personal practice
How does this innovation impact you in your professional practice?

Response 1:
Chief Complaint: A 42-year-old patient post op abdominal cholecystectomy. complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.
A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies. I would ask when did the pain began? I would ask what will make the pain worse ?  I would ask the patient to describe what symptoms she has when she dorsiflexes the leg.  I would ask if the pain radiates anywhere else. I would ask how often she goes for walks? I would ask if she has noticed any discoloration on left calf. I would ask If she wears any compression stockings post-surgery. I would ask what is how much pain medicine does she take in a day? I would ask if she has had any injuries to her calf ? I would ask if there are any open wounds in the left calf? Has she been able to walk on both legs?
Ears, Nose, Mouth, and Throat: Sore throat, slight cough no phlegm, difficulty hearing, reports no sinus issues
Neurological: Dizziness, stable gait, fatigued , no double vision, no tremors, reports no fainting
Cardiac: no chest pain, no significant weight gains recently
Respiratory: Shortness of breath, persistent cough not coughing up blood or any phlegm
GI: Heartburn, constipation, no diarrhea, no blood in stools, no nausea or vomiting, change in bowel habits
GU: Painful urination, recent UTI, burning urination, bladder issues
Skin: no rashes on the skin, skin pale in color
Musculoskeletal: left swollen left calf, unsteady gait does to pain on left calf
Psychiatric: no Depression, reports slight anxiety and sadness, no suicidal ideations,
O – Objective:
Patient Alert x4, calm and cooperative, able to speak full sentences,
I will be pulling this patient’s vital signs, I would pull patients physical exams, I would like to perform a physical inspection of Bilateral lower extremity , I would like to see both the limbs and check for symmetry, I would like to see unilateral swelling , skin changes, I would like to see if the patient had any varicose veins, I would like to check for heat with your hand above the suspected area of DVT before palpation, I would like to check for pulses on both legs, I would also check capillary refills, I would want to see if the patient could bare weight on BLE, I would order CBC, CMP, lactic level, , CK , D- Dimer, I would also order proximal leg vein ultrasound
Working Diagnosis – Popliteal Deep Vein Thrombosis
Pertinent positive: post op, abdominal surgery, today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch, (2020)
Pertinent negative- none
Differential Diagnosis: : Cellulitis of Left lower extremity
Pertinent positive- swelling and painful left calf, warm to touch
Pertinent negative-none.
– Plan
I would order PT/INR CBC, CMP, lactic level, , CK , D Dimer, I would also order proximal leg vein ultrasound, have an accurate weight on the patient, I would start patient on Lovenox Pharmacy to dose based on kidney panel and patients weight, Drug, (2021). I would like to have a follow up 2 weeks later to see the respond to the medication.
What were your strengths in this course? – My strengths would be gaining knowledge on assessment and how to stop looking superficially but diving in deep to assess a patient snd their symptoms.
What was challenging? – I think what was most challenging was coming up with working diagnosis/differential diagnosis and figuring out the pertinent negative/pertinent positives for these.
What new learning or insight was developed? – I believe the new insight would be the SOAP. It allows the nurse to organize her discovery and able to solve the puzzle.
What new clinical skills have you gained? – I gained how to become a better interviewer and digging deep to able to give us a clear image of what the patient is going through.
Response 2:
2. A 66-year old woman complains of shortness of breath, numbness and heaviness of her arms when walking up the hill to her house. The pain subsides when she stops to rest.
S – Subjective
CC – Patient stating “Whenever I walk up the hill to my house, I get short of breath and I feel my arms get numb and heavy. I also get chest pain when walking, but that pain goes away when I stop to rest.”
HPI – Patient is a 66-year old woman who complains of shortness of breath, numbness and heaviness of her arms when walking up the hill to her house. She states that there is chest pain which subsides when she stops to rest.
PMH – Some questions to ask this patient would include: Do you have a history of heart issues? Do your mother and father have/had heart issues? Do you take any medications for heart issues? Please describe the pain you are feeling in your chest. Does the pain radiate anywhere else in the body? How long does the pain last? Is there anything you do to treat the pain? Have you gone to the hospital or emergency department before for this thing in the past?
