NR 601 Week 4 Discussion Part 1 and 2 Paper

Discussion Question Part One

Mrs. R. is a 66-year-old Caucasian female who presents to the clinic with pain in her left hip that worsens with walking, bending, standing, and squatting. When asked to describe where the pain occurs, she places her fingers around the anterolateral hip region. She denies any back pain, or pain in the posterior hip or along the lateral thigh. Denies any previous injury, stumbling, tripping or falling. She states that the pain has been getting gradually worse and is almost constant if she walks or stands for a long period of time. She denies back pain, numbness, tingling, or weakness in the extremities. She reports taking Ibuprofen 800 mg approximately 3 times/week whenever she has significant hip pain. She is concerned that she doesn’t know what is causing the pain and that she is having to take increased doses of ibuprofen to manage the pain. She reports a current pain level of 8/10 on the pain scale.

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Background Information

She walks approximately 1 mile a day. She recently retired as an office manager 4 years ago.

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PMH

Unremarkable

Immunizations

All vaccines are current

Screenings

Never had a colonoscopy

Last mammogram was 5 years ago

Social History

Has an occasional glass of wine with dinner

Does not smoke

Surgical history

Cholecystectomy 20 years ago

Hysterectomy 10 years ago

Current Medications

Ibuprofen 200-800 mg prn for hip pain

NR 601 Week 4 Discussion Part 1 and 2 – Discussion Questions Part One

What risk factors does this patient have that might contribute to her hip pain?
What ROS would you conduct on this patient?
What is your primary diagnosis? What evidence-based resource and patient data supports this diagnosis?
What two differential diagnoses are appropriate in this patient’s case? What evidence-based resource and patient data supports these two differential diagnoses?
What screening would you choose to best evaluate this patient’s chief complaint?

NR 601 Week 4 Discussion Part 1 and 2 – Discussion Part Two (graded)

Physical Exam:

Vital signs: blood pressure 128/84, heart rate 80 respirations 20, temperature 98.5

height 5’3”, weight 130 pounds

General: no acute distress

HEENT: Head normocephalic without evidence of masses or trauma. PERRLA, EOMs intact. Noninjected. Fundoscopic exam unremarkable. Ear canal without redness or irritation, TMs clear, pearly, bony landmarks visible. No discharge, no pain noted. Neck negative for masses. No thyromegaly. No JVD distention

Skin: intact

CV: S1 and S2 RRR, no murmurs, no rubs

Lungs: Clear to auscultation

Abdomen: Soft, nontender, nondistended, bowel sounds present all 4 quadrants, no organomegaly, and no bruits

Musculoskeletal: No pain to palpation; Antalgic gait noted when patient rises from seated position to standing and begins to walk. Active and passive ROM decreased with stiffness

Neuro: Sensation intact to bilateral upper and lower extremities; Bilateral UE/LE strength 5/5.

Discussion Questions Part Two

For the primary diagnosis explain how you would proceed with your work-up and include the following: lab work and imaging studies
How would you manage this patient pharmacologically? Is it appropriate that she is taking Ibuprofen prn?
What non-pharmacological strategies would be appropriate?
Describe patient education strategies.
Describe follow-up and any referrals that may be necessary.

Grading Rubric

Criterion

Exceptional

Outstanding or highest level of performance

Exceeds

Very good or high level of performance

Meets

Satisfactory level of performance

Needs Improvement

Poor or failing level of performance

Developing

Unsatisfactory level of performance

Content

Possible Points = 180

Assessment

50 Points

44 Points

41 Points

20 Points

0 Points

All three diagnostic categories are present.

Each diagnosis, primary, secondary and differential, includes the ICD10 codes in parentheses next to each diagnosis.

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient. All lab results are interpreted within the rationale statement.

All three diagnostic categories are present.

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis.

Each diagnosis includes a one to two sentence paraphrased pathophysiology statement explains the diagnosis and a rationale statement.

The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient.

All lab results are not interpreted within the rationale statement.

All three diagnostic categories are present.

Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis.

The pathophysiology statement is not present or not paraphrased,

The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam which links this diagnosis to your patient.

All lab results are not interpreted within the rationale statement.

All three diagnostic categories are not developed: a primary, secondary or differential diagnosis category is not included.

Diagnoses are not present.

