NRNP 6540 – Advanced Practice Care of Older Adults Course Guide, Assignments & Examples
NRNP 6540 – Advanced Practice Care of Older Adults (3 credits)
NRNP 6540 – Advanced Practice Care of Older Adults Course Description
In this course, students focus on the complex healthcare and management needs of older adults by advanced nurse practitioners in acute and primary care settings. Students learn to plan, implement, and evaluate therapeutic regimens of older adults through the application of knowledge in multiple settings. Additionally, students examine content related to end-of-life care and caregiver issues to gain the knowledge and sensibilities needed to implement positive change for the quality of life available to this vulnerable population.
NRNP 6540: Advanced Practice Care of Older Adults – interdisciplinary geriatric care teams essay assignment paper – assisted living, home care, hospitals, long-term care, and rehabilitation facilities
NRNP 6540: Advanced Practice Care of Older Adults
Week 3
Introduction Resources Discussion Assignment Week in Review Looking Ahead
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NRNP 6540: Advanced Practice Care of Older Adults
Week 3
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NRNP 6540: Advanced Practice Care of Older Adults
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A female caretaker assists senior women in knitting while a man reads a book in the background at the nursing home.
Week 3: Geriatric Care Teams
Interdisciplinary geriatric care teams are a critical component of geriatrics, and I truly believe that geriatrics really does interdisciplinary care probably better than most other areas of health care because we have to—because we need to. Older adults have care needs that require the expertise of a community. No single provider can do it all well. The needs are just so vast.
—Dr. Barbara Resnick, CRNP, FAAN, FAANP, AGSF, President of the American Geriatrics Society
Dr. Resnick emphasizes the importance of interdisciplinary geriatric care teams, as geriatric patients often have complex health needs. This was the case for 90-year-old Gus Snare. A diagnosis of bile duct cancer resulted in the need for surgery to remove parts of his stomach, duodenum, pancreas, bile duct, and gallbladder. Snare’s care team included a geriatrician, surgical oncologist, and a team of nurses, including an advanced practice nurse. Together, they determined his eligibility for surgery, performed the surgery, and developed a treatment and management plan post-surgery (The University of Chicago Medicine, 2011). As an advanced practice nurse, you must identify your role within care teams for patients like Snare to ensure patients receive comprehensive care.
This week you explore models of interdisciplinary geriatric care teams and compare the roles of advanced practice nurses at various sites of care. Then, as you complete your first SOAP Note, you examine the assessment, diagnosis, and treatment of a geriatric patient from your practicum site.
Learning Objectives
By the end of this week, students will:
Compare models of interdisciplinary geriatric care teams
Analyze models of interdisciplinary geriatric care teams used in various sites
Analyze the roles of advanced practice nurses in different clinical sites
Evaluate diagnoses for patients*
Evaluate treatment and management plans*
*These Learning Objectives support assignments that are assigned this week, but due in Week 4.
Photo Credit: Maskot/ Maskot/Getty Images
Learning Resources
Note: To access this week\’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Resnick, B. (Ed.). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatrics Society.
Chapter 18, “Hospital Care” (pp. 134-145)
This chapter explores systems of care for assessing and managing hospitalized older patients. It also examines alternatives to hospital care and transitions from hospital care.
Chapter 20, “Rehabilitation” (pp. 152-166)
This chapter describes essential components of geriatric rehabilitation, including sites of rehabilitation, roles of core health care providers on rehabilitation teams, and disease-specific care plans for older adults. It also explores mobility aids, orthotics, adaptive methods, and environmental modifications for older adults with disabilities.
Chapter 21, “Nursing-Home Care” (pp. 167-174)
This chapter identifies the demographic and functional characteristics of older adults living in nursing homes as well as the availability of nursing homes in the United States. It also describes staffing patterns, quality issues, and legislation related to nursing home care.
Chapter 22, “Community-Based Care” (pp. 175-180)
This chapter explores characteristics of care in communities, including home care, community-based services not requiring a change in residence, and community-based services requiring a change in residence. It examines older adult populations, health care issues, and the primary provider’s role in these sites of care.
Chapter 23, “Outpatient Care Systems” (pp. 181-185)
This chapter describes current approaches that maximize patient outcomes in geriatric outpatient care systems. It also examines new approaches that may benefit older adults in outpatient care systems.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.
Chapter 26, “Recording Information” (pp. 792–813)
This chapter outlines the components of SOAP notes and provides guidelines for writing SOAP notes after patient examinations.
Note: You should have this textbook in your personal library, as it was the required text in NURS 6512: Advanced Health Assessment and Diagnostic Reasoning.
Arbaje, A., Maron, D., Yu, Q., Wendel, V., Tanner, E., Boult, C., & … Durso, S. (2010). The geriatric floating interdisciplinary transition team. Journal of the American Geriatrics Society, 58(2), 364–370.
This article examines the Geriatric Floating Interdisciplinary Transition Team, a geriatric transitional care model. It describes the roles of health care providers on this care team and identifies potential benefits of this model.
The geriatric floating interdisciplinary transition team. Journal of the American Geriatrics Society, 58(2), by Arbaje, A., Maron, D., Yu, Q., Wendel, V., Tanner, E., Boult, C., & … Durso, S. Copyright 2010 by John Wiley& Sons, Inc. Journals. Reprinted by permission John Wiley & Sons, Inc. Journals via the Copyright Clearance Center.
Gagan, M. (2009). The SOAP format enhances communication. Nursing New Zealand, 15(5), 15.
Note: Retrieved from the Walden Library databases.
This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings.
American Geriatrics Society. (2011). The principles of geriatric care. Retrieved from http://www.americangeriatrics.org/files/documents/Adv_Resources/PayReform_fact3.pdf
This article identifies the principles of geriatric care, focusing on the geriatric care team, geriatric assessment, and care coordination. It also presents three models of care that encompass geriatric assessment and care coordination: the GRACE (Geriatric Resources for Assessment and Care of Elders) model, PACE (Program of All-inclusive Care for the Elderly) model, and the Guided Care model.
American Geriatrics Society. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Retrieved from http://www.guideline.gov/content.aspx?id=49933
This article examines three categories of medications that impact older adults: those that are potentially inappropriate and must be avoided, those that are potentially inappropriate and must be avoided in older adults with certain diseases, and those that must be used with caution.
Document: Comprehensive SOAP Note Template (Word document)
Required Media
Laureate Education (Producer). (2013b). Care team models [Video file]. Baltimore, MD: Author.
Note: The approximate length of this media piece is 16:29 minutes.
In this video program, Dr. Kristen Mauk and Dr. Barbara Resnick discuss the importance of interdisciplinary geriatric care teams, as well as the role of the advanced practice nurse within these teams.
Accessible player
Discussion: Models of Interdisciplinary Geriatric Care Teams
With the growing population of frail elders, there is an increase of geriatric patients requiring ongoing care for multiple medical conditions. This creates the need for interdisciplinary geriatric care teams. Often, the dynamics and culture of these teams differ across various sites of care, such as assisted living, home care, hospitals, long-term care, and rehabilitation facilities. As an advanced practice nurse, it is important to understand your role in the care team as well as your potential impact on patient care. In this Discussion, you explore models of interdisciplinary geriatric care teams for different sites of care and the varying roles of the advanced practice nurse.
Consider the following three case studies:
Case Study 1
Mrs. Martinez is an 83-year-old Mexican American widow who lives in her own home and is cared for by her adult daughter. Mrs. Martinez owns the home, and her daughter lives with her and provides the care. Her daughter brought her mother to the clinic today to ask to speak to the social worker. She requests that her mother be placed in a nursing home. The daughter states that her mother has nothing to do during the day. The television is on The Weather Channel most of the day because Mrs. Martinez has limited English capability and is unable to read closed-captioning. Mrs. Martinez also has two sons who do not live in the local area, but they do call regularly and check in with their mother and sister. The two sons are opposed to moving their mother to a nursing home because they had promised her that they would “never put her away.”