MEDS – Are you taking any medications currently? Do you take medications for heart issues? Do you take any medications for your pain?
Allergies – Are you allergic to any medications? Are you allergic to any foods? Are you allergic to anything in the environment such as dust, pollen, pet dander?
FH – Does anyone in your family have or had any heart issues issues? Has anyone in your family died of a heart attack? Does anyone in your family have issues with cholesterol?
Social history – Do you smoke cigarettes, if so how often? Do you smoke marijuana? Do you take recreational drugs? Do you drink alcohol, if so much and how often?
Health related behaviors – Do you exercise? Are you active in your lifestyle? Explain what you normally do for work. What do you do on your free time? What does your diet consist of? What do you normally eat?
Review of Systems:
Constitution/General – I would ask the patient how she is generally currently feeling. I would ask if she feels tired, unwell, or lethargic.
Neurological – I would ask her if she has any issues with double vision, issues with walking, issues with balance. I would ask if she has had dizziness or fainting spells.
Respiratory – I would ask her if she has current shortness of breath, if it hurts when she breathes in, if the chest pain hurts when breathing out. I would ask when she gets short of breath when walking up the hill how long it takes for her to catch her breath. I would ask if she uses oxygen at home.
Cardiac – I would ask her if she has any feelings of racing heart beat, skipping heart beat, feeling like she can faint, swelling of arms or legs, what her chest pain feels like and do an OLDCART assessment, and if anything that makes it feel better. I would ask about her lifestyle and what she does. I would ask if she has had previous chest pain like this in past.
Psychiatric – I would ask the patient about a history of depression, anxiety, feelings of worthlessness, suicidal ideations, hearing voices or thoughts of harming self or others.
O – Objective
I would obtain vital signs, numeric pain scale, oxygen saturation and temperature. I would obtain lab results such as a CBC, CMP, lipid panel, troponin, EKG, and order a cardiac stress test.
General – Patient is awake, alert, oriented to time, place, person, situation. Appropriate in speech and language, clear and logical. No acute distress noted.
Cardiac – S1 and S2 auscultated, no murmurs or gallops present, heart rate and rhythm WNL, pulses palpable BL all extremities +2. Patient skin warm to touch and normal turgor. BP = 143/89, HR = 98. Patient is obese BMI 35.
Respiratory – Chest wall is symmetric, atraumatic, lung sounds WNL in all quadrants, SpO2 98%.
Psychiatric – Patient is calm and cooperative, patient has good judgement and insight, denies suicidal or homicidal ideations.
A – Assessment
Working Diagnosis – Angina pectoris, unspecified – 2022 ICD-10-CM Diagnosis Code I20.9
Pertinent positive: Chest pain that subsides with rest. Chest pain that subsides with rest or medication (nitroglycerin) is a common symptom of stable angina (Sullivan, 2018).
Pertinent negative: Patient is obese and has high blood pressure. These are risk factors for having stable angina (Sullivan, 2018).
Differential Diagnosis – Acute ischemic heart disease, unspecified – 2022 ICD-10-CM Diagnosis Code I24.9
Pertinent negative: Sudden numbness and heaviness with shortness of breath are symptoms of an acute coronary event such as a myocardial infarction (Mayo Clinic, 2021).
Differential Diagnosis – Nonrheumatic aortic (valve) stenosis – 2022 ICD-10-CM Diagnosis Code I35.0
Pertinent negative: Shortness of breath when walking short distances, chest pain, fatigue on exertion are all signs and symptoms of aortic valve stenosis (American Heart Association, 2020).
P – Plan
The patient states she has chest pain on exertion. In order to make sure the patient isn’t having an active myocardial infarction an EKG will be done along with troponin. My working diagnosis is stable angina or angina pectoris due to the chest pain relief on rest. Since that is my working diagnosis I would still perform an EKG and also a stress test. A stress test may show EKG changes on exercise and will also show me if the patient gets symptomatic again with exercise (Sullivan, 2018). I also would like to order an ECHO as well to rule out aortic valve stenosis due to patient’s age at 66 years-old and similar symptoms (American Heart Association, 2020). The ECHO will show me valve changes and will confirm my diagnosis. If lifestyle changes are not met to reduce symptoms, medication such as nitroglycerin can be given. If nitroglycerin stops working, further measures such as a coronary angiography will be needed to see the extent of a multi-vessel disease and possible coronary bypass will be needed.
