NR601 Week 5 Case Study

NR601 Week 5 Case Study

Order NR601 Week 5 Case Study

This assignment is submitted through Turn It In (TII).* Students are allowed two opportunities to submit. The first Turn It In submission allows the student to view the Turn It In Score and edit the assignment if necessary. The second submission is considered the final submission and will be graded. Any further Turn IT In submissions will not be considered for grading. 

*due to the amount of common case study content it is not unusual that the TII may exceed 25%. It is the original work, such as rationale statements and treatment plans that are evaluated for similarity by the faculty. 

Total Points Possible:  160 

 Requirements: 

The assignment is a paper, which is to be written in APA format using the provided assignment template. The paper shall not exceed 10 pages, excluding title page and references.  

NR601 _week 5 case study paper template_Nov 19.docx

Case Study Patient – March 2020

Review the provided patient visit information. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose the case study patient and develop the management plan for this case study patient.  Keep in mind this is a complex patient who has more than one diagnosis, which is common in primary care.  

Use the provided case study template for your paper. Review the APA Manual to adhere to APA formatting.  

Introduction: briefly discuss the purpose of this paper.  (no more than 5 sentences)  

Assessment:  review the provided case study information.  

Identify the primary and secondary diagnosis for the patient. Each diagnosis will include the following information:   

  1. ICD 10 code. 
  2. A brief pathophysiology statement which is no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis and proper citation. 
  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. An evidence-based 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. 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 requiring the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited.  Include all future follow up labs for each listed diagnosis.  
  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 Clinical 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. Review the ADA guidelines for specific follow up recommendations. 
  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.  

Assessment of Comorbidities: in this section students will review the ADA Standards of Medical Care in Diabetes (the guidelines) Assessment of Comorbidities section on comorbidities subsection and choose one listed comorbidity.  Students will discuss the significance of and the relationship between the patient’s primary diagnosis and the chosen comorbidity, explaining how one diagnosis affects the other diagnosis.  Any recommended screening, diagnostic testing, and referrals are also included.   

Medication costs: in this section students will research the costs of all prescribed and OTC monthly medications that you have prescribed and that the patient is currently taking that you would like to continue.  Students may use Good Rx, Epocrates or another resource (students may 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.  

 

ASSIGNMENT CONTENT 

Category 

Points 

% 

Description 

Assessment: Primary diagnosis    

24  

15  

Presentation of the case study patient’s primary diagnosis includes the following required elements:  

Diagnosis is consistent with the cited guideline recommendations or scholarly reference, ICD10 code is listed, rationale statement includes a one to two sentence paraphrased pathophysiology statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to the case study patient. Pertinent lab results are included and interpreted within the rationale statement.  

Assessment: Secondary diagnosis (es)   

16  

10  

Presentation of the case study patient’s secondary diagnosis (es) include (s)the following required elements:  

Diagnosis is consistent with the cited guideline recommendations or scholarly reference, ICD10 code is listed, rationale statement includes a one to two sentence paraphrased pathophysiology statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to the case study patient. Pertinent lab results are included and interpreted within the rationale statement.  

Evidence-Based Practice (EBP)  

40  

25  

National guidelines are used to support all diagnoses and develop the management plan.   

The American Diabetes Association Standards and Medical Care in Diabetes-2019 or later, (or article related to 2019 or later Guidelines) are used to support the primary diagnosis and develop the management plan.   

Every diagnosis rationale must include an in-text citation to a scholarly reference as listed in the Reference Guidelines document. Each action step or order within all plan sections includes an in-text citation to an appropriate reference as listed in the Reference Guidelines document. Reference interpretation is accurate.  

Plan: Diagnostics  

8 

5 

All ordered diagnostics tests are linked to a diagnosis listed in the assessment section and include a paraphrased EBP rationale with citation and include date when test should be performed (ie: today, 1 week, 1 month). Further testing/diagnostics for the differential diagnosis is included. Plans are consistent with the cited guideline recommendations or scholarly reference.   

