NR 661 APN Capstone Practicum Chamberlain College of Nursing (NR661)

Exam (elaborations) NR 661 APN Capstone Practicum Chamberlain College of Nursing (NR661) PORTFOLIO 2 Hinal Patel NR661-APN Capstone Practicum Chamberlain College of Nursing March 2020 NR 661 APN Capstone Practicum Chamberlain College of Nursing 2 PORTFOLIO 2 Table of Contents Exemplar 1 – NR 503: Reflection of the course----------------------------------------------------4 Program outcome, MSN essential, and NONPF ---------------------------------6 Concept ----------------------------------------------------------------------------------7 Reflection---------------------------------------------------------------------------------7 Exemplar 2 NR 508: Class Discussion ------------------------------------------------------------8 Program outcome, MSN essential, NONPF ---------------------------------------10 Concepts-----------------------------------------------------------------------------------11 Reflection---------------------------------------------------------------------------------11 Exemplar 3 NR 509: Reflection of the course ----------------------------------------------------12 Program outcome, MSN essential, NONPF-------------------------------------12 Concepts -------------------------------------------------------------------------------14 Reflection ------------------------------------------------------------------------------14 Exemplar 4 NR 510 APN development Paper -----------------------------------------------------15 Program outcome, MSN essential, NONPF---------------------------------------19 Concepts --------------------------------------------------------------------------------20 Reflection -------------------------------------------------------------------------------20 Exemplar 5 NR 511Case Study-----------------------------------------------------------------------21 Program outcome, MSN essential, NONPF ---------------------------------------25 Concepts ---------------------------------------------------------------------------------26 Reflection ---------------------------------------------------------------------------------27 Exemplar 6 R601 Course Reflection -----------------------------------------------------------------28 Program outcome, MSN essential, NONPF -----------------------------------------29 Concepts -----------------------------------------------------------------------------------31 3 PORTFOLIO 2 Reflection ----------------------------------------------------------------------------------31 Exemplar 7 NR 601 Case study Assignment ----------------------------------------------------32 Program outcome, MSN essential, NONPF------------------------------------51 Concepts -----------------------------------------------------------------------------52 Reflection -----------------------------------------------------------------------------52 Exemplar 8 NR602Marginalized Women Paper -------------------------------------------------53 Program outcome, MSN essential, NONPF-------------------------------------62 Concepts ------------------------------------------------------------------------------63 Reflection------------------------------------------------------------------------------64 Exemplar 9 NR602 Case study discussion ---------------------------------------------------------64 Program outcome, MSN essential, NONPF--------------------------------------69 Concepts --------------------------------------------------------------------------------70 Reflection -------------------------------------------------------------------------------71 Exemplar 10 NR603Case study discussion --------------------------------------------------------71 Program outcome, MSN essential, NONPF--------------------------------------76 Concepts ---------------------------------------------------------------------------------78 Reflection --------------------------------------------------------------------------------78 Conclusion---------------------------------------------------------------------------------------------------79 Appendix # 1 Table of Exemplars ---------------------------------------------------------------------80 Appendix # 2Nursing Concept Map------------------------------------------------------------------ 81 References-------------------------------------------------------------------------------------------------- 82 4 PORTFOLIO 2 The primary purpose of a master portfolio is to document, categorize, and, skills, and abilities; growth; and progress of a student, and as a professional. This is especially critical for healthcare providers and students learning and working in increasingly complex communities of education and practice. This has achieved through class discussions, case studies, assignments, clinical rotation, clinical encounters, and reflection. The paper will discuss this learning using exemplars. The purpose of this paper will introduce the student personal and professional goal, as well as her professional career and plan of study using evidence-based resources and core competency at chamberlain university. The summary of reflections is based on the evidences of the knowledge that this student has learned during the entire course of MSN. Exemplar 1: NR 503 Population Health Epidemiology and Statistical Principles Summary of Reflection: This class helps the student to gain knowledge regarding the current issue and data of epidemiology. As a nurse practitioner that is the duty to provide the care across the life span without any judgment, bias and option. This class helped the student to establish a good base to be able to recognize the origin of disease processes, how to extract medical information in order to discern the problem, and how to choose the best diagnostic test and treatment options based on the disease process. During this class the student wrote the paper on Hepatitis B as well as Diabetes Mellites that provide education and emotional support are necessary to assist in coping with this potentially life-threatening disease. Student learned about the Epidemiologic Triage which provide the information on disease progression through susceptible host, causative agent and environment (CDC, n. d.). 5 PORTFOLIO 2 This class help the student to applied and integrates broad, organizational, client-centered and culturally appropriate concept in planning, delivery, management and evaluation of evidence-based clinical prevention and population care and services to individuals, family and population (AACN, 2011 P. 5). This Class helps to screening, Identify the risk factors which helps people on primary, secondary and tertiary level prevention. FNP incorporate AACN essentials to delivery of optimal care. This class was a very informative class that greatly increased her knowledge of epidemiology and its use in the medical field. She did not realize how important epidemiology was to the medical field and how it can be used to guide public health policies to promote health in our communities and across our nation. The student write one Healthy People 2020 assignment gave her the opportunity to identify sources of epidemiological data as it related to the Hepatitis B, review demographic and epidemiological data on morbidity and mortality risk, research screening and diagnostic tests available for Hepatitis , and finally identify a program plan to decrease the incidence of Hepatitis through the Healthy People 2020 goals and objectives. References: American Association of Colleges of Nursing (AACN) Essentials. (2011). Retrieved April 10, 2018, from an external site.) CDC. (n.d). Introduction to epidemiology. Retrieved March 23, 2018, from in Nursing (MSN) in Advanced Clinical and Non-Clinical Roles. (n.d.). Retrieved April 10, 2018, from 6 PORTFOLIO 2 Chamberlain Program Outcomes, MSN Essential and/or NONPF Competencies Met by Exemplar #1 Program Outcome #1: Provide high quality, safe, patient-centered care grounded in holistic health principles: This class has helped this understudy