Referral: Cardiologist. If interventions are needed for an acute MI an interventional cardiologist will be recommended. If bypass is needed for advanced blockage, cardiothoracic surgery will be consulted.
Treatment: Since we are in the beginning stages of a cardiovascular event such as stable angina I would recommend to the patient lifestyle changes first. Eating a heart healthy diet with fruits, whole grains, and vegetables, along with moderate exercise daily, and smoking cessation can help with advancing heart disease (Sullivan, 2018).
Medications: If lifestyle alone cannot fix symptoms nitroglycerin can be prescribed. Nitroglycerin 0.4 mg sublingual tablets are prescribed as place one tablet under the tongue. If pain does not completely subside in 5 minutes, take another tablet. Take a max of 3 tablets in 15 minutes. If pain does not subside in 15 minutes, call 911. It is also recommended to take 1 tablet 5-10 min before exercise (Aremu, 2021). One of the more common side effects of nitroglycerin tablet is complaint of headaches, dizziness, weakness, nausea, and fast heart rate. Do not drink alcohol with this medication as it can cause low blood pressure (Aremu, 2021).
Follow-up: If the patient is still symptomatic with nitroglycerin and lifestyle changes, further examination will be done in order to rule out multi-vessel disease and possible interventions such as PCI or bypass. Patient will need to follow up in at least a week with cardiologist to assess effectiveness of medications and treatment.

Response 1:
Despite our advancement and so-called progressivism, there is still a stigma against mental illness. A stigma occurs at several levels such as intrapersonal, interpersonal, and structural (Knaak et al., 2015). Intrapersonal stigmas people with mental illness report are feeling devalued, dismissed, and dehumanized by many healthcare professionals. Feeling this way discourages people with mental illness from seeking much-needed further care. The key themes that lead to these feelings include feeling excluded from making decisions, receiving subtle or overt threats of coercive treatment, being made to wait excessively long when seeking help, and being given insufficient information about one’s condition, among others (Knaak et al., 2015). Major obstacles stem from organizational culture rather than individual factors. System changes that can help overcome these obstacles are creating a culture of acceptance by raising awareness and education on mental health illnesses. The ARNP in an administrative position, can create policies and initiatives that help their facility support those with mental health issues. Programs that focus on crisis intervention prevention have proven effective at decreasing suicide among U.S veterans and can be initiated at healthcare facilities (Hester, 2017). Although healthcare professionals do not experience the same stress level as veterans, they experience similar feelings of depression and anxiety that lead them to burnout and substance abuse.
Nurses across all fields can help those with mental illness get the attention they need. Through education and empowerment, nurses can help their patients promote their health. The advanced practice nurse can use social work and case management resources to find patients outpatient care or therapies that may be useful. The advanced practice nurse can talk to insurance companies on their patient’s behalf to help them get the support they need. Partnering with available support systems during the care plan process can make them aware of any crisis prevention or damage control plans for when the patient is in crisis. The advanced practice nurse can also continue to follow-up with their patients after leaving their care.
Response 2:
Mental health is an essential and integral health component involving an individual’s state of well-being in which they can productively work and contribute to their communities, cope with everyday life stressors, and realize their abilities. In workplaces, mental health stigma is a significant challenge where most employees with employer-provided insurance feel uncomfortable approaching the employer for help due to workplace reprisals. Despite all this, system changes can improve fear of workplace reprisals, how nurses can get more individuals to seek mental health, and support patients and their families once they leave care despite insurance barriers.