Case Study 2
Mr. Williams, a 79-year-old African American widower, resides in a foster care home. He has lived there for 4 years since his wife died. He is a former minister. His medical history includes long-term diabetes, high blood pressure, and benign prostatic hypertrophy. The home care provider has requested a home visit to evaluate Mr. Williams’s ability to remain in the home. The provider states that because Mr. Williams’s vision is seriously compromised (he is nearly blind), and because he has been unable to get to the toilet as quickly as necessary (he is very unsteady on his feet), his care is becoming burdensome. According to the home care provider, for safety reasons, Mr. Williams may not fit the criteria for remaining in the foster care home.
Case Study 3
Mrs. Randall is a 77-year-old female who resides in a long-term care facility. She has a history of frequent falls and is severely cognitively impaired. The nursing staff at the long-term care facility called the nurse practitioner at the medical home office to report the recent development of productive cough and high fever. There have been cases of flu in the facility; however, Mrs. Randall has had a flu shot. The nurse practitioner in the office requests a chest x-ray in the long-term care facility. The nurse on duty in the facility states that there is no portable chest x-ray equipment available. She further requests that Mrs. Randall be transferred to the emergency room of the local hospital. Mrs. Randall’s daughter has durable power of attorney for health care decisions for her mother. The long-term care facility has notified the daughter of the change in her mother’s condition. The daughter says whatever the nursing home wants is fine with her.
To prepare:
Review this week’s media presentation, as well as the American Geriatrics Society and Arbaje et al. articles in the Learning Resources.
Research models of interdisciplinary geriatric care teams that are used at various sites, such as assisted living, home care, hospitals, long-term care, and rehabilitation facilities.
Consider the model used for the interdisciplinary geriatric care teams at your current practicum site. Compare this model to models used at other sites.
Reflect on how the role of the advanced practice nurse differs according to the site of care.
Select one of the three case studies. Consider how care should be facilitated for the patient in the case you selected based on the model used for the interdisciplinary geriatric care teams at your practicum site.
By Day 3
Post a comparison of the model used for the interdisciplinary geriatric teams at your current practicum site to models used at other sites. Then, explain how the role of the advanced practice nurse differs according to the site of care. Finally, explain how care should be facilitated for the patient in the case you selected based on the model used for the interdisciplinary geriatric teams at your practicum si
NRNP 6540: Advanced Practice Care of Older Adults – interdisciplinary geriatric care teams eassy assignment paper – assisted living, home care, hospitals, long-term care, and rehabilitation facilities
NRNP 6540 Raymond Young Week 1 Assessment of Older Adults Instructions
As patients age, they are more likely to develop health issues. While some of these health issues are normal changes due to aging, some of them are abnormal and require further evaluation. Consider a 92-year-old patient who has been diagnosed with several disorders, including obstructive sleep apnea, hypertension, mild chronic anemia, restless leg syndrome, and osteoporosis. Despite these disorders, he can independently perform all basic activities of daily living, walk a quarter mile without difficulty, and pass functional and cognitive assessments. However, he did report that he fell a few times and had lost his way while driving to a familiar location (Carr & Ott, 2010).
As an advanced practice nurse caring for geriatric patients, you will likely encounter patients like this. While he can pass the basic assessments, the report of falls and confusion might indicate underlying issues of immobility, sensory deprivation, and/or cognitive dysfunction that require further attention. To identify these potential underlying issues and distinguish between normal and abnormal changes due to aging, healthcare providers use a variety of assessments. These assessments are a key tool in the care of geriatric patients.
This week, you examine assessment tools and evaluation plans used to assess geriatric patients presenting with potential issues of immobility, sensory deprivation, and cognitive dysfunction.
Reference:
Carr, D. B., & Ott, B. R. (2010). The older adult driver with cognitive impairment: “It’s a very frustrating life.” Journal of the American Medical Association, 303(16), 1632–1641. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915446/
NRNP 6540 Raymond Young Week 1 Assessment of Older Adults Learning Objectives
Students will:
- Analyze assessment tools used to assess older adults
- Design evaluation plans for patients with immobility, sensory deprivation, and/or cognitive dysfunction
- Identify immunization requirements related to health promotion and disease prevention for older adults
Learning Resources
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Changes with aging. In Advanced practice nursing in the care of older adults (2nd ed., pp. 2–5). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Health promotion. In Advanced practice nursing in the care of older adults (2nd ed., pp. 6–18). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Exercise in older adults. In Advanced practice nursing in the care of older adults (2nd ed., pp. 19–24). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Comprehensive geriatric assessment. In Advanced practice nursing in the care of older adults (2nd ed., pp. 26–33). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Symptoms and syndromes. In Advanced practice nursing in the care of older adults (2nd ed., pp. 34–94). F. A. Davis.
Centers for Disease Control and Prevention. (2020). Recommended adult immunization schedule for ages 19 years or older. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
Coll, P. P., Costello, V. W., Kuchel, G. A., Bartley, J., & McElhaney, J. E. (2019). The prevention of infections in older adults: Vaccination. Journal of the American Geriatrics Society, 68(1), 207–214. https://doi.org/10.1111/jgs.16205
Hartford Institute for Geriatric Nursing. (2020). General assessment series. In Try This: Series. Author. https://consultgeri.org/try-this/general-assessment
U.S. Preventive Services Task Force. (n.d.). Information for health professionals. Retrieved June 8, 2020 from https://www.uspreventiveservicestaskforce.org/uspstf/information-health-professionals
U.S. Preventive Services Task Force. (2019). Appendix III. USPSTF LitWatch process. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual-appendix-iii-uspstf-litwatch-process
Goldberg, C. (2019). Role of physical exam, general observation, skin screening and vital signs. https://meded.ucsd.edu/clinicalmed/assets/docs/Vital%20Signs%20and%20Introduction%20to%20the%20Exam.pdf
Engage-IL (Producer). (2017m). Geriatric health promotion and disease prevention [Video]. https://engageil.com/modules/geriatric-health-promotion-and-disease-prevention/
Note: View the Geriatric Health Promotion and Disease Prevention video module available in this free course. If you choose to view the Engage-IL media, you will need to create a free account at the Engage-IL website.
Engage-IL (Producer). (2017w). The process of aging [Video]. https://engageil.com/modules/the-process-of-aging/
Note: View the Process of Aging video module available in this free course.
Discussion: Evaluation Plan
As geriatric patients age, their health and functional stability may decline resulting in the inability to perform basic activities of daily living. In your role as a nurse practitioner, you must assess whether the needs of these aging patients are being met. Comprehensive geriatric assessments are used to determine whether these patients have developed or are at risk of developing age-related changes that interfere with their functional status. Since the health status and living situation of older adult patients often differ, there are a variety of assessment tools that can be used to evaluate wellness and functional ability. For this Discussion, you will consider which assessment tools would be appropriate for a patient in a case scenario.
Photo Credit: LIGHTFIELD STUDIOS / Adobe Stock
To prepare:
- Review this week’s Learning Resources, considering how assessment tools are used to evaluate patients.
- Your Instructor will assign a case study to use for this Discussion. Review the case study and, based on the provided information, think about a possible patient evaluation plan. As part of your evaluation planning, consider where the evaluation would take place, whether any other professionals or family members should be present, appropriate assessment tools and guidelines, and any other relevant information you may wish to address.
- Consider whether the assessment tool you identified was validated for use with this specific patient population and if this poses issues. Think about additional factors that might present issues when performing assessments such as language, education, prosthetics, missing limbs, etc.
- Consider immunization requirements that may be needed for this patient.