Plan: Medications 

8 

5 

The plan includes both prescribed and OTC medications written in prescription format.  The plan includes a minimum of one OTC medication. Each prescribed and OTC medication is linked to a diagnosis listed in the assessment section   

Diagnosis is clearly stated in the rationale statement. And includes a paraphrased rationale EBP rationale  

Plan: Education 

8 

5 

All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale.   

 This section is written exactly how you would discuss the education to the patient. Use vocabulary which the patient can understand, not medical terminology.  

Section includes personalized detailed education on diagnoses, medications, diet, exercise and any warning signs.  Personalized diet and exercise recommendations are appropriate for the case study patient and include specific instructions for the case study patient such as a specific exercise- length of time to exercise and frequency/week. Any published diet recommendations, such as a Mediterranean diet, will include a rationale statement as to why this recommendation is beneficial for the case study patient.   

Plans are consistent with the guideline recommendations or scholarly reference.  

Plan: Referrals  

8 

5 

All recommended referrals are appropriate for the patient diagnoses:  

each referral is linked to a specific diagnosis each which was listed in the assessment section and includes a paraphrased EBP rationale.  All referrals related to the primary diagnosis are obtained from the ADA guidelines. 

Plans are consistent with the cited guideline recommendations or scholarly reference  

Plan: Follow up  

8 

5 

Follow up includes a specific time/date to return to PCP office. EBP rationale with in text citation is included.  Only follow up information is listed in this section. Additional information, such as future testing, education or referrals are not listed in follow up but within the appropriate paper sections. Plans are EBP and consistent with the guideline recommendations. 

Assessment of comorbidities   

16 

10 

The ADA guidelines includes a Comprehensive Medical Evaluation and Assessment of Comorbidities section which includes comorbidities that providers should consider when managing disorders of glucose metabolism.   

Choose one of the listed comorbidities from the ASSESSMENT OF COMORBIDITIES subsection*    

Explain the significance of and the relationship between your primary diagnosis and your chosen comorbidity. Explain how one diagnosis affects the other diagnosis in no more than 3-5 sentences. Include any recommended screening, diagnostic testing, and referrals in no more than 2-3 sentences.   

* the chosen comorbidity cannot be any secondary diagnosis already discussed in your paper’s assessment section.  

Medication costs 

8 

5  

All monthly medication costs are calculated, including the current medications the patient may be already taking.  

A total cost for all the month’s medication is included.   

All medications including OTCs are included.   

Medication cost reference source is included.  Summary/reflection statement regarding medication costs and any medications changes based on cost  or polypharmacy concerns is included.  

 

 

 

 

Total CONTENT Points= [144 pts] 

ASSIGNMENT FORMAT 

Category 

Points 

% 

Description 

Grammar, Syntax, APA  

  

8 

5 

APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one error. All referenced information is cited, “according to” is not used. All cited information is paraphrased, no quotes are included in the paper.  

Organization  

8 

5 

Paper is developed in a logical, meaningful, and understandable sequence.  

Provided assignment template is used to develop the paper.  The rationale length does not exceed template directions. The paper length does not exceed 10 pages, excluding title page and references.   

 

 

 

 

Total FORMAT Points= [16 pts] 

 

 

 

ASSIGNMENT TOTAL=160 points 

       

 

 

 

 

Rubric

NR601_Week 5 Case Study _Nov19

NR601_Week 5 Case Study _Nov19

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeAssignment Content Possible Points = 144 Points

Assessment of primary diagnosis  


1)the ICD10 code is listed in parentheses next to diagnosis. 


2) Diagnosis is consistent with the cited guideline recommendations or scholarly reference 


3) Includes a one to two sentence paraphrased pathophysiology statement. 


4) 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. Pertinent lab results are included and interpreted within the rationale statement


(4 required elements)

24.0 pts

Excellent

All 4 required elements are present

22.0 pts

V. Good

1 required element is missing

20.0 pts

Satisfactory

2 required elements are missing

12.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing  OR Section includes information that does not pertain to the case study patient such as pregnancy information or gender information that does not pertain to the case study patient’s listed gender or age.

24.0 pts

This criterion is linked to a Learning OutcomeAssessment of secondary diagnosis (es)

1) the ICD10 code is listed in parentheses next to diagnosis. 