According to the American Psychiatric Association (2019), while 70% of employees with benefits are familiar with ways of accessing mental health care and 62% of them are somewhat at ease about obtaining services via their employer, workers exceeding one-quarter are not sure of ways of accessing mental health services via their employer. Most employees get worried about being fired or retaliation when seeking mental health services. To improve this situation, workplace wellness programs can be incorporated to identify those at risk of mental health issues, link them to treatment, and offer support systems to aid individuals to cope with and minimize stress (CDC, 2019). Developing psychological health in workplaces “how to” guide would offer assessment tools and notify effective program designs to establish if current programs are successful and have an impact (Goetzel et al., 2018). Further, there is a necessity to have a distinct set of metrics, mainly when working with community partners, insurance companies, wellness vendors, and mental health providers.
In mental health care, promoting health is considered a process-oriented intervention that establishes that health is a developmental process, and the relationship between a patient and a nurse is significant since they impact one another. Also, the result of promoting health is dependent on the interaction quality. The essence in promoting mental health is practical support, educational support, and empowerment portrayed via a good alliance. The alliance involves a conversation concerning two or more people and a nurturing interaction centered on a personal relationship, mutuality, and trust to promote health. Conversely, the development of the alliance is achieved when nurses develop a relationship with the patient as an individual, have smiling faces, are kind, and continue interacting with the patient expansively.
When individuals develop mental illness, they usually require long-term care that the insurance company must cater to the cost. However, insurance company physicians who never personally attend to the patient typically deny long-term care, despite the disapproval of the psychiatrist treating them. An incident is illustrated by Pelley (2015) concerning Ashley, who suffered from bipolar disorder and was denied long-term treatment. In cases like this, APRNs should follow up with their patients once they leave care since most are susceptible to suicide. Also, APRNs can aid outpatient individuals by volunteering or starting outreach programs that cater to their requirements. Other options include participating in local health events targeting those not insured and educating them about national and state programs that are accessible to offer them services. Workplaces that support individuals with mental disorders and promote mental health are more capable of benefiting from related economic advances, increasing productivity, and reducing absenteeism. Working is beneficial for mental health, but a negative work setting leads to mental and physical health complications. Therefore, individuals need to seek mental health care to enhance their functional capability and productivity in the community with nurses at the frontline to curb mental-health-related stigma in the workplace.                                                                                                 

Response 1:
Chief Complaint: A 42-year-old patient post op abdominal cholecystectomy. complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.
A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies. I would ask when did the pain began? I would ask what will make the pain worse ?  I would ask the patient to describe what symptoms she has when she dorsiflexes the leg.  I would ask if the pain radiates anywhere else. I would ask how often she goes for walks? I would ask if she has noticed any discoloration on left calf. I would ask If she wears any compression stockings post-surgery. I would ask what is how much pain medicine does she take in a day? I would ask if she has had any injuries to her calf ? I would ask if there are any open wounds in the left calf? Has she been able to walk on both legs?
Ears, Nose, Mouth, and Throat: Sore throat, slight cough no phlegm, difficulty hearing, reports no sinus issues
Neurological: Dizziness, stable gait, fatigued , no double vision, no tremors, reports no fainting
Cardiac: no chest pain, no significant weight gains recently
Respiratory: Shortness of breath, persistent cough not coughing up blood or any phlegm
GI: Heartburn, constipation, no diarrhea, no blood in stools, no nausea or vomiting, change in bowel habits
GU: Painful urination, recent UTI, burning urination, bladder issues
Skin: no rashes on the skin, skin pale in color
Musculoskeletal: left swollen left calf, unsteady gait does to pain on left calf
Psychiatric: no Depression, reports slight anxiety and sadness, no suicidal ideations,
O – Objective:
Patient Alert x4, calm and cooperative, able to speak full sentences,
I will be pulling this patient’s vital signs, I would pull patients physical exams, I would like to perform a physical inspection of Bilateral lower extremity , I would like to see both the limbs and check for symmetry, I would like to see unilateral swelling , skin changes, I would like to see if the patient had any varicose veins, I would like to check for heat with your hand above the suspected area of DVT before palpation, I would like to check for pulses on both legs, I would also check capillary refills, I would want to see if the patient could bare weight on BLE, I would order CBC, CMP, lactic level, , CK , D- Dimer, I would also order proximal leg vein ultrasound
Working Diagnosis – Popliteal Deep Vein Thrombosis
Pertinent positive: post op, abdominal surgery, today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch, (2020)
Pertinent negative- none
Differential Diagnosis: : Cellulitis of Left lower extremity
Pertinent positive- swelling and painful left calf, warm to touch
Pertinent negative-none.
