NR601 Case Study Assignment 1 Week 5 2018 July

Purpose

The purpose of this case study assignment is to

1) Analyze provided subjective and objective information to diagnose and develop a management plan for the case study patient.

2) Apply national diabetes guidelines to case study patient management plan.

3) Demonstrate mastery of SOAP note writing.

Course Outcomes

Through this assignment, the student will demonstrate the ability to:

1. Employ appropriate health promotion guidelines and disease prevention strategies in the management of mature and aging individuals and families.

2. Formulate appropriate diagnoses and evidence-based plans of care for mature and aging individuals and families using subjective and objective data.

3. Incorporate unique patient cultural preferences, values, and health beliefs in the care of mature and aging individuals and families

4. Integrate theory and evidence based practice in the care of mature and aging individuals and their families

6. Conduct pharmacologic assessment addressing polypharmacy, drug interactions and other adverse events in the care of mature and aging individuals and their families.

7. Apply evidence-based screening tools to perform functional assessments with aging individuals and their families as appropriate.

Due Date:Sunday 11:59 p.m. MT at the end of Week 5

Total Points Possible: 200 points

The assignment is a paper, which is to be written in APA format. This includes a title page and reference page. The paper shall not exceed 20 pages.

Review the attached patient visit information. The patient has presented for an acute care visit. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose and develop the management plan for this case study patient.

Use the categories below to create section headings for your paper. Review the APA Manual for paper format instructions.

Introduction: briefly discuss the purpose of this paper.

Assessment: review the provided case study information.

Identify the primary, secondary and differential diagnoses for the patient. Use the 601 SOAP note format as a guide to develop your diagnoses.

Each diagnosis will include the following information:

1. ICD 10 code.

2. A brief pathophysiology statement which his no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis.

3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement, which links the subjective and objective findings (including lab data and interpretation).

4. A rationale statement, which summarizes why the diagnosis was chosen.

5. Do not include quotes, paraphrase all scholarly information and provide an in text citation to your scholarly reference. Use the Reference Guidelines document for information on scholarly references.

Plan (there are five (5) sections to the management plan)

1. Diagnostics. List all labs and diagnostic test you would like to order. Each test includes a rationale statement following the listed lab, which includes the diagnosis for the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited.

2. Medications: Each medication is listed in prescription format. Each prescribed and OTC medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for prescribing.

3. Education: section includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise recommendations and warning sign for diagnosis and medications if applicable. All education steps are linked to a diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601 SOAP note guideline for more detailed information.

4. Referrals: any recommended referrals are appropriate to the patient diagnosis and current condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale with in text citation.

5. Follow up: Follow up includes a specific time, not a time range, to return to PCP office for next scheduled appointment. Includes EBP rationale with in text citation.

Medication costs:in this section students will research the costs of all prescribed and OTC monthly medications. Students may use Good Rx, Epocrates or another resource (can use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications and provide the total costs of the month’s medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice.

SOAP note: A focused SOAP note, written on a separate page, follows the assignment. The SOAP note is written following the provided SOAP note format.

· The subjective section is organized to follow the SOAP note format. The ROS is focused; only pertinent body systems are included. Only provided information is included in the ROS. No additional data is added.

· The objective section is maintained as written, no additional information is added.

· The assessment section includes only the diagnoses and ICD 10 codes. Diagnosed are labeled as primary, secondary or differential diagnoses. Rationale is not included in the SOAP note.

· The plan includes five sections. Rationale is not included in the SOAP note.