accomplish her program result # 1 by learning the ideas of the study of disease transmission and coordinate that proficient information into network and recognize the individuals in danger by utilizing abilities and information on evaluation, hazard factors, rate, predominance rate, existing observation techniques, screening tests to analyze diabetes and distinguishing their affectability and particularity and assist them with developing healthy lifestyle.. MSN Essential IV: Translating and Integrating Scholarship into Practice: This understudy accomplished this fundamental by composing task on epidemiological issue of diabetes mellitus, where she led insightful research on subtleties of diabetes mellitus and utilized it in her evaluation, conclusion, the board plan, observation strategies, and treatment plan. This data gas helped this understudy in teaching her recently determined and existing patients to have diabetes. According to Richardson, nurture experts have improved the patient results and self-viability for diabetes patients in the essential consideration groups (2014). NP Core Competency # 6 Policy Competency: Focuses on being competent with healthcare policies and utilize the knowledge of clinical practice to improve the patient outcomes (The National Organization of Nurse Practitioner Faculties [NONPF], 2017). The job of APN includes concentrating on illness avoidance and wellbeing advancement. Finding out about clinical practice rules of diabetes during this class and applying it to clinical turn has helped this understudy recognize in danger patients and has helped her met this competency. It is significant for another NP to approach social insurance arrangement to guide and bolster their training and 7 PORTFOLIO 2 give protected, productive, and quality consideration to the patient. This class has helped in remain concentrated on recent developments in the study of disease transmission to guarantee the conveyance of confirm based practice. Concepts: Health Care Systems: healthcare system, is the organization of people, institutions, and resources that deliver health care services to meet the health needs of target populations. (Pallipedia, 2019). Such healthcare infrastructure includes, home, physician’s office, nursing homes, hospitals, community centers. The role of APN varies based on the type of infrastructure and type of the patients in providing primary, specialty, and emergency care. NPs have proven their effectiveness in delivering high quality, lower cost heath care services. Interprofessional collaboration: This exemplar describes how interprofessional collaboration is active and ongoing partnerships of different healthcare professionals (HCP) who work together in solving problems and providing healthcare services. This knowledge helps her to promotes safe, cost-effective, quality care through engaged in partnerships and collaboration to other health care personals like pharmacy, other specialist, agency hospital and other health care facility. As a new NPs she should found to create respectful relationships among professionals, relay information through timely, open, and effective communication, and share decision-making activities to encourage critical discourse supporting a common plan of care (Christina et al., 2016). Reflection This class helps the student to gained insightful knowledge on how to understand and verified studies and statistics within epidemiology. This class also supported on how to use public health policies in promoting health and quality care to our communities and future 8 PORTFOLIO 2 patients. This course showed the importance of screening for conditions and providing interventions to provide patients with the best possible health outcomes. Evidence-based research should be the foundation for practice and this research evidence must be disseminated to ensure the utilization of the most up-to-date information. This course connected research to practice through our assigned discussion posts and papers. This will help the student to individualize care for patients based on their identified risk factors to promote health. This class has really opened my eyes to all of the thought that must go into who to screen for a disease and with what methods and tests, and how to determine the accuracy of the results and need for further followup. Exemplar# Two NR 508 Discussion Threads This class mainly focus on the medication, prescribing authorities as per state and safety and precautionary measured taken before prescribing the medication to all ages specially the elderly. This class also discussed about the cost-effective health care provided by healthcare workers. This class also includes medication, side effect and interaction with other medication. Mostly emphasis on what placed on the decision-making process utilized to safely and effectively prescribe and monitor pharmacotherapeutics for the treatment of acute and chronic diseases appropriate to the patient situation. In the community, however, drug addiction is becoming more prevalent. Many people misuse medications such as heroin, antidepressants and powerful pain medication. Illegal and abuse of these medications induces high rates of morbidity and mortality. It affects not only a 9 PORTFOLIO 2 patient's health condition but also their physical, social, psychological and financial status. To prevent this, a comprehensive history and assessment of pain and other non-pharmacological treatments should be done first before administering pain medicines. When narcotic analgesics are administered, constant monitoring, testing for any possible risk factors, urine drug screening, informed consent, pain consent and agreement should be done to help mitigate the risk of dependency (Hudspeth, 2016). Some measures that could be effective in reducing dependency include making patients aware of all potential treatment choices, their costs and benefits, and the effects of opioid addiction or overuse (Hudspeth, 2016). It is the professional duty of all nurse practitioners to prescribe within their field of practice and to follow state and federal laws and guidelines for patient safety and legal issue affected to licensure. By taking the pharmacology class, this student has helped understand the pharmacokinetics and pharmacodynamics of the medications and the appropriate prescription steps to prevent adverse reactions, reduce side effects and risks. The advent of electronic health records (EHRs) and pharmacy interfacing has significantly eliminated many such medication reactions and complications. This also helps clinicians monitor prescribing trends for opioids and other controlled drugs and prevent harmful drug adverse effects. That ensures patient and provider privacy and protection (Health IT, 2019). Health care providers should help patients understand whether or not there is a genuine medical problem that supports the use of controlled drugs, adequate treatment time and referral to specialists, and rehabilitation target to minimize opioid dependence and dependency (National Institute on Drug Abuse, 2018). References: 10 PORTFOLIO 2 Health IT. (2019). How can electronic health records help me prevent adverse medication events? Retrieved September 2019 from, health-records-help-me-prevent-adverse-medication-events Hudspeth, R.S. (2016). Safe opioid prescribing for adults by nurse practitioners: Part 2. Implementing and managing treatment. Retrieved September 2019 from, National Institute on Drug Abuse. (2018). How can prescription drug misuse be prevented? Retrieved September 2019 from, misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented Chamberlain Program outcomes, MSN Essential and/or NONPF Competencies Met by Exemplar #2 Program Outcome #4 Integrate professional values through scholarship and service in health care: This course has helped me translate my current knowledge into practice while building confidence in caring for patients at all level in health care delivery system. I think this class really help to provide knowledge about prescription authority, medication information, errors and how to reduce risk among patient. This student also learned the process and importance of reconciling medicines particularly in elderly patients to avoid polypharmacy complication. On the same hand, it is very important for this student as a primary care provider to regularly interact with other specialists in order to prevent overlap and missed orders. MSN Essential IX: Master’s-Level Nursing Practice: This student accomplished this vital by actively engaging in all the class discussion, presentations and questions of the teacher using academic, revised and peer-reviewed articles that endorsed the purpose of practice on the basis of evidence (Hudspeth, 2016). 