– Plan
I would order PT/INR CBC, CMP, lactic level, , CK , D Dimer, I would also order proximal leg vein ultrasound, have an accurate weight on the patient, I would start patient on Lovenox Pharmacy to dose based on kidney panel and patients weight, Drug, (2021). I would like to have a follow up 2 weeks later to see the respond to the medication.
What were your strengths in this course? – My strengths would be gaining knowledge on assessment and how to stop looking superficially but diving in deep to assess a patient snd their symptoms.
What was challenging? – I think what was most challenging was coming up with working diagnosis/differential diagnosis and figuring out the pertinent negative/pertinent positives for these.
What new learning or insight was developed? – I believe the new insight would be the SOAP. It allows the nurse to organize her discovery and able to solve the puzzle.
What new clinical skills have you gained? – I gained how to become a better interviewer and digging deep to able to give us a clear image of what the patient is going through.
Response 2:
2. A 66-year old woman complains of shortness of breath, numbness and heaviness of her arms when walking up the hill to her house. The pain subsides when she stops to rest.
S – Subjective
CC – Patient stating “Whenever I walk up the hill to my house, I get short of breath and I feel my arms get numb and heavy. I also get chest pain when walking, but that pain goes away when I stop to rest.”
HPI – Patient is a 66-year old woman who complains of shortness of breath, numbness and heaviness of her arms when walking up the hill to her house. She states that there is chest pain which subsides when she stops to rest.
PMH – Some questions to ask this patient would include: Do you have a history of heart issues? Do your mother and father have/had heart issues? Do you take any medications for heart issues? Please describe the pain you are feeling in your chest. Does the pain radiate anywhere else in the body? How long does the pain last? Is there anything you do to treat the pain? Have you gone to the hospital or emergency department before for this thing in the past?
MEDS – Are you taking any medications currently? Do you take medications for heart issues? Do you take any medications for your pain?
Allergies – Are you allergic to any medications? Are you allergic to any foods? Are you allergic to anything in the environment such as dust, pollen, pet dander?
FH – Does anyone in your family have or had any heart issues issues? Has anyone in your family died of a heart attack? Does anyone in your family have issues with cholesterol?
Social history – Do you smoke cigarettes, if so how often? Do you smoke marijuana? Do you take recreational drugs? Do you drink alcohol, if so much and how often?
Health related behaviors – Do you exercise? Are you active in your lifestyle? Explain what you normally do for work. What do you do on your free time? What does your diet consist of? What do you normally eat?
Review of Systems:
Constitution/General – I would ask the patient how she is generally currently feeling. I would ask if she feels tired, unwell, or lethargic.
Neurological – I would ask her if she has any issues with double vision, issues with walking, issues with balance. I would ask if she has had dizziness or fainting spells.
Respiratory – I would ask her if she has current shortness of breath, if it hurts when she breathes in, if the chest pain hurts when breathing out. I would ask when she gets short of breath when walking up the hill how long it takes for her to catch her breath. I would ask if she uses oxygen at home.
Cardiac – I would ask her if she has any feelings of racing heart beat, skipping heart beat, feeling like she can faint, swelling of arms or legs, what her chest pain feels like and do an OLDCART assessment, and if anything that makes it feel better. I would ask about her lifestyle and what she does. I would ask if she has had previous chest pain like this in past.
Psychiatric – I would ask the patient about a history of depression, anxiety, feelings of worthlessness, suicidal ideations, hearing voices or thoughts of harming self or others.
O – Objective
I would obtain vital signs, numeric pain scale, oxygen saturation and temperature. I would obtain lab results such as a CBC, CMP, lipid panel, troponin, EKG, and order a cardiac stress test.
General – Patient is awake, alert, oriented to time, place, person, situation. Appropriate in speech and language, clear and logical. No acute distress noted.
