NRNP 6540 RaymondYoung Week 1 Assessment of Older Adults

NRNP 6540 RaymondYoung Week 1 Assessment of Older Adults Example

Assessment of Older Adults

Advancement of age is associated with many chronic health issues that affect the quality of life. Elderly patients form a unique subset of the patient population that many advanced practice nurse practitioners (APNP) will interact with in their practice for evaluation and treatment. Some of the chronic conditions associated with advancing age include dementia, osteoporosis, and other forms of cognitive impairment. It is the mandate of the health care providers to ensure that elderly patients have a full functional ability to care for themselves fully. To elicit problems facing elderly patients, comprehensive history taking, physical examination, and mental state examination are necessary. Several assessment tools for their health conditions and functioning are available; hence, APNPs should appropriately use those that can be of help in evaluating the patients they meet. 

Assessment Tools

In this case, Mr. W is a 92-year-old retired college professor living at home with his wife in an upscale suburban neighborhood that offers little public transport. Her wife prefers him to drive despite her ability to operate a motor vehicle. Mr. W’s medical history includes obstructive sleep apnea (OSA), hypertension managed with lifestyle modification, chronic anemia, osteoporosis, edema, history of prostate cancer, and edema. However, he can carry out his activities of daily living appropriately. He reports presenting to his geriatrician 8 years ago and reported forgetfulness when he lost his way while driving to a family museum. He has a history of difficulty in recalling his personal art collection and has experienced falls. In 2009, he reported troublesome memory loss that made his driving more difficult, although there were no reported unsafe practices. His geriatrician diagnosed him with mild cognitive impairment (MCI) secondary to early onset Alzheimer’s disease with recommendations of assessment at a driving evaluation clinic. 

In developing an evaluation plan for the patient, it is important to note that the history of falls and confusion indicating underlying immobility, cognitive dysfunction, and sensory deprivation may require adequate attention. From the history, only hypertension is being managed and his only medication is vitamin B12. There is a need for the patient to be on iron supplements to manage the anemia as well as restless leg syndrome (Trotti & Becker, 2019), as well as bisphosphonates, which will manage his osteoporosis and reduce the risk of falls (Reid & Billington, 2022). The edema would be suggesting a cardiac issue such as heart failure and being that he is hypertensive, it is crucial to evaluate the cardiovascular system comprehensively. 

There are many assessment tools for the patient. As stated by Arevalo-Rodriguez et al. (2021), the mini-mental state examination (MMSE) is a brief neuropsychological test that is used in evaluating for cognitive function in the setting of individuals with symptoms of cognitive dysfunction. Patients who have mild cognitive impairment, like Mr. W, should be evaluated and monitored as they have a high risk of progressing into dementia.

As outlined in the history, the patient underwent two MMSE evaluations, for which, in the first presentation, he scored 30/30 and in the second assessment, 29/30. The MMSE is a 30-question assessment of cognitive function that is based on attention, orientation, memory, registration, recall, calculation, language, and the ability to draw a complex polygon. The MMSE is appropriate for this patient, with no ethical issues being involved. Since he is still driving, there are assessment tools that can be used to measure his driving competency. According to Toups et al. (2022), driving is a complex work that requires learned skills and coordination of complex cognitive and physical tasks. On-road evaluations such as performance-based road tests and driving simulation studies can be used to identify and remediate poor driving behaviors to prevent adverse outcomes (Toups et al., 2022). Again, the MMSE can be a psychometric evaluation test that can be used to evaluate driving competency as it evaluates cognitive functioning, which is applied in driving. 

The comprehensive geriatric assessment (CGA) is a multidisciplinary instrument that can be used in elderly patients with a risk of falling (Appeadu & Bordoni, 2023). The instrument uses scales such as the Berg Balance Scale to evaluate static and dynamic balance, the Falls Efficacy Scale to assess the fear of falling, and the Timed Up and Go Test to assess a patient’s mobility. Other assessment tools for fall risk among elderly patients include the Tinetti Gait and Balance Assessment Tool and the one-legged and tandem stance assessments (Appeadu & Bordoni, 2023).  