11 PORTFOLIO 2 NP Core competency # 6 Policy Competencies: Many local, state, and federal programs are available to support clinicians in preventing and mitigating drug abuse and how to administer safe medicine. This student was able to achieve this ability by studying and knowing and incorporating these policies into her practice (Hudspeth, 2016). This experience was also gained by understanding the risks of abuse of the drugs on patients and their quality of life. Concepts Safety: This exemplar explains the value of maintaining patient health both from real and possible harms. This example focuses on how NP can use its learning to provide patient-centered treatment and use available tools and evidence to ensure their health in all types of patient care (Hudspeth, 2016). Patient safety is most important part for all healthcare provider. Clinical Decision Making: This example illustrates how a new NP will use its clinical decision-making capabilities to evaluate their patient care preparation, diagnosis, implementation and assessment. Clear clinical decision taking is key to health outcomes and patient care (ANA, 2019). This expertise includes knowledge of different types of medicine that are administered to the patient with and without any other comorbidities. Reflection Throughout this class, this student regularly engaged in discussion threads and assignments focused on creating care plans for patients with various comorbidities, considering their experiences with other current medicines and medical diagnosis, and predicted medication outcomes. Advanced pharmacology awareness is very important for a good career in NP. Patient awareness about their medication was essential to this class because many drug related concerns can be easily avoided if patients have knowledge about their own medication and its effect on their body (Hudspeth, 2016). 12 PORTFOLIO 2 As a primary care provider, we need to educate our patient, and to do so, this student uses on her phone apps like epocrates to search for drug knowledge. Use EHRs makes it easy to warn patients about reactions and drug interactions with other medications. It also makes it easier to share the patient's drug history with a specialist and pharmacy who initiates the treatment process faster than to drop the script personally to the pharmacy and wait for the drugs to be ready (Porterfield, Engelbert, & Coustasse, 2014). Exemplar # Three NR 509 Advanced Physical Assessment Summary of Reflection: This course has helped student to achieve the program outcome number one in many ways. The Shadow Health assignments enabled to gain experience in providing quality and safe patient care while focusing on the holistic principles of the patients. Although the weekly shadow health assignments were system focused, other health systems were evaluated to assess and treat the patient’s overall health and wellbeing. This course has been challenging as student learned to expand knowledge and help to make assessment skills perfect. This course has strengthened assessment skills and knowledge on how to adequately obtain a thorough health history. The Student learned the importance of building a good rapport with the patient and family member that could help divulge pertinent information to help identify a diagnosis. The immersion weekend was a weekend full of very useful knowledge. Appearing at the Immersion Weekend was also one of the ideas for achieving the program's outcome. This weekend, the student learned assessment techniques, such as palpation, percussion, and auscultation, which provided her with a thorough assessment of her patients.3P Exam helped the student to identify her weak areas that need more attention. The three areas that she scored less was Men’s health, urology and pregnancy. After this, this student made sure to 13 PORTFOLIO 2 read and prepare herself for next APEA exams and national licensure exam. I plan to incorporate studying not only these three categories, but all domains to increase my knowledge and understanding of my future role. Chamberlain Program outcomes, MSN Essential and/or NONPF Competencies Met by Exemplar #3 Program Outcome #1 Provide high quality, safe, patient-centered care grounded in holistic health principles: Advance physical assessment class has helped me establish a strong framework to achieve program outcome by providing classwork information on how to complete a history and physical assessment on a patient. The “scatter group” classes gives experience and knowledge to identify, diagnosis, and treat various ailments our patients will present with. MSN Essential I Background for Practice from Sciences and Humanities: The student achieved this essential by participating in discussion during debriefing session with instructor and classmates. During the debriefing process, students reflect upon their simulation experience and revisit their assessments, interventions, observations, and patient response through virtually. The delivery of evidence-based practices ensures improved and improved patient outcomes (Melnyk, 2018). Holistic care is essential part which uses from evidence based. NP Core Competency #1 Scientific Foundation Competencies: competence was achieved through the use of scientific knowledge concepts to gather health- from patients to meet their health needs and objectives (NONPF, 2017). This class provided the student with an assessment tool and a reference to the collection of subjective and objective data, using the OLDCART, SOAP note format to collect and document the history. With advanced physical assessment class, this student learned the techniques of how to ask more questions relevant to their chief complaints and identify the difference between normal and abnormal findings. At the end of this 14 PORTFOLIO 2 class, this student learned the role of different race, ethnicity, culture, lifestyle habits increase the likelihood of developing certain diseases. Concepts Assessment: This exemplar describes skills and techniques of performing body assessment, which is the first step in nursing process (American Nurse Association [ANA], 2019). Throughout the assessment process, the new graduate NP must identify opportunities for health promotion and educate patients and coworkers as needed which includes maintaining a safe environment through the use of effective infection control concepts. Nursing Process: This exemplar defines nursing method as an integral component of patient-centered care practice (ANA, 2019). The nursing process includes the steps of assessment, diagnosis, planning, implantation and eventually assessment of interventions 'efficacy (ANA, 2019). This student learned the principles of the nursing method during this class which covers whole physical exam and will use them in future for patient care. Reflection Advanced physical assessment course has taught the student many valuable tools that the student will utilize in current and future practices. This course challenged for student and required to utilize critical thinking skills and research skills in order to perform well on weekly debriefings, assignments, and exams. This class taught the student how important is to collect detailed history which includes subjective and objective data can help to identify the