Cardiac – S1 and S2 auscultated, no murmurs or gallops present, heart rate and rhythm WNL, pulses palpable BL all extremities +2. Patient skin warm to touch and normal turgor. BP = 143/89, HR = 98. Patient is obese BMI 35.
Respiratory – Chest wall is symmetric, atraumatic, lung sounds WNL in all quadrants, SpO2 98%.
Psychiatric – Patient is calm and cooperative, patient has good judgement and insight, denies suicidal or homicidal ideations.
A – Assessment
Working Diagnosis – Angina pectoris, unspecified – 2022 ICD-10-CM Diagnosis Code I20.9
Pertinent positive: Chest pain that subsides with rest. Chest pain that subsides with rest or medication (nitroglycerin) is a common symptom of stable angina (Sullivan, 2018).
Pertinent negative: Patient is obese and has high blood pressure. These are risk factors for having stable angina (Sullivan, 2018).
Differential Diagnosis – Acute ischemic heart disease, unspecified – 2022 ICD-10-CM Diagnosis Code I24.9
Pertinent negative: Sudden numbness and heaviness with shortness of breath are symptoms of an acute coronary event such as a myocardial infarction (Mayo Clinic, 2021).
Differential Diagnosis – Nonrheumatic aortic (valve) stenosis – 2022 ICD-10-CM Diagnosis Code I35.0
Pertinent negative: Shortness of breath when walking short distances, chest pain, fatigue on exertion are all signs and symptoms of aortic valve stenosis (American Heart Association, 2020).
P – Plan
The patient states she has chest pain on exertion. In order to make sure the patient isn’t having an active myocardial infarction an EKG will be done along with troponin. My working diagnosis is stable angina or angina pectoris due to the chest pain relief on rest. Since that is my working diagnosis I would still perform an EKG and also a stress test. A stress test may show EKG changes on exercise and will also show me if the patient gets symptomatic again with exercise (Sullivan, 2018). I also would like to order an ECHO as well to rule out aortic valve stenosis due to patient’s age at 66 years-old and similar symptoms (American Heart Association, 2020). The ECHO will show me valve changes and will confirm my diagnosis. If lifestyle changes are not met to reduce symptoms, medication such as nitroglycerin can be given. If nitroglycerin stops working, further measures such as a coronary angiography will be needed to see the extent of a multi-vessel disease and possible coronary bypass will be needed.
Referral: Cardiologist. If interventions are needed for an acute MI an interventional cardiologist will be recommended. If bypass is needed for advanced blockage, cardiothoracic surgery will be consulted.
Treatment: Since we are in the beginning stages of a cardiovascular event such as stable angina I would recommend to the patient lifestyle changes first. Eating a heart healthy diet with fruits, whole grains, and vegetables, along with moderate exercise daily, and smoking cessation can help with advancing heart disease (Sullivan, 2018).
Medications: If lifestyle alone cannot fix symptoms nitroglycerin can be prescribed. Nitroglycerin 0.4 mg sublingual tablets are prescribed as place one tablet under the tongue. If pain does not completely subside in 5 minutes, take another tablet. Take a max of 3 tablets in 15 minutes. If pain does not subside in 15 minutes, call 911. It is also recommended to take 1 tablet 5-10 min before exercise (Aremu, 2021). One of the more common side effects of nitroglycerin tablet is complaint of headaches, dizziness, weakness, nausea, and fast heart rate. Do not drink alcohol with this medication as it can cause low blood pressure (Aremu, 2021).
Follow-up: If the patient is still symptomatic with nitroglycerin and lifestyle changes, further examination will be done in order to rule out multi-vessel disease and possible interventions such as PCI or bypass. Patient will need to follow up in at least a week with cardiologist to assess effectiveness of medications and treatment.