Issues Affecting Assessments

A number of geriatric patients have problems with memory, concentrating, learning, or making decisions that impact their daily lives because of their age (Khanna & Metgud, 2020). When evaluating such patients, there should be more effort during evaluation to obtain adequate information, especially during history taking because of their cognitive impairment that may disturb their memory. Their level of education may impact their assessment as well as the language being used. Therefore, as an advanced nurse practitioner, there should be a demonstration of cultural competency when evaluating adults, as most tend to incline their thoughts and symptoms to culture. 

Immunization Requirements

At a personal level, life course vaccination programs substantially contribute to lowering the burden of infectious disease, decreasing mortality, and mitigating infection-related mortality (Michel & Frangos, 2022). Similarly, with the implementation of more vaccination programs in countries like the United States, United Kingdom, Canada, and Australia, the incidence of morbidity and mortality of infectious diseases has drastically decreased by over 90%. Vaccines are of the essence in the elderly population. It has been documented that tetanus, polio, and flu vaccines may play a role in preventing the onset of Alzheimer’s disease (AD) (Michel & Frangos, 2022). It will be important to ensure the patient receives his annual flu vaccine to ensure he does not contract influenza or pneumococcal pneumonia. According to Michel and Frangos (2022), patients aged above 65 years should receive tetanus, polio, and flu vaccines. 

References

Appeadu, M., & Bordoni, B. (2023, June 4). Falls and Fall Prevention in the Elderly. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560761/

Arevalo-Rodriguez, I., Smailagic, N., Roqué-Figuls, M., Ciapponi, A., Sanchez-Perez, E., Giannakou, A., Pedraza, O. L., Bonfill Cosp, X., & Cullum, S. (2021). Mini-Mental State Examination (MMSE) for the Early Detection of Dementia in People with Mild Cognitive Impairment (MCI). Cochrane Database of Systematic Reviews, 2021(7). https://doi.org/10.1002/14651858.cd010783.pub3

Khanna, A., & Metgud, C. (2020). Prevalence of cognitive impairment in elderly population residing in an urban area of Belagavi. Journal of Family Medicine and Primary Care, 9(6), 2699. https://doi.org/10.4103/jfmpc.jfmpc_240_20

Michel, J.-P., & Frangos, E. (2022). The Implications of Vaccines in Older Populations. Vaccines, 10(3), 431. https://doi.org/10.3390/vaccines10030431

Reid, I. R., & Billington, E. O. (2022). Drug therapy for osteoporosis in older adults. The Lancet, 399(10329), 1080–1092. https://doi.org/10.1016/s0140-6736(21)02646-5

Toups, R., Chirles, T. J., Ehsani, J. P., Michael, J. P., Bernstein, J. P. K., Calamia, M., Parsons, T. D., Carr, D. B., & Keller, J. N. (2022). Driving Performance in Older Adults: Current Measures, Findings, and Implications for Roadway Safety. Innovation in Aging, 6(1), igab051. https://doi.org/10.1093/geroni/igab051

Trotti, L. M., & Becker, L. A. (2019). Iron for the treatment of restless legs syndrome. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd007834.pub3

Week 1: Assessment of Older Adults

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/}

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

Also Read: NRNP 6540 Week 9 Assignment

Learning Resources

Required Readings (click to expand/reduce)

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

 

Recommended Reading (click to expand/reduce)

 

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

 

Recommended Media (click to expand/reduce)

 

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!

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NRNP_6540_Week1_Discussion_Rubric

Grid View

List View

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

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:

1. CXR—no cardiopulmonary findings. WNL
2. CT head—diffuse Cerebral Atrophy
3. 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 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

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
PreviousNext

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:

• Tamsulosin – hives

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:

• Heart Attack, Father

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

• Na 127>128>122
• Monitor

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.

Also Read: NRNP 6540 Week 9 Assignment

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:

1. CXR – The last CXR showed no cardiopulmonary findings. WNL
2. TSH/Free T4, T3 – as noted below in lab results
3. Basic Metabolic Panel and CBC as shown below
4. 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