2) Diagnosis is consistent with the cited guideline recommendations or scholarly reference 


3) includes a one to two sentence paraphrased pathophysiology statement. 


4) 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. Pertinent lab results are included interpreted within the rationale statement.


(4 required elements)

16.0 pts

Excellent

All 4 required elements are present

14.0 pts

V. Good

1 required element is missing

13.0 pts

Satisfactory

2 required elements are missing

8.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing  OR Section includes information that does not pertain to the case study patient such as pregnancy information or gender information that does not pertain to the case study patient’s listed gender or age.

16.0 pts

This criterion is linked to a Learning OutcomeEvidence-Based Practice

National guidelines are used to support all diagnoses and develop the plan.  


1) The American Diabetes Association Standards and Medical Care in Diabetes-2019 or later, (or article related to 2019 or later Guidelines) are used to support the primary diagnosis and develop the plan.  


2) Every diagnosis rationale must include an in text citation to a scholarly reference as listed in the Reference Guidelines document. 


3) Each action step or order within all plan sections includes an in text citation to an appropriate reference as listed in the Reference Guidelines document.  


4) Reference interpretation is accurate


(4 required elements)

40.0 pts

Excellent

All 4 required elements are present

36.0 pts

V. Good

1 required element is missing

33.0 pts

Satisfactory

2 required elements are missing

20.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing

40.0 pts

This criterion is linked to a Learning OutcomePlan: Diagnostics

1) All ordered diagnostic test  are presented individually 


2) All ordered diagnostics tests are linked to a diagnosis listed in the assessment section  


3) All ordered tests include a paraphrased EBP rationale with citation and include date when test should be performed (ie: today, 1 week, 1 month)  


4) Plans are consistent with the cited guideline recommendations or scholarly reference


(4 required elements)

8.0 pts

Excellent

All 4 required elements are present

7.0 pts

V. Good

1 required element is missing

6.0 pts

Satisfactory

2 required elements are missing

4.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing

8.0 pts

This criterion is linked to a Learning OutcomePlan: Medications

Each  listed medication 


1) is linked to a diagnosis listed within the assessment section or a current patent medication


2) an OTC medication is included in recommended medications 


3) includes a paraphrased EBP rationale for prescribing  


4) written in prescription format  


( 4 required elements)

8.0 pts

Excellent

All 4 required elements are present

7.0 pts

V. Good

1 required element is missing

6.0 pts

Satisfactory

2 required elements are missing

4.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing

8.0 pts

This criterion is linked to a Learning OutcomePlan: Education

This section is written exactly how you would discuss the education to the patient. Use vocabulary which the patient can understand. 


1) All education steps are linked to a diagnosis which was listed in the assessment section, paraphrased, and includes an EBP rationale.  


2) Section includes personalized detailed education on diagnoses, medications, diet, exercise and warning signs. 


3) Personalized diet and exercise recommendations which include specific instructions and are appropriate for the case study patient.


4) Plans are consistent with the cited guideline recommendations or scholarly reference


( 4 required elements)

8.0 pts

Excellent

All 4 required elements are present

7.0 pts

V. Good

1 required element is missing

6.0 pts

Satisfactory

2 required elements are missing

4.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing

8.0 pts

This criterion is linked to a Learning OutcomePlan: Referral

1) each referral is linked to a specific diagnosis which was listed in the assessment section. 


2) All referrals related to the primary diagnosis are obtained from the ADA guidelines.


3) each referral includes a paraphrased EBP rationale. 


4) Referral plans are consistent with the cited guideline recommendations or scholarly reference


( 4 required elements)

8.0 pts

Excellent

All 4 required elements are present

7.0 pts

V. Good

1 required element is missing

6.0 pts

Satisfactory

2 required elements are missing

4.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing

8.0 pts

This criterion is linked to a Learning OutcomePlan: Follow-Up

1) Includes a specific time frame or date to return to PCP office.  A time range is not acceptable (i.e. 2-4 weeks)  


2) Includes EBP rationale with in text citation for chosen follow up date  


3) Plans are EBP and consistent with the cited guideline recommendations.  


4) Only follow up information is listed in this section.  