Response 1:
Despite our advancement and so-called progressivism, there is still a stigma against mental illness. A stigma occurs at several levels such as intrapersonal, interpersonal, and structural (Knaak et al., 2015). Intrapersonal stigmas people with mental illness report are feeling devalued, dismissed, and dehumanized by many healthcare professionals. Feeling this way discourages people with mental illness from seeking much-needed further care. The key themes that lead to these feelings include feeling excluded from making decisions, receiving subtle or overt threats of coercive treatment, being made to wait excessively long when seeking help, and being given insufficient information about one’s condition, among others (Knaak et al., 2015). Major obstacles stem from organizational culture rather than individual factors. System changes that can help overcome these obstacles are creating a culture of acceptance by raising awareness and education on mental health illnesses. The ARNP in an administrative position, can create policies and initiatives that help their facility support those with mental health issues. Programs that focus on crisis intervention prevention have proven effective at decreasing suicide among U.S veterans and can be initiated at healthcare facilities (Hester, 2017). Although healthcare professionals do not experience the same stress level as veterans, they experience similar feelings of depression and anxiety that lead them to burnout and substance abuse.
Nurses across all fields can help those with mental illness get the attention they need. Through education and empowerment, nurses can help their patients promote their health. The advanced practice nurse can use social work and case management resources to find patients outpatient care or therapies that may be useful. The advanced practice nurse can talk to insurance companies on their patient’s behalf to help them get the support they need. Partnering with available support systems during the care plan process can make them aware of any crisis prevention or damage control plans for when the patient is in crisis. The advanced practice nurse can also continue to follow-up with their patients after leaving their care.
Response 2:
Mental health is an essential and integral health component involving an individual’s state of well-being in which they can productively work and contribute to their communities, cope with everyday life stressors, and realize their abilities. In workplaces, mental health stigma is a significant challenge where most employees with employer-provided insurance feel uncomfortable approaching the employer for help due to workplace reprisals. Despite all this, system changes can improve fear of workplace reprisals, how nurses can get more individuals to seek mental health, and support patients and their families once they leave care despite insurance barriers.
According to the American Psychiatric Association (2019), while 70% of employees with benefits are familiar with ways of accessing mental health care and 62% of them are somewhat at ease about obtaining services via their employer, workers exceeding one-quarter are not sure of ways of accessing mental health services via their employer. Most employees get worried about being fired or retaliation when seeking mental health services. To improve this situation, workplace wellness programs can be incorporated to identify those at risk of mental health issues, link them to treatment, and offer support systems to aid individuals to cope with and minimize stress (CDC, 2019). Developing psychological health in workplaces “how to” guide would offer assessment tools and notify effective program designs to establish if current programs are successful and have an impact (Goetzel et al., 2018). Further, there is a necessity to have a distinct set of metrics, mainly when working with community partners, insurance companies, wellness vendors, and mental health providers.
In mental health care, promoting health is considered a process-oriented intervention that establishes that health is a developmental process, and the relationship between a patient and a nurse is significant since they impact one another. Also, the result of promoting health is dependent on the interaction quality. The essence in promoting mental health is practical support, educational support, and empowerment portrayed via a good alliance. The alliance involves a conversation concerning two or more people and a nurturing interaction centered on a personal relationship, mutuality, and trust to promote health. Conversely, the development of the alliance is achieved when nurses develop a relationship with the patient as an individual, have smiling faces, are kind, and continue interacting with the patient expansively.
When individuals develop mental illness, they usually require long-term care that the insurance company must cater to the cost. However, insurance company physicians who never personally attend to the patient typically deny long-term care, despite the disapproval of the psychiatrist treating them. An incident is illustrated by Pelley (2015) concerning Ashley, who suffered from bipolar disorder and was denied long-term treatment. In cases like this, APRNs should follow up with their patients once they leave care since most are susceptible to suicide. Also, APRNs can aid outpatient individuals by volunteering or starting outreach programs that cater to their requirements. Other options include participating in local health events targeting those not insured and educating them about national and state programs that are accessible to offer them services. Workplaces that support individuals with mental disorders and promote mental health are more capable of benefiting from related economic advances, increasing productivity, and reducing absenteeism. Working is beneficial for mental health, but a negative work setting leads to mental and physical health complications. Therefore, individuals need to seek mental health care to enhance their functional capability and productivity in the community with nurses at the frontline to curb mental-health-related stigma in the workplace.