By Day 3
Post an explanation of your evaluation plan for the patient in the case study provided, and explain which type of assessment tool you might use for the patient. Explain whether the assessment tool was validated for use with this patient’s specific patient population and whether this poses issues. Include additional factors that might present issues when performing assessments, such as language, education, prosthetics, etc. Also explain the immunization requirements related to health promotion and disease prevention for the patient.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days in one or more of the following ways:
- Suggest alternative assessment tools and explain why these tools might be appropriate for your colleagues’ patients.
- Recommend strategies for mitigating issues related to use of the assessment tools your colleagues discussed.
- Explain other health promotion considerations for patients in this population or with related issues.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Post to Discussion Question link, and then select Create Thread to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
NRNP 6540 Raymond Young Week 1 Assessment of Older Adults Rubric Detail
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Name: NRNP_6540_Week1_Discussion_Rubric
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Excellent
Point range: 90–100 Good
Point range: 80–89 Fair
Point range: 70–79 Poor
Point range: 0–69
Main Posting:
Response to the discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.
40 (40%) – 44 (44%)
Thoroughly responds to the discussion question(s).
Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.
No less than 75% of post has exceptional depth and breadth.
Supported by at least 3 current credible sources.
35 (35%) – 39 (39%)
Responds to most of the discussion question(s).
Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module.
50% of the post has exceptional depth and breadth.
Supported by at least 3 credible references.
31 (31%) – 34 (34%)
Responds to some of the discussion question(s).
One to two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis.
Somewhat represents knowledge gained from the course readings for the module.
Post is cited with fewer than 2 credible references.
0 (0%) – 30 (30%)
Does not respond to the discussion question(s).
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only 1 or no credible references.
Main Posting:
Writing
6 (6%) – 6 (6%)
Written clearly and concisely.
Contains no grammatical or spelling errors.
Further adheres to current APA manual writing rules and style.
5 (5%) – 5 (5%)
Written concisely.
May contain one to two grammatical or spelling errors.
Adheres to current APA manual writing rules and style.
4 (4%) – 4 (4%)
Written somewhat concisely.
May contain more than two spelling or grammatical errors.
Contains some APA formatting errors.
0 (0%) – 3 (3%)
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style.
Main Posting:
Timely and full participation
9 (9%) – 10 (10%)
Meets requirements for timely, full, and active participation.
Posts main discussion by due date.
8 (8%) – 8 (8%)
Posts main discussion by due date.
Meets requirements for full participation.
7 (7%) – 7 (7%)
Posts main discussion by due date.
0 (0%) – 6 (6%)
Does not meet requirements for full participation.
Does not post main discussion by due date.
First Response:
Post to colleague’s main post that is reflective and justified with credible sources.
9 (9%) – 9 (9%)
Response exhibits critical thinking and application to practice settings.
Responds to questions posed by faculty.
The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.
8 (8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting.
7 (7%) – 7 (7%)
Response is on topic, may have some depth.
0 (0%) – 6 (6%)
Response may not be on topic, lacks depth.
First Response:
Writing
6 (6%) – 6 (6%)
Communication is professional and respectful to colleagues.
Response to faculty questions are fully answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in Standard, Edited English.
5 (5%) – 5 (5%)
Communication is mostly professional and respectful to colleagues.
Response to faculty questions are mostly answered, if posed.
Provides opinions and ideas that are supported by few credible sources.
Response is written in Standard, Edited English.
4 (4%) – 4 (4%)
Response posed in the discussion may lack effective professional communication.
Response to faculty questions are somewhat answered, if posed.
Few or no credible sources are cited.
0 (0%) – 3 (3%)
Responses posted in the discussion lack effective communication.
Response to faculty questions are missing.
No credible sources are cited.
First Response:
Timely and full participation
5 (5%) – 5 (5%)
Meets requirements for timely, full, and active participation.
Posts by due date.
4 (4%) – 4 (4%)
Meets requirements for full participation.
Posts by due date.
3 (3%) – 3 (3%)
Posts by due date.
0 (0%) – 2 (2%)
Does not meet requirements for full participation.
Does not post by due date.
Second Response:
Post to colleague’s main post that is reflective and justified with credible sources.
9 (9%) – 9 (9%)
Response exhibits critical thinking and application to practice settings.
Responds to questions posed by faculty.
The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.
8 (8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting.
7 (7%) – 7 (7%)
Response is on topic, may have some depth.
0 (0%) – 6 (6%)
Response may not be on topic, lacks depth.
Second Response:
Writing
6 (6%) – 6 (6%)
Communication is professional and respectful to colleagues.
Response to faculty questions are fully answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in Standard, Edited English.
5 (5%) – 5 (5%)
Communication is mostly professional and respectful to colleagues.
Response to faculty questions are mostly answered, if posed.
Provides opinions and ideas that are supported by few credible sources.
Response is written in Standard, Edited English.
4 (4%) – 4 (4%)
Response posed in the discussion may lack effective professional communication.
Response to faculty questions are somewhat answered, if posed.
Few or no credible sources are cited.
0 (0%) – 3 (3%)
Responses posted in the discussion lack effective communication.
Response to faculty questions are missing.
No credible sources are cited.
Second Response:
Timely and full participation
5 (5%) – 5 (5%)
Meets requirements for timely, full, and active participation.
Posts by due date.
4 (4%) – 4 (4%)
Meets requirements for full participation.
Posts by due date.
3 (3%) – 3 (3%)
Posts by due date.
0 (0%) – 2 (2%)
Does not meet requirements for full participation.
Does not post by due date.
Total Points: 100
Name: NRNP_6540_Week1_Discussion_Rubric
Week 2: Psychosocial Disorders
In so many countries, to be old is shameful; to be mentally ill as well as old is doubly shameful. In so many countries, people with elderly relatives who are also mentally ill are ashamed and try to hide what they see as a disgrace on the family.
—Dr. Nori Graham, Psychiatrist and Honorary Vice President of Alzheimer’s Disease International
In this quote, Dr. Graham is expressing her observations and experiences in her work with numerous international organizations. Many patients and their families experience feelings of anxiety and shame upon receiving a diagnosis of dementia, delirium, or depression. Among caregivers, 36% report having tried to hide the dementia diagnosis of their family member (Alzheimer’s Disease International, 2019). As an advanced practice nurse providing care to patients presenting with dementia, delirium, and depression, it is critically important to consider the impact of these disorders on patients, caregivers, and their families. A thorough understanding of the health implications of these disorders, as well as each patient’s personal concerns, will aid you in making effective treatment and management decisions.
This week, you explore geriatric patient presentations of dementia, delirium, and depression. You also examine assessment, diagnosis, and treatment for these disorders and complete a SOAP (subjective, objective, assessment, and plan) note.
Reference:
Alzheimer’s Disease International. (2019). World Alzheimer report 2019: Attitudes to dementia. Author. https://www.alz.co.uk/research/world-report-2019
Learning Objectives
Students will:
- Evaluate patients presenting with symptoms of dementia, delirium, or depression
- Develop differential diagnoses for patients with psychosocial disorders
- Develop appropriate treatment plans, including diagnostics and laboratory orders, for patients with psychosocial disorders
Assignment: Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression
Photo Credit: Getty Images
With the prevalence of dementia, delirium, and depression in the growing geriatric population, you will likely care for elderly patients with these disorders. While many symptoms of dementia, delirium, and depression are similar, it is important that you are able to identify those that are different and properly diagnose patients. A diagnosis of one of these disorders is often difficult for patients and their families. In your role as an advanced practice nurse, you must help patients and their families manage the disorder by facilitating necessary treatments, assessments, and follow-up care.
To prepare:
- Review the case study provided by your Instructor. Reflect on the way the patient presented in the case, including whether the patient might be presenting with dementia, delirium, or depression.
- Reflect on the patient’s symptoms and aspects of disorders that may be present. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.
By Day 7
Learning Resources
-
- Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Psychosocial disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 428–469). F. A. Davis.
- Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Appendix B: Laboratory values in the older adult. In Advanced practice nursing in the care of older adults (2nd ed., pp. 505–506). F. A. Davis.
