NIGHTINGALE COLLEGE DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET NURSING PROCESS TEMPLATE: Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? • Subjective Data: Jameela's report of feeling anxious for almost a year. ⚫ Difficulty sleeping and concentrating. Increased feelings of irritability and fatigue. Physical symptoms: nausea and diarrhea. Persistent worries about work performance (forgetting clients) and health (diagnosis of cancer). • Reduced work hours due to anxiety Objective Data: • Age: 40s. Profession: Successful lawyer, indicating a high-stress occupation. • No notable medical history or trauma. Mental Health History: Duration of symptoms (almost one year). Impact on daily functioning and work (cutting back hours). Most Important Client Data: Duration and persistence of anxiety symptoms. Physical symptoms that could indicate anxiety (nausea, diarrhea). Impact on occupational functioning (cutting back work hours). Difficulty concentrating, which can affect job performance. Immediate Concerns: • The physical symptoms (nausea and diarrhea) may require further evaluation to rule out any underlying medical issues. The risk of worsening anxiety and its potential effects on Jameela's professional life and overall well-being. The possibility of anxiety leading to burnout or significant impairment in daily functioning. Consistent Client Conditions: Jameela's symptoms are consistent with Generalized Anxiety Disorder (GAD), characterized by excessive worry about various aspects of life, including health and work performance. ⚫ The physical symptoms (nausea and diarrhea) can be associated with anxiety and stress responses. Supporting Cues for Client Condition: ⚫ Chronic anxiety over a year with physical manifestations supports a diagnosis of GAD. ⚫ Difficulty sleeping and concentrating aligns with common symptoms of anxiety disorders. ⚫ The occupational impairment indicates the severity of anxiety affecting her ability to function. Cues of Concern: Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning-specific, measurable, attainable, realistic/relevant, time-restricted - Goal setting) Implementation (Take actions) How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk) Evaluation (Evaluating Outcomes) What signs point to improving/declining/unchanged status? What interventions were effective? Are there other interventions that could be more effective? Did the client's care outlook or status improve? Persistent worry about serious health issues (cancer diagnosis) raises the need for mental health support to address health-related anxiety. ⚫ The increase in irritability and fatigue may suggest potential burnout or emotional exhaustion, which can affect both personal and professional life. Additional Information to Establish Significance: A complete mental health assessment, including any history of anxiety or mood disorders in her family, could help clarify the situation. • Information about any coping mechanisms or strategies Jameela has tried, along with her social support system, would provide insight into her resilience and areas where she might need support. • Lab tests to rule out other medical conditions that could be contributing to her physical symptoms.

NIGHTINGALE COLLEGE DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET NURSING PROCESS TEMPLATE: Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? • Subjective Data: Jameela's report of feeling anxious for almost a year. ⚫ Difficulty sleeping and concentrating. Increased feelings of irritability and fatigue. Physical symptoms: nausea and diarrhea. Persistent worries about work performance (forgetting clients) and health (diagnosis of cancer). • Reduced work hours due to anxiety Objective Data: • Age: 40s. Profession: Successful lawyer, indicating a high-stress occupation. • No notable medical history or trauma. Mental Health History: Duration of symptoms (almost one year). Impact on daily functioning and work (cutting back hours). Most Important Client Data: Duration and persistence of anxiety symptoms. Physical symptoms that could indicate anxiety (nausea, diarrhea). Impact on occupational functioning (cutting back work hours). Difficulty concentrating, which can affect job performance. Immediate Concerns: • The physical symptoms (nausea and diarrhea) may require further evaluation to rule out any underlying medical issues. The risk of worsening anxiety and its potential effects on Jameela's professional life and overall well-being. The possibility of anxiety leading to burnout or significant impairment in daily functioning. Consistent Client Conditions: Jameela's symptoms are consistent with Generalized Anxiety Disorder (GAD), characterized by excessive worry about various aspects of life, including health and work performance. ⚫ The physical symptoms (nausea and diarrhea) can be associated with anxiety and stress responses. Supporting Cues for Client Condition: ⚫ Chronic anxiety over a year with physical manifestations supports a diagnosis of GAD. ⚫ Difficulty sleeping and concentrating aligns with common symptoms of anxiety disorders. ⚫ The occupational impairment indicates the severity of anxiety affecting her ability to function. Cues of Concern: Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning-specific, measurable, attainable, realistic/relevant, time-restricted - Goal setting) Implementation (Take actions) How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk) Evaluation (Evaluating Outcomes) What signs point to improving/declining/unchanged status? What interventions were effective? Are there other interventions that could be more effective? Did the client's care outlook or status improve? Persistent worry about serious health issues (cancer diagnosis) raises the need for mental health support to address health-related anxiety. ⚫ The increase in irritability and fatigue may suggest potential burnout or emotional exhaustion, which can affect both personal and professional life. Additional Information to Establish Significance: A complete mental health assessment, including any history of anxiety or mood disorders in her family, could help clarify the situation. • Information about any coping mechanisms or strategies Jameela has tried, along with her social support system, would provide insight into her resilience and areas where she might need support. • Lab tests to rule out other medical conditions that could be contributing to her physical symptoms.

Understanding Health Insurance: A Guide to Billing and Reimbursement

14th Edition

ISBN:9781337679480

Author:GREEN

Publisher:GREEN

Chapter7: Cpt Coding

Section: Chapter Questions

Problem 8R

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