future risk and established the proper diagnosis. The student gained the skills that includes writing SOAP notes, differential diagnosis, assessmnet and planning as per diagnosis. Creating the SOAP note is important and the student learned in depth about how to create SOAP note by daily practice. Also, achieving program outcome number one was by attending Immersion weekend and learning 15 PORTFOLIO 2 about different body systems, diseases, and assessment techniques while rotating through various nursing stations. These learning activities exposed the student to high-quality assessments for patient-centered care. This class will help the student to continue grow from a variety of educational and clinical experiences that will enhance future practices. Advanced physical assessment course has taught the student many valuable tools that will utilize in current and future practices. Exemplar #Four NR 510: Leadership and Role of the APN APN Professional Development Plan Paper Preparing for this assignment helped the student learn how to become a good new NP graduate. This student learned more in depth about the nature of APN experience during this task. This student carried out her own personal evaluation and built a strategy using networking and marketing tactics to get a job as a new FNP. Conducting personal assessment helped us to consider any weaknesses and strength. Due to the new work requirement and being inexperienced in the field the transitory time between the graduate NP and the newly hired NP can be very demanding and stressful. This class, however, made this student conduct their own personal and professional assessment which helped her recognize her strengths and weakness as a newly hired NP. This will help her concentrate on things she wants to pay more attention to enough knowledge and confidence will help the new NP to develop the smooth plan from one phase to another. To start from novice to expert practitioner the student uses 5 steps within the model and use of this model this student will better understand their weakness and strengths to obtain the future goal as well as set up the proper outline for the future practice. To focused care as a 16 PORTFOLIO 2 novice, a new practitioner’s drive practice by rules. From advance beginner to competent provider the new NP must prioritizing and begin to form their care by using past experiences which help to prioritize needs and routinely predict accurate outcomes. Through current geriatric experience, this student feels more comfortable to interact and establish therapeutic relationships through adults and elderly people. This student is also very positive in giving adult and their families health education. In addition to English, this student has the ability to read, write and speak Hindi and Gujarati which can be used as an additional aid in connection with her patients. With her desire to speak more than one language she feels like breaking the language barrier. Working as nursing director, this student depends on her leadership, mentoring, administrative, and managerial responsibilities. DON's position in public and private insurance and its reimbursement policies has also made her knowledgeable. The one thing that this student feels less comfortable is prescribing her patients right medications. The state of New Jersey falls in to Reduced practice states where NPs are requiring having physician supervision for some actions. Despite this, New Jersey NPs are considered as ‘licensed independent providers. They have right to diagnose and treat their patient medically without any supervision by physicians (Nurse Practitioner scope of practice, 2014). The prescription pad of NJ NPs carries information of NP and collaborative physician. Even though, the NPs of state of New Jersey are given authority to announce the death of the person, the cause of death must be determined by MD. An A.P.N. in New Jersey, prior to prescribing any medication or medical device need prescriptive authority and is required to have a joint protocol with a collaborating physician who is licensed in New Jersey ((Nurse Practitioner scope of practice, 2014). 17 PORTFOLIO 2 Professional Scope is a national occupational specialty, and advanced practice registered nursing organizations broadly defined scope of practice for each role. The state of New Jersey falls in to Reduced practice states where NPs are requiring having physician supervision for some actions. NPs should have collaboration with NJ physician in order for them to write the scripts. Such collaborative physician can be reached out off-site via means of e- mail, phone call, or video conference (Nurse Practitioner scope of practice, 2014). Newly graduated NPs could begin to practice right after completion of their NP program and before appearing for their national NP certification exam. They will also apply for work permit so that they can train before certification. The NJ state is entitled to withhold this temporary work permit if the test fails twice (Nurse Practitioner scope of practice, 2014). To overcome the feeling of making mistakes and failure, my primary focus would be on learning proper history taking and acquiring assessment skills to properly diagnose and prescribe right medications to my patients, so to avoid the complications of misdiagnosis and medication errors. In order to be productive and obtain a decent job in the current competitive job market, NPs need clear and efficient marketing and networking strategies that require careful preparation to be implemented (Phillips, 2012). An overview of your strengths, potential objectives, weaknesses, ambitions, and opportunities is also equally relevant (Phillips, 2012). Job searching can be done through web sources and newspaper ads, yellow pages, technical magazines or publications (Phillips, 2012). NPs that benefit from becoming or being a member of national or state professional organizations, such as the American Association of Nurse Practitioners (AANP), the American College of Nurse Practitioners (ACNP) (Nurse Practitioner Schools, n.d.) I am an active and current member of the National Association of 18 PORTFOLIO 2 Indian Nurses of America (NAINA) which sends various ARPNs and RNs posting jobs to their members. I expect to use work posts from this association in future to help me find a job. It takes time to apply via internet sources and removes the ability to show the employer your professional skills. Contacting and applying directly to the facility or making use of personal and professional connections in seeking a job is more accurate and efficient. NPs may use their professional and social connections to pursue a job, including their preceptor physician. AANP is one of the largest nurse practitioners 'associations that not only provides opportunities to NPs but also offers free continuing education credits, updated healthcare topics, invitations to seminars and conferences, and professional development and networking tools (AANP, 2017). Professional networking is defined as a community or person to which NPs can connect in various ways in order to promote their own work practices (Taylor, 2013). Some of the networking methods include physical face-to-face contact and virtual communication through email, video chat, telephone conversation and the use of other social media (Taylor, 2013). NPs will, however, consider networking with the community to encourage them to grow and evolve professionally, strengthen their clinical work practices, and provide them with an opportunity to bring positive improvements to the healthcare environment and positively impact patient care. As a future NP, student should have personal goals, strengths, objectives, planning and opportunities is important for effective networking as well as positive health environment. References American Association of Nurse Practitioners. (2017). Retrieved November 21, 2017, from New Jersey Scope of Practice Policy - State Profile. (n.d.). Retrieved November 11, 2017, from 19 PORTFOLIO 