NRNP 6540 Week 2 RaymondYoung 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 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 >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