Evidence-Based Practice

50 Points

44 Points

41 Points

20 Points

0 Points

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.

Every diagnosis rationale must include an intext citation to a scholarly reference. Each action step or order within all plan sections includes an intext citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.

Every diagnosis rationale must include an intext citation to a scholarly reference.

One or two steps or orders within all plan sections may be missing an intext citation to an appropriate reference as listed in the Reference Guidelines document. All cited information is paraphrased, no quotes included.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017, are used to support the primary diagnosis and develop the plan.

Every diagnosis rationale does not include an intext citation to an appropriate reference as listed in the Reference Guidelines document.

The American Diabetes Association Standards and Medical Care in Diabetes-2017 is not used as reference.

Every diagnosis rationale does not include an intext citation to an appropriate reference as listed in the Reference Guidelines document.

Two steps or orders within any plan section are be missing an intext citation to an appropriate reference as listed in the Reference Guidelines document.

Scholarly information includes quotations.

National guidelines, including the American Diabetes Association Standards and Medical Care in Diabetes-2017 are not used as references.

10 Points

9 Points

8 Points

4 Points

0 Points

Plan: Diagnostics

All ordered diagnostics tests are linked to a diagnosis and include a paraphrased EBP rationale.

All ordered diagnostics tests include an EBP rationale.

A diagnosis is not included within the rationale statement.

All ordered diagnostics tests are linked to a diagnosis;

EBP rationale with in text citation is missing;

Rationale is a quotation.

Diagnostic tests include an intext citation to a non-scholarly internet or application source.

Diagnostic tests are not included

Diagnostic tests do not include an intext citation.

10 Points

9 Points

8 Points

4 Points

0 Points

Plan: Medications

Each prescribed and OTC medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale and in text citation. Diagnosis is clearly stated in the rationale statement.

All prescribed and OTC medication include a paraphrased EBP rationale and in text citation. The diagnosis is not clearly listed within the rationale statement.

Each prescribed and OTC medication is linked to a specific diagnosis. The diagnosis is clearly listed within the rationale statement. An EBP rationale is not included

Rationale is a quotation.

Prescribed and OTC medications are listed.

Not every medication is linked to a diagnosis, and include a paraphrased rationale EBP rationale and in text citation.

Prescribed and OTC medications are not included in the case study.

10 Points

9 Points

8 Points

4 Points

0 Points

Plan: Education

All education steps linked to a diagnosis, paraphrased, and include an EBP rationale. Section includes personalized detailed education on diagnosis, medications, diet, exercise and warning signs.

All education steps are linked to a diagnosis, paraphrased and include an EBP rationale. One or 2 educational areas are not detailed or personalized to the patient.

All education steps are linked to a diagnosis and includes an EBP rationale.

EBP rationale

is a quotation.

Three (3) or more education areas do not include personalized detailed information.

Any education step is not linked to a diagnosis, paraphrased or an EBP rational is not provided.

Education section is not present.

10 Points

9 Points

8 Points

4 Points

0 Points

Plan: Referral

All recommended referrals are appropriate for the patient diagnosis and condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering.

Some recommended referrals are appropriate for the patient diagnosis and condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering.

All recommended referrals are appropriate for the patient diagnosis and condition, includes a paraphrased EBP rationale for ordering, specific diagnosis is not stated for every referral.

EBP rationale

is a quotation.

Some recommended referrals are appropriate for the patient diagnosis and condition

Does not include a paraphrased EBP rationale for ordering.

Referral section is not present.

10 Points

9 Points

8 Points

4 Points

0 Points

Plan: Follow Up

Follow up includes a specific time frame to return to PCP office. Includes EBP rationale with in text citation.

Follow up is included in the plan but a specific time is not included (a range is included). Includes EBP rationale with in text citation.

Follow up is included in the plan but a specific time is not included.

Follow up is included in the plan, recommended follow up visit time frame is not EBP.

Follow up section not present.

20 Points

18 Points

16 Points

8 Points

0 Points

SOAP note

SOAP note included at end of assignment before reference page.

SOAP note includes all elements and is formatted exactly as described in the SOAP note guidelines document. Rationales are not included.

SOAP note included at end of assignment before reference page.

SOAP note includes all elements as listed in the SOAP note but not exactly as formatted in guidelines document.