- Note: See the labs that are relevant to this week’s topics.
- Laske, R. A., & Stephens, B. A. (2018). Confusion states: Sorting out delirium, dementia, and depression. Nursing Made Incredibly Easy!, 16(6), 13–16. https://doi.org/10.1097/01.NME.0000546254.38666.1f
- NIH National Institute on Aging. (2017). Basics of Alzheimer’s disease and dementia: What is Alzheimer’s disease? [Multimedia file]. https://www.nia.nih.gov/health/what-alzheimers-disease
- Document: Focused SOAP Note Template (Word Document) (attach sent)
Rubric Detail Tutor needs to FOLLOW
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Name: NRNP_6540_Week2_Assignment_Rubric
| |
Excellent |
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Fair |
Poor |
| Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications, checked against Beers Criteria
• Allergies
• Patient medical history (PMHx)
• Review of systems |
9 (9%) – 10 (10%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. |
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7 (7%) – 7 (7%)
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing. |
0 (0%) – 6 (6%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing. |
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
9 (9%) – 10 (10%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. |
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7 (7%) – 7 (7%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. |
0 (0%) – 6 (6%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing. |
In the Assessment section, provide:
• At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. |
23 (23%) – 25 (25%)
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected. |
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18 (18%) – 19 (19%)
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. |
0 (0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. |
In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned. |
27 (27%) – 30 (30%)
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. |
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21 (21%) – 23 (23%)
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics. |
0 (0%) – 20 (20%)
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing. |
| Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. |
9 (9%) – 10 (10%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions. |
. |
7 (7%) – 7 (7%)
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan. |
0 (0%) – 6 (6%)
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan. |
Written Expression and Formatting—Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. |
|
3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.
Purpose, introduction, and conclusion of the assignment is vague or off topic. |
0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.
No purpose statement, introduction, or conclusion were provided. |
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and proper punctuation |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. |
|
3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors. |
0 (0%) – 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
5 (5%) – 5 (5%)
Uses correct APA format with no errors. |
|
3 (3%) – 3 (3%)
Contains several (three or four) APA format errors. |
0 (0%) – 2 (2%)
Contains many (≥ five) APA format errors. |
| Total Points: 100 |
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Name: NRNP_6540_Week2_Assignment_Rubric
Week 2: Psychosocial CASE SCENARIO
Week 2 Case 1: Dementia
HPI: Ms. Peters is a 70-year-old female who is brought to your office by her son with reports of acute confusion (more than usual) and some agitation and restlessness. She has a known history of dementia, managed with Aricept 10 mg. daily. Her son, Jared, reports that 2 days ago she began to become more confused than usual and very easily agitated. He reports that yesterday, she couldn’t remember where she was in her own home. She had a doctor’s appointment 3 days ago and her HCTZ (hydrochlorothiazide) was increased to 50 mg. due to increased bp’s.
Ms. Peter’s last Mini-Mental State Exam (MMSE) score was 18/30. The assessment was repeated, and the score remained unchanged.
Ms. Peters and her son denies her having any falls or contributing traumas recently. She denies any changes in diet or routine regimens. No reported dysuria, no fever, nausea, or vomiting.
Note: Be sure to review the MMSE and how to interpret results (Mental State Assessment Tests). Make sure you document the patient’s score in your SOAP note document. Also review the Geriatric Depression Assessment (Geriatric Depression Scale [GDS]).
Ms. Peters is a 70-year-old female who is alert but easily distracted, at times, during today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert but disoriented to place and time. She denies any falls, denies any pain. Her son does say she has had some “stumbling” and balance issues but no reported falls.
All other Review of System and Physical Exam findings are negative other than stated.
Vital Signs: 98.1 120/64 HR-72 20
PMH: Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis
Allergies: Atorvastatin
Medications:
- Multivitamin daily
- Losartan 50mg daily
- HCTZ 50mg daily
- Fish Oil 1 tablet daily
- Glyburide 5mg daily
- Metformin 500mg BID
- Donepezil 10mg daily
- Alendronate 70mg orally once a week
Social History: As stated in Case Study
ROS: As stated in Case study
Diagnostics/Assessments done:
- CXR—no cardiopulmonary findings. WNL
- CT head—diffuse Cerebral Atrophy
- MMSE—Ms. Peters scored 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall at a previous visit. At today’s visit, there is no change. The score suggests moderate dementia.
- Hemoglobin A1C7.2%
- Basic Metabolic Panel as shown below
| TEST |
RESULT |
REFERENCE RANGE |
| GLUCOSE |
90 |
65–99 |
| SODIUM |
130 |
135–146 |
| POTASSIUM |
3.4 |
3.5–5.3 |
| CHLORIDE |
104 |
98–110 |
| CARBON DIOXIDE |
29 |
19–30 |
| CALCIUM |
9.0 |
8.6–10.3 |
| BUN |
20 |
7–25 |
| CREATININE |
1.00 |
0.70–1.25 |
| GLOMERULAR FILTRATION RATE (eGFR) |
77 |
>or=60 mL/min/1.73m2 |
Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
- Location: Head
- Onset: 3 days ago
- Character: Pounding, pressure around the eyes and temples
- Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
- Timing: After being on the computer all day at work
- Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
- Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).
ROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
- General:
- Head:
- EENT (eyes, ears, nose, and throat):
- Etc.:
Note: You should list these in bullet format, and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
- Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
- Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O (objective)
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A (assessment)
Differential diagnoses: List a minimum of three differential diagnoses. Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P (plan)
Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Also included in this section is the reflection. Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.
Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).
References
You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
NRNP 6540—Week 2 Case Study
Mr. Y is a 78-year-old man who was born in Korea and moved to the U.S with his wife 50 years ago. Together, the couple opened a floral shop and ran the business for 40 years. Mrs. Y enjoyed watching her husband’s talent and love of nature come out in his flower arrangements.
When Mr. Y was in his late 60’s, he starting having difficulty making his favorite flower arrangements. Their son also noticed Mr. Y misplacing tools, losing paper orders, and forgetting important pick-up times. At home, Mrs. Y noticed her husband having problems remembering recent events, and waking up at odd hours in the night thinking it was time to open the shop. Mr. Y was becoming irritable at home and at the shop.
When Mr. Y was 70 years old, the family decided to sell the business. Their health-care providers confirmed that Mr. Y was presenting with early stage Alzheimer’s disease. The family then decided that Mrs. Y would be appointed as her husband’s Power of Attorney for personal care and property. She continued to care for her husband at home.
When Mr. Y turned 75 years old, he was having increased difficulty remembering where things were in the house. He often woke his wife at odd hours of the night thinking it was time to get up and ready. When Mrs. Y reoriented her husband that it was still night-time, he would get confused and easily upset. Mr. Y was also becoming more physically weak, but did not perceive his limitations. He was having frequent falls at home. A few times, Mr. Y had become lost outside of their home, forgetting where he had to go and which house was his.
Their son recognized that his mother was not as happy as she used to be. She was constantly worrying about her husband’s increasing care needs, and could not enjoy activities she used to do. She was stressed and was not sleeping properly. With support from their health-care providers, the family decided that a long-term care setting would benefit Mr. Y and Mrs. Y’s well-being.
Admission to long-term care
At the admission conference, the long-term care home’s social worker and charge nurse met Mr. Y and his family, and learned more about his history and preferences. His medical diagnosis includes moderate Alzheimer’s disease and osteoarthritis, with a history of urinary tract infections. Mr. Y hears well, uses reading glasses, and wears upper and lower dentures. Mr. Y also requires reminders to use his walker properly. Mrs. Y always prompted her husband for toileting, as well as when to eat and take medications. Mr. Y requires limited assistance from his wife during activities of daily living, such as dressing or transfers. As for his preferences, Mr. Y loves homemade Korean food, pastries, and warm drinks. He had always enjoyed baths in the evenings.