2 Nurse Practitioner Scope of Practice (2014). New Jersey. Retrieved November 20, 2017, from Phillips, B. C. (2012). Marketing-getting specific. Nurse Practitioner World News, 17(1/2), 1-9. Taylor, R. (2013). Networking in primary health care: How connections can increase social capital. Primary Health Care, 23(10), 34-40. Chamberlain Program outcomes, MSN Essential and/or NONPF Competencies Met by Exemplar #4 Program Outcome #3: Engage in lifelong personal and professional growth through reflective practice and appreciation of cultural diversity This student obtained this outcome by creating her own professional development program, by defining her strengths and weaknesses. She identified the methods for overcoming her limitations and learned how to make her transition from nursing to advanced position easier. She is pleased in her multilingual ability to provide culturally diverse treatment. During her nursing career, she also built strong administrative and leadership skills which will support her in her new position as APN. MSN Essential IV: Translating and Integrating Scholarship into Practice This principle illustrates the need to recognize and apply the technical expertise to our work. Through knowledge and evidence derived from robust scholarly methods should drive NP’s clinical practice, decisions and change to improve the way she delivers care for the patient. Translating research evidence to clinical practice is essential to safe, transparent, effective and efficient healthcare provision and meeting the expectations of patients as well as family. NP Core Competency # 9 Independent Practice Competencies 20 PORTFOLIO 2 This student accomplished this core competency by developing her own professional development plan to recognize her weak and strong areas and then built a strategy for a smooth transition from inexperienced to professional level and in the future becoming a prosperous NP (NONPF, 2017). Concepts Legal Issues: This example allowed this student to define NP's function and scope in different states and compared it to New Jersey state. New Jersey has limited scope of practice, and this student has discovered the limits that she will have as an NP in New Jersey state in the future (Nurse Practitioner scope of practice, 2014). Cultural diversity: Is described as awareness and appreciation of various values, health attitudes, and behavioral thinking among different populations (American Nurses Association [ANA], 2019). This example illustrates how this student established their career plan by studying the principles of cultural diversity to be a productive one in future. The student's expertise in more than one language would allow the student to support culturally diverse patients in the future. Reflection To enter and prepared the advanced practice nursing profession, this course has furthered the student knowledge and leadership abilities with knowing the strength and weakness of area and needs of improvement. The student knows the role of a nurse practitioner and leader are united with a common goal to influence others, creating change, and patient advocacy. To know the course A student should have a vision for the future with the courage to make that concept happen. Healthcare is always changing, which is one aspect of nursing that keeps it exciting and with that new aspects the student will improve herself for weakest area and keep updating herself 21 PORTFOLIO 2 with policy and procedures. The essentials, and the leadership competencies of this course have better prepared the student to become an efficient Nurse Practitioner. Exemplar Five NR 511- Differential Diagnosis: Case study: H&P A 56-year old Caucasian female reported to the clinic with Chief complain of constant Fatigue for 2 to 3 months. She reports the symptoms feeling of tiredness, getting worse since its onset, reports sleeping 8 hours/night but still feel unrested. Aggravating factors is Exertion that increased fatigue and 2 week ago she missed work for 1 day because she “couldn’t get out of bed”. ROS: Reports 5lb of weight gain in last 6 months, problem of constipation, Positive Cold intolerance, worsening of depressive symptoms, generalized weakness, and intermittent muscles cramp in calves. Past medical history shows depression, HTN and postmenopausal status. Family history is significant for cardiac diseases such as HTN, hyperlipidemia, DM and her youngest son is having Bipolar depression, ADHA and anxiety. Significant findings on Physical Exam are reveals BP-146/95mmhg, weight- 180lbs, B/L tonsillectomy, skin- dry, coarse and thick, and +1 deep tendon reflexes at knees and ankles. Hypothyroidism: Hypothyroidism, also called underactive thyroid or low thyroid, is a disorder of the endocrine system in which the thyroid gland located in the neck does not produce enough thyroid hormone (National Institute of Diabetes and Digestive and Kidney Diseases, 2016). In blood, almost all thyroid hormone (99.97%) is bound to plasma proteins such as thyroxine-binding globulin; only the free unbound thyroid hormone is biologically active. 22 PORTFOLIO 2 Overexpression of deiodinase can thus lead to consumptive hypothyroidism (Weber et. al., 2017). This is my first differential diagnosis due the presence of following positive pertinent symptoms: Reports fatigue in the last 2-3 months, 5-pound weight gain in 6 months, constipation, cold intolerance, generalized weakness, intermittent muscle cramping in calves, and increased depression; overall dry skin; coarse hair; and 1+ reflexes at knees and ankles. Pertinent negative symptoms: Low thyroid level slows down the forces and speed of body process including heartbeat and blood pressure and causes symptoms such as bradycardia, hypotension, low body temperature which in above given patient is not present. Thyroid is midline, small, and firm without palpable masses; no hair loss, brittle nails, bradycardia, or edema On contrary, her vitals are T- 98.2, HR-74bpm, and BP- 146/95mmhg and thus, this could not be one of the real diagnosis (Vigario et al., 2013). Depression: Even though there are numerous studies attempting to shed light on the pathophysiology of depression, it remains elusive. This is in fact the major reason for the slowpaced drug development against this disease. For decades, depression pharmacotherapy and a resultant explanation for the underlying pathology. The monoamine-deficiency hypothesis suggests that symptoms are related to decreased levels of norepinephrine, serotonin, and or dopamine in the brain (Cai, Huang, & Hao, 2015). Pertinent positive findings: constant, generalized fatigue x 2-3 months; lacks energy for daily activities; weight gain; history of depression; takes Prozac 20 mg; increased depression attributed to feeling unproductive that are related to the common symptoms of depression (De 23 PORTFOLIO 2 Man-van Ginkel et al., 2015). Pertinent negative findings: no suicidal or homicidal thoughts; no irritability, no history of a sleeping disorder or any other abnormality noted. IRON DEFICIENCY ANEMIA: Iron is essential for the production of hemoglobin. The depletion of iron stores may result from blood loss, decreased intake, impaired absorption, or increased demand. Iron deficiency will lead to microcytic hypochromic anemia on the peripheral blood smear. Because iron is the most common single-nutrient deficiency (Warner & Kamran, 2018). The causes of iron deficiency anemia include blood loss, inadequate iron intake, increased demand for iron, or poor iron absorption. Pertinent positive findings: fatigue x 2-3 months; generalized weakness, lacking energy for daily activities, intermittent muscle cramping in calves. Negative pertinent symptoms are: Weight gain of 5 lb., negative psychosis symptoms, BP-146/95mmhg (High BP), Temp-98.2, HR-74 bpm, negative symptoms of abdominal pain and other GI symptoms, mental confusion, tachycardia, tachypnea, murmur, pallor of nails, or koilonychia; no menstruation. To confirm the diagnosis of hypothyroidism, Laboratory