Rationales are not included.

SOAP note included at end of assignment before the reference page.

SOAP note is formatted exactly as listed in the SOAP note guidelines document but is missing provided subjective or objective information.

SOAP note included, but not located at end of assignment before the reference page.

SOAP note is not formatted exactly as shown in the SOAP note guidelines document and missing provided subjective or objective information.

Rationales are included.

SOAP note not included in assignment.

10 Points

9 Points

8 Points

4 Points

0 Points

Medication costs

Monthly medication costs are calculated.

All medications including OTCs are included.

Medication cost citation is included. Summary/reflection statement is included.

Monthly medication costs are calculated.

All medications including OTCs are included.

Medication cost reference is not included. Summary/reflection statement is included.

Monthly medication costs are calculated.

All medications including OTCs are included.

Summary/reflection statement is not included.

Monthly medication costs are calculated.

Summary statement/reflection is included.

OTCs are not included in monthly medication calculations.

Medication costs not calculated.

Content Subtotal

_____of 180 points

Format

Possible Points = 20

Grammar, Syntax,

10 Points

9 Points

8 Points

4 Points

0 Points

APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors.

Two to four errors in APA format, grammar, spelling, and syntax noted.

Five to seven errors in APA format, grammar, spelling, and syntax noted.

Eight to nine errors in APA format, grammar, spelling, and syntax noted.

Post contains ten or greater errors in APA format, grammar, spelling, and/or punctuation.

Organization

10 Points

9 Points

8 Points

4 Points

0 Points

Paper is developed in a logical, meaningful, and understandable sequence using categories in instructions as section headings

SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

Assignment contains all elements but may not be written following provided format.

SOAP note presents case study findings in a logical, meaningful, and understandable sequence following provided format.

Paper does not contain all components and/or may be missing data.

SOAP note is not written in SOAP note format as outlined in the NR 601 SOAP note format document.

Paper is missing three or more required sections or

Diagnoses or

plans are sometimes unclear to follow and may not always be relevant to topic.

Paper is not relevant to case study patient

SOAP note is not relevant to case study.

Format Subtotal

_____of 20 points

Total Points

_____of 200 points

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Mrs G, a 50 year old Hispanic female, presents to the office for sick visit. Lately she has been very fatigued and just does not seem to have any energy. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has lost very little weight. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She came to the clinic today to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This is irritating to her, but she is able to fall immediately back to sleep.

Current medications: Tylenol daily for knee pain. Daily multivitamin

PMH: Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to date.

GYN hx: G1 P1. 1 child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal PAP

FH: parents alive, well, child alive, well. No siblings.

SH: works from home full time as a telemarketer. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use

Allergies: NKDA, allergic to cats and latex

Vital signs: BP 130/82; pulse 80, regular; respiration 20,regular

Height 5’2”, weight 190 pounds

General: obese female in no acute distress. Alert, oriented and cooperative.

HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. NUR601 Week 5 Case Study Assignment Paper

CV: S1 and S2 RRR without murmurs or rubs

Lungs: Clear to auscultation bilaterally, respirations unlabored.

Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.

Labwork:

CBC: WBC 6,000/mm3 Hgb 12.9 gm/dl Hct 40% RBC 4.6 million MCV 92 fl MCHC 34 g/dl RDW 13.8%

UA: pH 5, SpGr 1.015, Leukocyte esterase negative, nitrites negative, 1+ glucose; 1+ protein; negative for ketones

CMP:

Sodium 138

Potassium 4.2

Chloride 101

CO2 29

Glucose 90

BUN 12

Creatinine 0.7

GFR est non-AA 90 mL/min/1.73

GFR est AA 101 mL/min/1.73

Calcium 9.4

Total protein 7.6

Bilirubin, total 0.7

Alkaline phosphatase 72

AST 25

ALT 29

Anion gap 8.11

Bun/Creat 17.7

Hemoglobin A1C: 7.7 %

TSH: 2.30, Free T 4 0.7

Cholesterol: TC 228 mg/dl, LDL 143 mg/dl; VLDL 36 mg/dl; HDL 37mg/dl, Triglycerides 232

EKG: normal sinus rhythm. NR 601 Week 4 Discussion Part 1 and 2

NR 601 Week 4 Discussion Part 1 and 2 Paper