At the end of the second week in LTC, Mr. Y was no longer pacing the halls. He was often found napping in his room during the days. One afternoon, a nurse went into Mr. Y’s room and found him sleeping. She tried to gently wake Mr. Y, but he was not easy to arouse. She tried a second time and asked very loudly, “Mr. Y, it’s lunch time, are you ready to go?” Mr. Y slowly opened his eyes. The nurse repeated her question, and Mr. Y replied slowly, “Oh, I ate last week.” The nurse then asked, “I know you had breakfast this morning, now it’s lunch time.
Are you hungry?” Mr. Y paused and closed his eyes. The nurse gently woke him again by rubbing his arm and repeated her question. Mr. Y slowly replied, “Yes, my wife is cooking, I will eat”. Together, they walked slowly to the dining room.
In the dining room, Mr. Y stared out the window and did not answer the CNAs when they asked him for his lunch preference. When approached a third time, Mr. Y rambled slowly in English and in Korean to the CNAs. He continued to speak Korean to the CNAs as they tried to assist him with his lunch, but he was unfocused and inattentive. He was unable to finish his meal because of his behavior. The staff were worried that he was not eating or drinking enough since admission.
When there were group activities, the therapists found it harder to encourage Mr. Y to attend and participate like he had been doing before. It took a lot of encouragement and assistance to have him attend. During the activity, he did not participate or sometimes fell asleep in the middle of the exercise or social program.
A few nights in a row, he was found wandering outside his bedroom without his walker. One time, he told the nurse, “Someone is looking for me.” The nurse reassured him that he is safe, and tried to direct him back to his room. But Mr. Y walked past the nurse and said, “I have to go to the bus stop.” After a few attempts, the nurse was able to direct Mr. Y to his room to sleep, and reoriented him to the use of the call bell. This behavior continued with increasing disorientation. The sleep disturbances resulted in Mr. Y being too drowsy in the mornings, and not able to eat any breakfast.
Although Mrs. Y was kept informed of her husband’s condition since admission to long-term care, it was not until her first visit during Mr. Y’s third week in long-term care when she realized how much her husband had changed. She was alarmed and asked the staff, “What is happening? What will be done for him? How can I help?”
NRNP 6540 Week 2 Assignment
Case Study: Week 2 Case 2 (Alzheimer’s )
Dela Cruz, Dedic, Famador, Finefrock, Fritcher, Gallik, Gelegdorj, Go, Joseph, Kabir, Lopez
Ms. Washington is a 67-year-old African American female who is brought to your office by her daughter with concerns about “forgetfulness.” She has lived with her daughter for 4 years now, and her daughter reports noticing she asks the same questions even after they have been answered. She even reports her mom getting lost in Walmart recently. Ms. Washington has lived with her daughter since losing her husband of 57 years about 4 years ago. Her daughter states her mother is a retired teacher and usually very astute but notices more forgetfulness.
According to Ms. Washington’s daughter, Angela, her mom has been demonstrating increased forgetfulness of more recent things but can easily recall historical moments and events. She also reports that sometimes her mom has difficulty “finding the right words” in a conversation and then will shift to an entirely different line of conversation. She also said her mother will “laugh off” things when she forgets important appointments and/or becomes upset or critical of others who try to point these things out.
Note: Be sure to review the Mini-Mental State Exam (MMSE) and how to interpret the results. Use the MMSE in the attached document to determine the patient’s MMSE score in the video. Make sure you document the patient’s score in your SOAP note document: Mental State Assessment Tests.
Ms. Washington is a 67-year-old female who is alert and cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place, but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain.
All other Review of System and Physical Exam findings are negative other than stated.
PMH: Hypertension, Hyperlipidemia, Osteoporosis
Allergies: Penicillin, Lisinopril
Medications:
- Amlodipine 10mg daily
- HCTZ 12.5mg daily
- Multivitamin daily
- Atorvastatin 40mg daily
- Alendronate 70mg orally once a week
Social History: As stated in the Case Study
ROS: As stated in the Case study
Diagnostics/Assessments done:
- CXR—no cardiopulmonary findings. WNL
- CT head—diffuse Cerebral Atrophy
- MMSE—Ms. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia.
To prepare:
- Review the case study provided by your Instructor. Reflect on the way the patient presented in the case, including whether the patient might be presenting with dementia, delirium, or depression.
- Reflect on the patient’s symptoms and aspects of disorders that may be present. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.
NRNP_6540_Week2_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint • History of present illness (HPI) • Current medications, checked against Beers Criteria • Allergies • Patient medical history (PMHx) • Review of systems 10 to >9.0 pts
Excellent
The response thoroughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. 9 to >8.0 pts
Good
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. 8 to >7.0 pts
Fair
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing. 7 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 10 to >9.0 pts
Excellent
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 9 to >8.0 pts
Good
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 8 to >7.0 pts
Fair
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 7 to >0 pts
Poor
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. 25 to >23.0 pts
Excellent
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected. 23 to >19.0 pts
Good
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected. 19 to >18.0 pts
Fair
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 18 to >0 pts
Poor
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned. 30 to >27.0 pts
Excellent
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. 27 to >24.0 pts
Good
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking. 24 to >21.0 pts
Fair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics. 21 to >0 pts
Poor
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
30 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. 10 to >9.0 pts
Excellent
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions. 9 to >8.0 pts
Good
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions. 8 to >7.0 pts
Fair
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan. 7 to >0 pts
Poor
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
10 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic. 2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation errors. 3 to >2.0 pts
Fair
Contains several (three or four) grammar, spelling, and punctuation errors. 2 to >0 pts
Poor
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 to >4.0 pts
Excellent
Uses correct APA format with no errors. 4 to >3.0 pts
Good
Contains a few (one or two) APA format errors. 3 to >2.0 pts
Fair
Contains several (three or four) APA format errors. 2 to >0 pts
Poor
Contains many (≥ five) APA format errors.
5 pts
Total Points: 100
NRNP 6540 Week 4 Head Neck and Face Case Study
A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally, the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.
Chief complaint: Persistent “runny nose” for the 3-week duration, associated clearing of the throat and nasal congestion on awakening in the morning.
Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20.
What further ROS questions will you want to ask her? List at least three.
What physical exam (PE) will you perform on this patient? List at least three.
What are the differential diagnoses that you are considering? Describe at least four.
What laboratory tests will help you rule out some of the differential diagnoses?
You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR).
Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient?
List at least two treatment options: medications with dose, side effects, and/or cautions in the older adult.
When will you have the patient follow-up? Be specific.
NOTE: Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP note. Be creative, but do not deviate from the main points of the case study.
NRNP_6540_Week4_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications, checked against Beers Criteria• Allergies• Patient medical history (PMHx) • Review of systems 10 to >9.0 pts
Excellent
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. 9 to >8.0 pts
Good
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. 8 to >7.0 pts
Fair
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing. 7 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 10 to >9.0 pts
Excellent
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 9 to >8.0 pts
Good
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 8 to >7.0 pts
Fair
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 7 to >0 pts
Poor
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. 25 to >23.0 pts
Excellent
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected. 23 to >20.0 pts
Good
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected. 20 to >18.0 pts
Fair
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 18 to >0 pts
Poor
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned. 30 to >27.0 pts
Excellent
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. 27 to >24.0 pts
Good
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking. 24 to >21.0 pts
Fair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics. 21 to >0 pts
Poor
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
30 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. 10 to >9.0 pts
Excellent
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions. 9 to >8.0 pts
Good
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions. 8 to >7.0 pts
Fair
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan. 7 to >0 pts
Poor
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic. 2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation errors. 3 to >2.0 pts
Fair
Contains several (three or four) grammar, spelling, and punctuation errors. 2 to >0 pts
Poor
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 to >4.0 pts
Excellent
Uses correct APA format with no errors. 4 to >3.0 pts
Good
Contains a few (one or two) APA format errors. 3 to >2.0 pts
Fair
Contains several (three or four) APA format errors. 2 to >0 pts
Poor
Contains many (≥ five) APA format errors.