testing of thyroid stimulating hormone levels in the blood is considered the best initial test for hypothyroidism, So, I would order blood test which includes Thyroid stimulating hormone (TSH), Free T3, Free T4 and anti- TPO antibodies (Sheehan, 2016). Anti-TPO antibodies stands for anti-thyroid peroxidase antibodies is an enzyme which is involved in synthesis of T3 and T4. The presence of anti-TPO antibodies in the significant sign of presence of any autoimmune thyroid disease, especially Hashimoto’s thyroiditis (Sheehan, 2016). To rule out my other differential diagnosis of depression I would use the Patient Health Questionnaire (PHQ-9) which is useful for monitoring functional impairment, symptoms, and 24 PORTFOLIO 2 treatment outcomes in patients with depression. Standardized screening tools such as the Zung Self-Rating Depression Scale and the Beck Depression Inventory (BDI-II) can be administered as an initial part of the diagnostic process of depression (Holle & Pravikoff, 2018). References: Cai, S., Huang, S., & Hao, W. (2015). New hypothesis and treatment targets of depression: An integrated view of key findings. Neuroscience, 31(1), 67-74. doi: 10.1007/s- 1486-4 De Man-van Ginkel, J. M., Hafsteinsdottir, T. B., Lindeman, E., Geerlings, M. I., Grobbee, D. E., & Schuurmans, M. J. (2015). Clinical manifestation of depression after stroke: Is it different from depression in other patient populations? Plos One, 10(12), e. Holle, M, N., Pravikoff, D. (2018). CINAHL Nursing Guide, EBSCO Publishing, 2018 Nov 30 (Quick Lesson - CEU), Database: Nursing Reference Center Plus. National Institute of Diabetes and Digestive and Kidney Diseases. March 2013. Archived from the original on 5 March 2016. Retrieved 5 March 2016 Sheehan, M. T. (2016). Biochemical testing of the thyroid: TSH is the best and, oftentimes, only test needed - A review for primary care. Clinical Medicine & Research, 14(2), 83–92. Vigario, P. dos S., Vaisman, F., Coeli, C. M., Ward, L., Graf, H., Carvalho, G., … Vaisman, M. (2013). Inadequate levothyroxine replacement for primary hypothyroidism is associated with poor health-related quality of life-a Brazilian multicenter study. Endocrine, 44(2), 434–440. 25 PORTFOLIO 2 Warner, M, J., Kamran, M, T. Anemia, Iron Deficiency. [Updated 2018 Nov 14]. In: Stat Pearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2019 Jan-. Available from: Weber, Pasa, M., Selbach, Scheffel, R., Borsatto, Zanella, A., Maia, A, L., Dora, J, M. (November 2017). "Consumptive Hypothyroidism: Case Report of Hepatic Hemangioendotheliomas Successfully Treated with Vincristine and Systematic Review of the Syndrome". European Thyroid Journal. 6 (6): 321–327. doi:10.1159/. PMC . PMID . Chamberlain Program outcomes, MSN Essential and/or NONPF Competencies Met by Exemplar #5 Program Outcome #5 Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice This student obtained this result by correctly diagnosing the patient by gathering the information needed and then reviewing the facts relevant to particular disease. This result was also accomplished by presenting patients with the most reliable evidence for effective care and awareness for diseases. The student has obtained the outcome by working with her preceptor and other professional on her treatment plan to improve the patient care (Melnyk, 2018). MSN Essential III: Quality Improvement and Safety This student met this vital of quality management and safety by collecting subjective and objective data, past medical, personal, social, surgical history from patients as well as family members in a family practice office during my clinical encounters. She also conducted physical examination, and based on this knowledge, she separated abnormal findings from standard and order diagnostic tests. She discovered during this case study how to differentiate medical 26 PORTFOLIO 2 diagnosis from mental health diagnosis and screening methods that can be used to rule out mental health disorders. This knowledge is important for making the patient's final diagnosis and establishing their treatment plan that includes medications, further testing, referral, appropriate medication and disease education, and follow-ups. NP Core Competencies #4 Practice Inquiry Competencies: This student was able to acquire this ability by learning to base differential diagnosis on knowledge obtained and then using the latest evidence and data. She may rule out other variations and make final diagnoses. Preparing case study helped her use such facts to establish care plan. The student will able to fulfill the gap by identify the proper diagnosis, identify the differential diagnosis and treat accordingly. Using evidence-based practice also helps clinicians increase the overall quality of the patient's wellbeing and decreases treatment and cost variability (Melnyk, Gallagher‐Ford, Long, & Fineout‐Overholt, 2014). Concepts Critical Thinking: This example allowed the student to use of her critical thinking skills and sharpen them in making differential and final diagnoses. This example illustrates how to gather appropriate positive and negative data based on patient chief concerns for NP and use critical thinking skills to identify the patient diagnosis appropriately and effectively to discourage patient from misdiagnosing hazards and further complications (Balogh, 2015). Managing Care: This example focuses on the importance of how as a new NP managing patient care more efficiently which will not only help a new NP gain trust in their individual practice and patient but will also protect patients from misdiagnosing complications. It will also assist new NP progresses from beginner to experienced stage (Balogh, 2015). Reflection 27 PORTFOLIO 2 During this class the student will learned from her preceptor about how to take the complete history and do physical examination. Also, how to differentiate the diagnosis as well. The student will learn about the subjective and objective data collection and formet the complete SOAP note. The student preceptor helps the student to identify the problem and how to assess in actual way. This class will help the student in real way to perform the different examination and ensure to make correct diagnosis and thinking about the critical and differential diagnosis. This student preceptor helps and teach in many well-exams, sick exams, pre employment exam, hospital follow-ups, and exams of patients with many controlled and uncontrolled illnesses. The student learned how to use quite a few features within the electronic medical record (EMR) in clinic. Also, she learned about the writing e-prescription and soap notes, as well as the billing code, diagnosis code and writing the patient note. The preceptor allows the student to see and review the note of patient care as well as he teaches student how to work on with this software. She came across several patients with chronic conditions including diabetes, hypertension, thyroid disease and hyperlipidemia during this study. On this basis, she learned about existing and revised clinical practice guidelines for hypertension, hyperlipidemia and diabetes and will apply and monitor real patients as needed. She learned during this class how research makes it possible for primary care providers to inform their patients about their health condition and how important it is for them to accept it. Using SNAPPS model to introduce her preceptor and mentor to the patient is a simple way to know the condition of the patient without missing something and it encouraged her learning as a new NP. She thought that this class was the cornerstone of her clinical practice career and after this class, she felt more comfortable in interacting with patients. Exemplar Six 28 PORTFOLIO 2 NR 601 Care of Aged Family Practicum Course Reflection: During this class the student gain lots pf knowledge regarding different type of examination, screening test for breast cancer, cervical cancer, prostate cancer and others. Also, this class helps the student to gain knowledge