( 4 required elements)

8.0 pts

Excellent

All 4 required elements are present

7.0 pts

V. Good

1 required element is missing

6.0 pts

Satisfactory

2 required elements are missing

4.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing

8.0 pts

This criterion is linked to a Learning OutcomeAssessment of comorbidities

1) Comordidity chosen was listed within the listed comorbidities from the Assessments of comorbidities subsection*  


2) Discussed significance of and the relationship between primary diagnosis and chosen comorbidity.  


3) Explain how one diagnosis affects the other diagnosis in no more than 3-5 sentences.  


4) Included any recommended screening, diagnostic testing, and referrals in no more that 2-3 sentences.  


* the chosen comorbidity cannot be any secondary diagnosis already discussed in your paper’s assessment section


( 4 required elements)

16.0 pts

Excellent

All 4 required elements are present

14.0 pts

V. Good

1 required element is missing

13.0 pts

Satisfactory

2 required elements are missing

8.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing  OR the chosen comorbidity is also a secondary diagnosis already discussed within the paper’s  assessment section

16.0 pts

This criterion is linked to a Learning OutcomeMedication Costs

All monthly medication costs are calculated  


1 )All medications including current medications and OTCs are included.  


2) Each medication cost is calculated individually  


3) a total cost for the month’s medication is calculated 


4) Summary/reflection statement is included regarding medication costs and any medications changes based on cost or polypharmacy concerns


( 4 required elements)

8.0 pts

Excellent

All 4 required elements are present

7.0 pts

V. Good

1 required element is missing

6.0 pts

Satisfactory

2 required elements are missing

4.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing

8.0 pts

This criterion is linked to a Learning OutcomeAssignment Format Possible Points = 16 Points

Grammar, Syntax, APA 


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


1) All referenced information is cited at the end of the phrase or sentence 


2) All cited information is paraphrased, no quotes are included 


3) “according to” or “per” is not used when citing a scholarly source

8.0 pts

Excellent

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

7.0 pts

V. Good

Two to four errors in APA format, grammar, spelling, and syntax noted.     Three required elements are present

6.0 pts

Satisfactory

Five to seven errors in APA format, grammar, spelling, and syntax noted.”    1 required element is missing

4.0 pts

Needs Improvement

Eight to nine errors in APA format, grammar, spelling, and syntax noted.     OR   2 required elements are missing

0.0 pts

Unsatisfactory

Post contains ten or greater errors in APA format, grammar, spelling, and/or punctuation.   OR   3 required element are missing

8.0 pts

This criterion is linked to a Learning OutcomeOrganization

Paper is developed in a logical, meaningful, and understandable sequence  


 1) Provided assignment template is used to develop paper  


2) Rationale length does not exceed template directions.  


3) All required sections are included within the assignment  


4) The paper length does not exceed 10 pages. (not including title page and references)

8.0 pts

Excellent

All 4 required elements are present

7.0 pts

V. Good

1 required element is missing

6.0 pts

Satisfactory

2 required elements are missing

4.0 pts

Needs Improvement

3 required elements are missing

0.0 pts

Unsatisfactory

4 required elements are missing

8.0 pts

This criterion is linked to a Learning OutcomeLate Penalty Deductions

Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment. Quizzes and discussions are not considered assignments and are not part of the late assignment policy.