5 pts
Total Points: 100
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NRNP 6540 Week 5 Case Assignment
Case Title: A 67-year-old With Tachycardia and Coughing
Ms. Jones is a 67-year-old female who is brought to your office today by her daughter Susan. Ms. Jones lives with her daughter and is able to perform all activities of daily living (ADLs) independently. Her daughter reports that her mother’s heart rate has been quite elevated, and she has been coughing a lot over the last 2 days. Ms. Jones has a 30-pack per year history of smoking cigarettes but quit smoking 3 years ago. Other known history includes chronic obstructive pulmonary disease (COPD), hypertension,
vitamin D deficiency, and hyperlipidemia. She also reports some complaints of intermittent pain/cramping in her bilateral lower extremities when walking, and has to stop walking at times for the pain to subside. She also reports some pain to the left side of her back, and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-tinged sputum. She states she has COPD and has been using her albuterol inhaler more than usual. She says it helps her “get the cold up.” Her legs feel tired but denies any worsening shortness of breath. She admits that she has some weakness and fatigue but is still able to carry out her daily routine.
Vital Signs: 99.2, 126/78, 96, RR 22
Labs: Complete Metabolic Panel and CBC done and were within normal limits
CMP Component Value CBC Component Value
Glucose, Serum 86 mg/dL White blood cell count 5.0 x 10E3/uL
BUN 17 mg/dL RBC 4.71 x10E6/uL
Creatinine, Serum 0.63 mg/dL Hemoglobin 10.9 g/dL
EGFR 120 mL/min Hematocrit 36.4%
Sodium, Serum 141 mmol/L Mean Corpuscular Volume 79 fL
Potassium, Serum 4.0 mmol/L Mean Corpus HgB 28.9 pg
Chloride, Serum 100 mmol/L Mean Corpus HgB Conc 32.5 g/dL
Carbon Dioxide 26 mmol/L RBC Distribution Width 12.3%
Calcium 8.7 mg/dL Platelet Count 178 x 10E3/uL
Protein, Total, Serum 6.0 g/dL
Albumin 4.8 g/dL
Globulin 2.4 g/dL
Bilirubin 1.0 mg/dL
AST 17 IU/L
ALT 15 IU/L
Allergies: Penicillin
Current Medications:
ï‚· Atorvastatin 40mg p.o. daily
ï‚· Multivitamin 1 tablet daily
ï‚· Losartan 50mg p.o. daily
ï‚· ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
ï‚· Caltrate 600mg+ D3 1 tablet daily
Diagnosis: Pneumonia
Directions: Answer the following 10 questions directly on this template.
Question 1: What findings would you expect to be reported or seen on her chest X-ray results, given the diagnosis of pneumonia?
Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia)? What’s the difference/criteria?
Question 3:
ï‚· 3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?
ï‚· 3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.
Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your treatment be for her based on her diagnosis, case scenario, and evidence-based guidelines?
Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?
Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential diagnosis for this? Explain your reasoning.
a. DVT (Deep Vein Thrombosis)
b. Intermittent Claudication
c. Cellulitis
d. Electrolyte Imbalance
Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to further evaluate this?
Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.
Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?
Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.
NRNP 6540 Week 6 Focused SOAP Note Example
Patient Information:
GM, 79, Male, White
Subjective: Patient resting in bed quietly, endorses right flank pain, denies nausea/vomiting, or fever.
CC (chief complaint): Patient presents to hospital with right flank pain.
HPI: Patient is a 79 year old male with PMH of AFIB, HTN, HLD, and urinary retention that presents to the hospital with right flank pain. The right flank pain wraps around to the right upper quadrant, patient describes as a dull aching. This pain has been progressing over the last 2-3 days. Patient had nausea and 1-2 episodes of emesis. No fever, chills, diarrhea. Pain started while feeding cattle and has progressively worsened. Patient has taken Tylenol without relief in symptoms. Patient rates pain 10/10.
Current Medications:
- Eliquis 2.5mg PO BID, AFIB
- Aspirin 81mg PO QD, CHF
- Ancef 1G IV Q12H, UTI
- Colace 100mg PO QD, constipation
- Lasix 20mg PO QD, CHF
- Normal Saline 0.9 IV continous 100ml/hr, hydration
- Dilaudid 0.5mg IV q2h PRN, PAIN
- Melatonin 5mg PO PRN nightly, sleep
- Zofran 4mg PO q6h PRN, nausea
- Senna 8.6mg PO BID PRN, constipation
Allergies:
PMHx:
- AFIB
- CHF
- Closed nondisplaced fracture of third metacarpal bone of right hand
- Constipation
- Hypertension
- Mixed Hyperlipidemia
- Traumatic Compression fracture of T9 vertebra
Vaccines
- Tdap 2022
- PPSV23 2022
- FLU 9/1/23
- COVID negative
Soc and Substance Hx: Patient is a cattle farmer and raises them for meat. Patient still currently works on his own farm. Tobacco use: No, Alcohol use: Occasional mixed drink, Substance abuse: No. Patient always uses his seatbelt, has no issues obtaining food, medications, or making it to appointments. Patient lives at home with his wife. Close support from children.
Fam Hx:
Surgical Hx:
- Bilateral Cataract Extraction
- Colonoscopy 2014
- Cardiac Ablation 04/2023
- Hernia Repair
- Kidney Surgery
- Prostate Surgery
- EGD 2014
- Wrist Surgery
Mental Hx: No history of anxiety/depression. No history of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Patient feels safe in home and relationships.
Reproductive Hx: Not currently sexually active
ROS: Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: Shortness of breath, no cough, or sputum.
GASTROINTESTINAL: No anorexia or diarrhea. Nausea and vomiting. No abdominal pain or blood.
GENITOURINARY: No burning on urination. Chronic foley catheter.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness. Right flank pain.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Objective: BP 113/65, HR 90, Temp 98.9, RR 18, SpO2 94%
Physical exam:
General Appearance: Alert, acutely ill appearing, in mild acute distress
HEENT: Head normocephalic, Eyes-EOMI, sclera anicteric, Throat mucus membranes moist
Cardiovascular: regular rate and rhythm, normal S1, S2, no murmurs, rubs, clicks, gallops, peripheral edema absent
Respiratory: lungs clear to auscultation, without wheezes rales, or rhonchi, on nasal cannula 3L
Abdomen: soft, non-tender, right CVA tenderness, right upper quadrant pain, mildly distended
Genitourinary: chronic foley catheter in place
Neurological: oriented x3, normal speech, no focal findings or movement disorders noted
Musculoskeletal: no significant deformity, or tenderness to palpitation
Skin: normal coloration
Psych: Normal mood and affect
Diagnostic results:
Na 127
Creatinine 1.69
WBC 12.07
Urinalysis: Moderate blood, positive nitrates, large leukocyte esterase, WBC 69, RBC 12, Bacteria few, WBC clumps rare, Mucus rare
Urine Culture: Negative Bacilli
Blood Cultures: Pending
US Abdomen 9/16: No gallstones. Right hydronephrosis.
Chest X-Ray 9/17:
- Lungs: Pulmonary vascular congestion and interstitial prominence has developed. Mild hazy opacities of left perihilar region and right lung base. No definite effusion. No evidence of pneumothorax.
- Heart/mediastinum: Stable contours. Stable enlargement of cardiac silhouette.
- Bones: No acute bony abnormality.
- Impression: Findings are suspicious for pulmonary edema pattern versus mild CHF decompensation. Infiltrate is a secondary consideration.
CT Kidney Stone 9/15:
- Impression:
- Massive right chronic hydronephrosis and hydronephrotic sac, stable, presumably related to chronic UPJ stenosis. However, perinephric fluid is present on today’s examination, suggesting ascending urinary tract infection.