in depth. Student gain knowledge about the screening tools for mental health problem like PHQ-9 and GAD tool which is mostly useful in primary care for early detection. This course is more in depth then NR511 which includes patient’s symptoms, pathophysiology, diagnoses, plan of care, and when to treat symptoms. This class has been very beneficial for student for the simple fact the majority of clinical site population seen in clinic are advanced in age. As described throughout the readings for this class, the elderly may respond differently to medications due to their comorbidities, organ deterioration, and body fat. The student clinical experience this class was much better as she is feeling more confident in herself. She asks the preceptor this time in depth about the diagnosis, assessment and final treatment which helps the student to gain vital knowledge and inner growth. This class helps the student to know about the Beer’s criteria and other tools that can assist her in more efficiently identifying potentially harmful or unnecessary medications being taken by our elderly patients during a short office visit. The student learned the way a clinical preceptor can address polypharmacy is knowing when to refer the patient to a specialist that can help manage co-morbidities and why it is important to do the medicine reconciliation with every patient (Mestres, Puerta, Hernandez, Agusti, & Llagostera, 2016). This course has allowed for new knowledge to be gained to provide patient-centered, compassionate, and evidence-based practice care to every patient encountered in clinical and future practice. This class shows the elderly treatment differ from the young people which is 29 PORTFOLIO 2 vitally important and needs more skills to consider in the plan of care (Kennedy-Malone, Plank, & Duffy, 2019) References: American Association of Colleges of Nursing [AACN]. (2011). The essentials of master’s education in nursing. Retrieved from MastersE Kennedy-Malone, L., Martin-Plank, L., & Groenke-Duffy, E. (2019). Advanced practice nursing in the care of older adults. Philadelphia, PA: F.A. Davis Company. Mestres, C., Puerta, L., Hernandez, M., Agusti, A., & Llagostera, B. (2016). Improvement of drug treatment in elderly patients, through the collaborative work between pharmacists and physicians. International Journal of Integrated Care (IJIC), 16(6), 1–3. Chamberlain Program outcomes, MSN Essential and/or NONPF Competencies Met by Exemplar #6 Program Outcome # 5: Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice: This goal will achieve by advocating the patient for a positive outcome by being compassionate, collaborating with other providers and using evidence-based practice. Also, through screening test, proper treatment and assessment and using clinical guideline helps the student to achieve the goal and ensure the best patient safety and outcome. Masters Essential VIII: Clinical Prevention and Population Health for Improving Health This essential is important about health promotion includes recommendations to optimize one's health, whereas disease prevention includes counseling, screenings, and chemoprophylaxis for 30 PORTFOLIO 2 the various levels of prevention which includes primary, secondary, and tertiary level. She learned about diagnosing and treating and providing chronic management of older adults with a variety of disorders. During week 2, she prepared a discussion on the guideline for heart failure, its classification, and management. She learned how heart failure and its treatment are based on age-group, ethnic group- African Americans, the presence of other comorbidities such as diabetes, hypertension, and chronic kidney disease patients. Student learned how important it is to keep in mind other considerations while treating heart failure patients (Yancy et al., 2017) NP Core competency # 8 Ethics Competencies: In-patient treatment is very important to use ethics in decision-making (NONPF, 2017). Many patients come to the clinic and need regulated pain medication without trying any non-pharmacological treatments and use milder types of analgesics merely because they have learned about it from any friends or TV advertisements. This student has seen their preceptor describe the dangers and benefits of opioids and their existence of dependency and make decisions for patients rather than prescribing drugs without clarification. Likewise, as his first intervention, he recommends all his patients on lifestyle change to track and control their new onset of elevated HBA1c and lipid panel and continuously monitor them on routine follow up for prevention of future complication. Sometimes, many of patient demands to prescribe the antibiotics for the viral illness which is unnecessary for that illness. The student and her preceptor advice the patient about the risk of taking needless antibiotics in this scenario (Center for Disease Control and Prevention [CDC], 2018). Concepts 31 PORTFOLIO 2 Professional Behavior: This exemplar describes some good qualities which demonstrates accountability, responsibility, and respect for patients and families, including appropriate verbal and nonverbal communication as NP should acquire during future practice (The University of Arizona, 2019). Quality Improvement: This concept teaches patient-centered and culturally responsive strategies in the delivery of clinical prevention and health promote on interventions and/or services to individuals, families, communities, and aggregates/clinical populations. This student was able to improve the quality of the care that is provided be her by promoted low carb diet, tobacco cessation, and physical exercise in each patient at least three times a week thirty minutes each. I promoted healthy mental and physical habits to prevent the occurrence of chronic diseases and mental health illnesses. Reflection This course has taught the student to evaluate ethical consequences of decisions through the reading assignments each week. The reading assignments stressed how the client’s autonomy should be considered in every treatment plan. Each plan should be explained in detail to the patients and allow the patients to ask questions and if the patient makes the decision not to have a test for whatever reason or if there is no reason, the patient needs to be allowed to make their own decision about their health whether that goes along with your opinion or not. Providers should not try to use statistics or numbers to support the reason for ordering the test because that would not be ethically sound. A provider should always consider ethical consequences of their decisions. She should learn about the patient care is priory and she should find out the reason if patient not feeling comfortable. 32 PORTFOLIO 2 She learned how heart failure and its treatment are based on age-group, ethnic group- African Americans, the presence of other comorbidities such as diabetes, hypertension, and chronic kidney disease patients. She learned how important it is to keep in mind other considerations while treating heart failure patients. She developed a patient-centered case study on a diabetes patient during week 5 of this class including her treatment plan, information on changing the healthy lifestyle, referrals, and follow-ups. She made a list of and prioritized her primary and secondary diagnosis. There was a primary diagnosis based on her chief concern, symptoms and medical tests. Reading and answering back to peer post also helped her achieve this class 'learning target (American Diabetes Association [ADA], 2018). Exemplar# Seven NR601- Primary Care of the Maturing and Aged Family Case Study Assignment The purpose of the case study was to explain the process of nurse practitioner role implementation as it was occurring and to identify factors that could enhance the implementation process. Case study introduce realistic patient practice scenarios, which helps Nurse practitioner to analytical skills needed to successfully evaluate and treat patients. The case