0.0 pts

Manual Deductions

0.0 pts

Manual Deductions

0.0 pts

Total Points: 160.0

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id="exampleSelect1"> <option name="order_deadline" value="14.99"> 30 Days </option> <option name="order_deadline" value="18.99"> 14 Days </option> <option name="order_deadline" value="21.99"> 10 Days </option> <option name="order_deadline" value="24.99"> 5 Days </option> <option name="order_deadline" value="28.99"> 48 Hours </option> <option name="order_deadline" value="31.99"> 24 Hours </option> <option name="order_deadline" value="33.99"> 12 Hours </option> <option name="order_deadline" value="37.99"> 6 Hours </option> <option name="order_deadline" value="14.99"> 30 Days </option> <option name="order_deadline" value="18.99"> 14 Days </option> <option name="order_deadline" value="21.99"> 10 Days </option> <option name="order_deadline" value="24.99"> 5 Days </option> <option name="order_deadline" value="28.99"> 48 Hours </option> <option name="order_deadline" value="31.99"> 24 Hours </option> <option name="order_deadline" value="33.99"> 12 Hours </option> <option name="order_deadline" value="37.99"> 6 Hours </option> </select> </div> </div> <input id="order_amount" class="form-control fontbig form-control-plaintext" type="hidden" name="order_amount" value="$" id="example-text-input"> <br/> <div class="op-row"> <div class="op-col-6 op-text-right"> Price (USD)</div> <div class="op-col-6 op-text-right op-name"> <div class="orderamountc">$</div> </div> </div> <div class="op-row"> <div class="op-col-6 op-text-right"> </div> </div> <div class="op-row"> <div class="opc1btn"> <a class="op-sm-12" href="/order"> Write my paper </a></div> </div> <script type="text/javascript"> var addon = document.getElementsByClassName('addon'), total = document.getElementById('payment-total'); for (var i=0; i < addon.length; i++) { addon[i].onchange = function() { var add = this.value * (this.checked ? 1 : -1); total.innerHTML = parseFloat(total.innerHTML) + add document.getElementById('addontotal').value = total.innerHTML; } } </script> <script type="text/javascript"> $(document).on("change",function(){ var pages = $('[name="order_pages"]').val(); var ac=$('[name="order_deadline"]:checked').val(); var cap=$('[name="ops_aclevel"]:checked').val(); var num = (parseFloat(cap)*parseFloat(ac)*parseFloat(pages)); var n = num.toFixed(2); document.getElementById('order_amount').value = parseFloat(n); document.getElementById('words').value = parseFloat(pages)*275; $(".wordcount").html(parseFloat(pages)*250 + " words"); $(".orderamountc").html("$" + n); }); function myFunction() { var y = document.getElementById("a4").value; var z = document.getElementById("a3").value; var x = y + z; document.getElementById('a5').value = parseFloat(NameValue); } </script> <script type="text/javascript"> //plugin bootstrap minus and plus //http://jsfiddle.net/laelitenetwork/puJ6G/ $('.btn-number').click(function(e){ e.preventDefault(); fieldName = $(this).attr('data-field'); type = $(this).attr('data-type'); var input = $("input[name='"+fieldName+"']"); var currentVal = parseInt(input.val()); if (!isNaN(currentVal)) { if(type == 'minus') { if(currentVal > input.attr('min')) { input.val(currentVal - 1).change(); } if(parseInt(input.val()) == input.attr('min')) { $(this).attr('disabled', true); } } else if(type == 'plus') { if(currentVal < input.attr('max')) { input.val(currentVal + 1).change(); } if(parseInt(input.val()) == input.attr('max')) { $(this).attr('disabled', true); } } } else { input.val(0); } }); $('.input-number').focusin(function(){ $(this).data('oldValue', $(this).val()); }); $('.input-number').change(function() { minValue = parseInt($(this).attr('min')); maxValue = parseInt($(this).attr('max')); valueCurrent = parseInt($(this).val()); name = $(this).attr('name'); if(valueCurrent >= minValue) { $(".btn-number[data-type='minus'][data-field='"+name+"']").removeAttr('disabled') } else { alert('Sorry, the minimum value was reached'); $(this).val($(this).data('oldValue')); } if(valueCurrent <= maxValue) { $(".btn-number[data-type='plus'][data-field='"+name+"']").removeAttr('disabled') } else { alert('Sorry, the maximum value was reached'); $(this).val($(this).data('oldValue')); } }); $(".input-number").keydown(function (e) { // Allow: backspace, delete, tab, escape, enter and . if ($.inArray(e.keyCode, [46, 8, 9, 27, 13, 190]) !== -1 || // Allow: Ctrl+A (e.keyCode == 65 && e.ctrlKey === true) || // Allow: home, end, left, right (e.keyCode >= 35 && e.keyCode <= 39)) { // let it happen, don't do anything return; } // Ensure that it is a number and stop the keypress if ((e.shiftKey || (e.keyCode < 48 || e.keyCode > 57)) && (e.keyCode < 96 || e.keyCode > 105)) { e.preventDefault(); } }); </script>

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