- Short-segment circumferential thickening consistent at hepatic flexure at the distal ascending and proximal transverse colon without secondary bowel obstruction. These findings are likely secondary to inflammation from adjacent ascending urinary tract infection.
- Normal appendix. No adenopathy.
- No urinary tract calculi or hydronephrosis.
- Severe pectus excavatum deformity.
Assessment:
Primary Diagnosis: Right pyelonephritis with hydronephrosis, acute UTI
Secondary Diagnosis: CHF exacerbation due to fluid overload
Differential Diagnoses:
- Cholelithiasis/Cholecystitis: Due to location of pain in right flank and nausea, vomiting this is a potential diagnosis. This was ruled out by abdominal ultrasound (Cleveland Clinic, 2023).
- Renal colic due to kidney stone: Patient presented with flank pain and CVA tenderness. This was ruled out by CT Kidney stone. No stones found on CT (Time of Care, 2023).
- Shingles: shingles can cause deep nerve pain and is often found on the trunk of the body. This was ruled out due to the patient not having a rash (Keck Medicine of USC, 2020).
Plan.
Right pyelonephritis with hydronephrosis/Acute UTI
- CT Kidney Stone-massive right chronic hydronephrosis and hydronephrotic sac, related to chronic UPJ stenosis. Perinephric fluid present suggesting ascending UTI. US abdomen: No gallstones, right hydronephrosis, known UPJ obstruction.
- Consult Urology
- Rocephin started in ER, changed to Ancef 2G q12h (Diaz-Brochero, et al., 2022).
- Pain Management PRN
- UA- Large leukocytes, positive nitrates
- Urine Culture: Negative Bacilli
- Blood Culture Pending
- Care Management
Leukocytosis
- WBC 13.04>10.9
- Trend CBC
- No fevers
Chronic Kidney Disease
- Creatinine 1.62>1.6
- Baseline 1.7
- IV hydration-stopped due to fluid overload
Hyponatremia
Chronic AFIB s/p ablation 4/13/23
- Continue Eliquis
- Rate Controlled
- Keep K+>4, Mag >2
Hypertension Hyperlipidemia
- No current home medications
- Continue to monitor
HFrEF-CHF
- BNP-pending
- Echo 1/25/23 EF 67%
- Change Lasix to 40mg IV x1, then 20mg IV BID (Yoshioka, et al., 2022).
- Daily Weights
- Strict I&O
- Repeat Echocardiogram
- Weight up 8# since admission
- Chest Xray suspicious for pulmonary edema pattern vs mild CHF decompensation
Chronic Urinary Retention
- Chronic Indwelling Catheter
- Follows with Dr. Peck
- Consult Urology
Reflection
This patient was a truly unique case. He originally came in with right flank pain and ended up being fluid overloaded. The admitting doctor started the patient on IV hydration due to AKI on CKD and the acute urinary tract infection. Orders were not placed to keep a watch on the patient’s intake and output and daily weight. The patient did not have bilateral lower extremity edema and he only had diminished lung sounds. His main symptoms of fluid overload were a distended belly and shortness of breath. This patient needed his IV fluids stopped and his Lasix transitioned to IV. Once the patient started to put more out his shortness of breath resolved.
Objectives:
After viewing the presentation:
- You will be able to explain why the patient became fluid overloaded.
- Explain two ways to facilitate diuresis of the patient.
- Explain what was still pending that could narrow done the antibiotic choices.
Discussion Questions:
- The patient was initially started on Rocephin, and then switched to Ancef. The urine culture was not fully resulted and only showed negative bacilli. What additional information would you need to make sure that you have chosen the appropriate antibiotic therapy?
- What labs are important to monitor while a patient is receiving IV Lasix and why?
- What are the risks involved with having a chronic indwelling catheter? What education can you provide the patient?
References
Cleveland Clinic. (2023). Flank pain. Retrieved from https://my.clevelandclinic.org/health/symptoms/21541-flank-pain
Diaz-Brochero, C., Valderrama-Rios, M. C., Nocua-Baez, L. C., & Cortes, J. A. (2022). First-generation cephalosporins for the treatment of complicated upper urinary tract infections in adults: A systematic literature review. International Journal of Infectious Disease, 116, 403-410. Retrieved from https://www.sciencedirect.com/science/article/pii/S1201971221012613
Keck Medicine of USC. (2020). 5 reasons you might have flank pain. Retrieved from https://www.keckmedicine.org/blog/5-reasons-you-might-have-flank-pain/
Time of Care. (2023). Flank pain. Retrieved from https://www.timeofcare.com/flank- pain-ddx/
Yoshioka, K., Maeda, D., Okumura, T., Kida, K., Oishi, S., Akiyama, E., Suzuki, S., Yamamoto, M., Mizukami, A., Kuroda, S., Kagiyama, N., Yamaguchi, T., Sasano, T., Matsumura, A., Kitai, T., & Matsue, Y. (2022). Clinical implications of initial intravenous diuretic dose for acute decompensated heart failure. Scientific Reports, 12, 2127. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8825846/
NRNP 6540 Week 7 Assignment
R.B.is a 95-year-old white male, currently living in a skilled nursing facility (SNF)
Chief complaint: “My urine is really red.”
HPI: On Wednesday (2 days ago), the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.
Allergies: Penicillin: Hives
Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID
Code status: DNR
Diet: Regular diet, pureed texture, honey-thickened liquids
Vitals: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%
PMH: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-sided hemiplegia and hemiparesis from a previous ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on the left lower extremity, gross hematuria
Labs:
RBC 3.53 (L)
Hemoglobin 10.2 (L)
Microscopic Analysis, Urine, straight cath
Component:
WBC UA 42 (H) (0-5/ HPF)
RBC, UA >900 (H) (0-5/HPF)
Epithelial cells, urine 2 (0-4 /HPF)
Hyaline casts, UA 0 (0-2 /LPF)
Urinalysis
Color Red
Appearance (Urine) Clear
Ketones, UA Trace
Specific gravity 1.020 (1.005-1.025)
Blood, UA Large
PH, Urine 7.0 (5.0-8.0)
Leukocytes Small
Nitrites Positive
C&S results were not available yet.
Please include differential diagnosis with explanation and citation.
NRNP_6540_Week 7 Assignment Instructions
Accurate history taking of abdominal, urological, and gynecological complaints is essential for completing an assessment of the older adult. For this Assignment, as you examine this week’s patient case study, consider how you might evaluate and treat older adult patients who present with health concerns related to the abdominal, urological, or gynecological systems.
To prepare:
- Review the case study provided by your Instructor.
- Reflect on the patient’s symptoms and aspects of disorders that may be present.
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
NRNP_6540_Week7_Assignment_Rubric
NRNP_6540_Week7_Assignment_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications, checked against Beers Criteria• Allergies• Patient medical history (PMHx) • Review of systems
10 to >9.0 pts
Excellent
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
9 to >8.0 pts
Good
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
8 to >7.0 pts
Fair
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing.
7 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
10 to >9.0 pts
Excellent
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
9 to >8.0 pts
Good
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
8 to >7.0 pts
Fair
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
7 to >0 pts
Poor
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
25 to >23.0 pts
Excellent
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.
23 to >20.0 pts
Good
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.
20 to >18.0 pts
Fair
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
18 to >0 pts
Poor
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned.
30 to >27.0 pts
Excellent
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.
27 to >24.0 pts
Good
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.
24 to >21.0 pts
Fair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics.
21 to >0 pts
Poor
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
30 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.
10 to >9.0 pts
Excellent
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
9 to >8.0 pts
Good
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.
8 to >7.0 pts
Fair
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.
7 to >0 pts
Poor
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (three or four) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (one or two) APA format errors.
3 to >2.0 pts
Fair
Contains several (three or four) APA format errors.