study is identifying the chronic disease and applied the knowledge to identify the subjective as well as objective data and planning the treatment based on evidence-based guidelines and American diabetic association criteria. This case study is on 59-year Asian women who have complained of weight gain and fatigue including symptoms of hungrier and thirstier. The student will further review the SOAP note on base of the case study findings, also it will extensively discuss the 33 PORTFOLIO 2 assessment, differential diagnosis, medication, education, referrals cost of medication and detailed SOAP note. Assessment Primary diagnosis: Diabetes Mellitus (E11.9) Secondary diagnosis: Hyperlipidemia (E78.5) Differential Diagnosis: Metabolic syndrome (E88.81) Diabetes Mellitus Pathophysiology Type 2 diabetes deficiency occurs mostly in insulin secretary that is due to inflammation and metabolic stress in some of the contributing factors like genetics factors. The other pathophysiology includes degeneration of B-cell and its function for insulin secretion causes impaired glucose (hyperglycemia) status like normal, impaired or diabetics (Skyler et al., 2017). Pertinent positive findings Positive findings are age, race, symptoms of excessive hungry and thirsty, BMI 30. 67 (obesity), glucose 127, HgA1c 6.6% which are positive findings for diabetic mellites (ADA, 2019). Pertinent negative findings Normal and intact skin, normal CBC, TSH value, denies any symptoms of numbness and tingling. Normal vital signs (ADA, 2018). The student chooses this diagnosis based on patient complains, lab values and positive symptoms. Patient HGA1C is 6.6% and blood glucose 127 which meets the criteria for diabetes. Also, other risk factors like her race (Asian), age (59 years), her BMI (30.67), 34 PORTFOLIO 2 symptoms (polyphagia and polydipsia) that all strongly associated to confirm the diabetic mellites (ADA, 2019). Hyperlipidemia Pathophysiology The plasma lipids like triglycerides, cholesterol, low- density lipoprotein all is increasing in the blood. Mostly it is characterized by a high level of lipids in the blood. Due to the deposition of this fat in the wall of arteries causes the narrowing of the arteries. These all plasma protein elevations are risk factors of cardiovascular diseases. Usually, hyperlipidemia is classified as primary and secondary and it does not show any symptoms typically (Shattat, 2014). Pertinent positive findings are Lab value shows Total cholesterol 215 mg/dl, LDL 144mg/dl, triglycerides 229. Patient lab value is abnormal. Normal range of total cholesterol <200mg/dl, HDL > 40MG/DL, LDL < 130MG/DL, TRIGLYCERIDES <200MG/DL (Paul, 2018). Pertinent negative findings are Normal vital signs. Normal sinus rhythm and EKG normal. S1 and s2 normal without murmurs and rubs The student selected this diagnosis based on her complain of fatigue in the last 2 months, her BMI 30.67 and blood work. Her lipid panel shows abnormal triglyceride and LDL. Her triglycerides are 229, LDL 144, HDL 32, TC 215; the normal for triglycerides less than 150, LDL is less than 100, and HDL is greater than 40, and the TC less than 200, this would indicate hyperlipidemia (ADA, 2019). Differential Diagnosis: Metabolic syndrome (E88.81) 35 PORTFOLIO 2 Pathophysiology Metabolic syndrome covers several disorders together and it is affected by body systems. It is also called syndrome X and insulin resistance syndrome. Metabolic syndrome includes resistance of insulin, hypertension, obesity and, hyperlipidemia. The complex pathophysiology state that imbalance of intake calories and energy distribution affect the person genetics. (Saklayen, 2018). Pertinent positive: Her BMI 30.67 which considered as an obesity, Triglyceride level 229 which considered as hyperlipidemia and fasting blood glucose 127, HGA1C 6.6% which associated with diabetic mellites (Saklayen, 2018). Pertinent negative: Blood presure normal and vital within normal limit. TSH and urine result under normal value The student chooses this diagnosis as a differential because three criteria matches with metabolic syndrome which are diabetic mellites (HGA1C 6.6 % and blood glucose 127), Hyperlipidemia (Triglyceride 229, LDL 144), Obesity (BMI 30.67). That all lab values associated with this disease (Saklayen, 2018). Management Plan Diagnostics As I should recommend the rescreening for type 2 diabetic with informal assessment risk factors. The second screening test for HGA1C and Blood sugar will be ordered for confirmed the diagnosis (ADA, 2018). If the lab value of HGA1C and FBS will meet the criteria that will decide the confirmation of diagnosis. Also, I will conduct thorough history and physical examination to find out the associated risk factors. For metabolic syndrome, I 36 PORTFOLIO 2 will further order liver penal, c-reactive protein and uric acid to support the diagnosis (Chiarelli & Mohn, 2017). Besides that, I would not order any further diagnostic tests for evaluation. For a future diagnostic test, I will order vit B12 because long term metformin therapy cause b12 deficiency, HGA1C to monitor blood sugar level (ADA, 2019). I will obtain a lipid panel after 4-6 weeks of statin therapy to monitor the response of the medication and compliance (ADA, 2019). Medications Metformin 500 mg Disp # 60 Sig: 1 tab by mouth twice daily for DM Refill: 2 Metformin has the strongest evidence of long-term safety for the prevention of diabetic mellites. Also, this medication is available with cost-saving for everyone (ADA, 2019). Metformin is only one anti-diabetic drug that usually do not causes hypoglycemia. Due to several of the benefits like prevention of hypoglycemia, weight control, and fewer side effect, this is a safe drug to prescribed for Mrs., Wong (Nasri, & Rafieian-Kopaei, 2014). Lipitor 20 mg Disp # 30 Sig: 1 tab by mouth at bedtime Refill: 1 37 PORTFOLIO 2 Diabetic is associated with a high risk of cardiovascular diseases (ADA, 2019). The longer use of statin helps to prevent mortality and morbidity. Also, this drug is effective in lipid-lowering that is analytic and confirmed by Adams et al. (2015) and he concluded that this drug is more effective in women than men. Diabetic is the leading cause of cardiovascular disease and statin is beneficial in DM and it should be used as primary prevention in age between 40 to 75 years and LDL level id between 70 to 189mg/dl (Cui et al., 2018). Aspirin 81 mg Disp: 30 Tab Sig: 1 tab by mouth daily Refills: 1 Aspirin has its primary effect on the prevention of cardiovascular disease in a diabetic patient as well as reduced the risk of cardiovascular diseases (ADA, 2019). Diabetes patients can utilize Aspirin treatment as an auxiliary anticipation. Additionally, I can clarify and check if any contraindication and bleeding problems before endorsed this medicine (ADA, 2019). Education Clinical results, wellbeing status, and personal satisfaction are key objectives of diabetes self-management education as routine care. Diabetes self-education instruction and backing can improve results and decrease medical costs (ADA, 2019). Education is necessary and fundamental part of any diagnosis evaluation and its further progress. I would educate her regarding the disease and its preventative measures. Disease Specific Teaching 38 PORTFOLIO 2 I would teach her the sign and symptoms of hyper/hypoglycemia and its preventative measures. Assess and monitor the foot and skin condition, notify to the physician if any abnormality noted (ADA, 2019). I would advise her to keep the self-glucose monitor log and check the blood sugar level on daily base (ADA, 2019). Advise her to compliance with all medication. As per her abnormal lipid level, teach her about preventive measures. I would educate her to monitor any sign and symptoms of heart attack and stroke and immediately seek the medical care. She must adopt the lifestyle changes program including exercise, weight control, diet, monitor abnormal symptoms and notify to physician about any queries related to diagnosis (