2 to >0 pts
Poor
Contains many (≥ five) APA format errors.
5 pts
Total Points: 100
PreviousNext
NRNP 6540 Week 8 Assignment Paper
CC: Mrs. Derrick is a 78-year-old female who comes to the office with complaints of increasing symptoms of lethargy; fever, night sweats, a 15 lb. weight loss over 6 months; bleeding gums when she brushes her teeth; purplish patches in the skin; and shortness of breath.HPI:
She states that she has had a sensation of deep pain in her bones and joints.
She notes that her employment history includes working at a dry-cleaning shop for 15 years, with an exposure to dry cleaning chemicals (benzenes are known to be a possible cause of leukemias)
PE shows enlarged lymph nodes and swelling or discomfort in the abdomen.
You diagnose this patient with acute lymphoblastic leukemia (ALL).
Address the following in your SOAP note:
What additional history about her past work environment would you explore?
What additional objective data will you be assessing for?
What tests will you order? Describe at least four lab tests.
What are the differential diagnoses that you are considering? Describe two.
List at least two diagnostic tests you will order to confirm the diagnosis of ALL.
Will you be looking for a consultation? Please explain.
As the primary care provider for this patient with ALL:
- Describe the education and follow-up you will provide to this patient during and after treatment by the hematologist-oncologist.
- Describe at least three (3) roles as the PCP for the ongoing care of the ALL patient.
To prepare:
- Review the case study provided by your Instructor.
- Reflect on the patient’s symptoms and aspects of disorders that may be present.
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
NRNP_6540_Week8_Assignment_Rubric
NRNP_6540_Week8_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications, checked against Beers Criteria• Allergies• Patient medical history (PMHx) • Review of systems
10 to >9.0 pts
Excellent
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
9 to >8.0 pts
Good
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
8 to >7.0 pts
Fair
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing.
7 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
10 to >9.0 pts
Excellent
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
9 to >8.0 pts
Good
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
8 to >7.0 pts
Fair
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
7 to >0 pts
Poor
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
25 to >23.0 pts
Excellent
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.
23 to >20.0 pts
Good
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.
20 to >18.0 pts
Fair
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
18 to >0 pts
Poor
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned.
30 to >27.0 pts
Excellent
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.
27 to >24.0 pts
Good
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.
24 to >21.0 pts
Fair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics.
21 to >0 pts
Poor
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
30 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.
10 to >9.0 pts
Excellent
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
9 to >8.0 pts
Good
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.
8 to >7.0 pts
Fair
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.
7 to >0 pts
Poor
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (three or four) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (one or two) APA format errors.
3 to >2.0 pts
Fair
Contains several (three or four) APA format errors.
2 to >0 pts
Poor
Contains many (≥ five) APA format errors.
5 pts
Total Points: 100
PreviousNext
NRNP 6540 Week 9 Assignment
To prepare:
- Review the case study provided below
- Reflect on the patient’s symptoms and aspects of disorders that may be present.
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessment results?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential is in or out. Explain the critical thinking process that led you to your primary diagnosis. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
HPI: Ms. Juggenmeir is a 71-year-old Female who comes into your office with concerns about fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets. She is also concerned that she may need to come off one of her meds because her hair is thinning. She had labs done and was informed they would review the results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D daily as prescribed.
RESOURCE FOR THIS WEEK: Review Endocrine-related Evidence-Based Practice Guidelines.
Ms. Juggenmeir is a 71 y/o female who is AAOX4. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain.
(All other Review of System and Physical Exam findings are negative other than stated.)
Vital Signs: BP 137/82, HR 89, RR 20, Temp 98.1
PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency
Allergies: I.V. Contrast, ACE Inhibitors
Medications:
Women’s One A Day-Multivitamin daily
Chlorthalidone 25mg daily
Fish Oil 1 tablet daily
Amlodipine 5mg p.o. daily
Losartan 100mg p.o. daily
Atorvastatin 40mg p.o. at bedtime daily
Aspirin 81mg p.o. daily
Ergocalciferol 50,000 units PO once a month
Social History: as stated in the Case Study
ROS: as stated in the Case study
Diagnostics/Assessments done:
- CXR – The last CXR showed no cardiopulmonary findings. WNL
- TSH/Free T4, T3 – as noted below in lab results
- Basic Metabolic Panel and CBC as shown below
- Vitamin D Level – as noted below in lab results
| TEST |
RESULT |
REFERENCE RANGE |
| GLUCOSE |
85 |
65-99 |
| SODIUM |
134 |
135-146 |
| POTASSIUM |
4.2 |
3.5-5.3 |
| CHLORIDE |
104 |
98-110 |
| CARBON DIOXIDE |
29 |
19-30 |
| CALCIUM |
9.0 |
8.6- 10.3 |
| BUN |
20 |
7-25 |
| CREATININE |
1.01 |
0.70-1.25 |
| GLOMERULAR FILTRATION RATE (eGFR) |
76 |
>or=60 mL/min/1.73m2 |
| TEST |
RESULT |
REFERENCE RANGE |
| TSH |
23 |
0.4-4.0 |
| FREE T4 |
0.05 |
0.9-2.4 mcg/dl |
| T3 |
3.0 |
2.0-4.4 ng/dl |
| Vitamin D 1,25 OH |
14 |
36-144 |
| TEST |
RESULT |
REFERENCE RANGE |
| WBC |
7.3 |
3.4- 10.8 |
| RBC |
4.31 |
135-146 |
| HEMOGLOBIN |
14 |
13-17.2 |
| HEMATOCRIT |
42% |
36-50 |
| MCV |
90 |
80-100 |
| MCHC |
34 |
32-36 |
| PLATELET |
272 |
150-400 |
NRNP_6540_Week9_Assignment_Rubric
NRNP_6540_Week9_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications, checked against Beers Criteria• Allergies• Patient medical history (PMHx) • Review of systems
10 to >9.0 ptsExcellent
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
9 to >8.0 ptsGood
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
8 to >7.0 ptsFair
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing.
7 to >0 ptsPoor
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
10 to >9.0 ptsExcellent
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
9 to >8.0 ptsGood
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
8 to >7.0 ptsFair
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
7 to >0 ptsPoor
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
25 to >23.0 ptsExcellent
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.
23 to >20.0 ptsGood
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.
20 to >18.0 ptsFair
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
18 to >0 ptsPoor
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned.
30 to >27.0 ptsExcellent
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.
27 to >24.0 ptsGood
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.
24 to >21.0 ptsFair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains inaccuracies. Reflections on the case demonstrate adequate understanding of course topics.
21 to >0 ptsPoor
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
30 pts
This criterion is linked to a Learning outcome of at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.
10 to >9.0 ptsExcellent
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
9 to >8.0 ptsGood
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.
8 to >7.0 ptsFair
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.
7 to >0 ptsPoor
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based or do not support the treatment plan.
10 pts
This criterion is linked to a Learning outcome Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long, rambling, short, and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 ptsExcellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 ptsGood
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. The assignment’s purpose, introduction, and conclusion are stated, yet are brief and not descriptive.
3 to >2.0 ptsFair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. The assignment’s purpose, introduction, and conclusion are vague or off-topic.
2 to >0 ptsPoor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning outcome Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 ptsGood
Contains a few (one or two) grammar, spelling, and punctuation errors.
3 to >2.0 ptsFair
Contains several (three or four) grammar, spelling, and punctuation errors.
2 to >0 ptsPoor
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning outcome. Expression and Formatting – The paper follows the correct APA format for the title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 ptsExcellent
Uses the correct APA format with no errors.
4 to >3.0 ptsGood
Contains a few (one or two) APA format errors.
3 to >2.0 ptsFair
Contains several (three or four) APA format errors.
2 to >0 ptsPoor
Contains many (≥ five) APA format errors.
5 pts
Total Points: 100
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