NR601 Primary
Care of the Maturing and Aged Family
Week 2
Discussion
DQ1 ACC/AHA Guidelines Discussion
Chief complaint: medication refill "ran out of
medicine"
HPI: BJ, a 68-year-old AA female presents to the clinic for
prescription refills. The patient also indicates that she has noticed shortness
of breath which started about 3 months ago. The SOB gets worse with activity,
especially when she is playing with her grandchildren but it goes away once she
sits down to rest. She reports that she is also bothered by shortness of breath
that wakes her up at night, but it resolves after sitting upright on 3 pillows.
She also has lower leg edema which started 1 week ago. She also indicates that
she often feels light headed and faint while going up the stairs, but it
subsides after sitting down to rest. She has not tried any OTC medications at
home. She never filled her prescriptions, which she received at her checkup 6 months
ago, she did not think it was important.
PMH:
Hypertension
Previous history of MI in 2010
Surgeries:
2010-Left Anterior Descending (LAD) cardiac stent placement
Allergies: Amoxicillin
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Has never had a Pneumovax
Has not had a Td in over 20 years
Has not had the herpes zoster vaccine
Social history:
High school graduate, a widow with one son who loves out of
state. She drinks one 4-ounce glass of red wine daily. She is a former smoker
that stopped 20 years ago.
Family history:
Both parents are deceased. Father died of a heart attack;
mother died of natural causes. She had one brother who died of a heart attack
20 years ago at the age of 52.
ROS:
Constitutional: Lightheaded and faint with exertion.
Respiratory: Shortness of breath with exertion (playing with
grandchildren and stairs). + Orthopnea
Cardiovascular: + leg and ankle swelling x 1 week
Psychiatric: Not taking medications for 6 months - "ran
out"
Physical examination:
Vital Signs
Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP
150/86 T 98.0 oral P 100 R 22, non-labored;
HEENT: normocephalic, symmetric. Bilateral cataracts;
PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus
NECK: Neck supple; non-palpable lymph nodes; no carotid
bruits. Thyroid non-palpable
LUNGS: inspiratory crackles
HEART: Normal S1 with S2 split during expiration. An S4 is
noted at the apex; systolic murmur noted at the right upper sternal border without
radiation to the carotids.
ABDOMEN: Normal contour; active bowel sounds all four
quadrants; no palpable masses.
PV: Pulses are 2+ in upper extremities and 1+ in pedal
pulses bilaterally. 2+ pitting edema to her knees noted bilaterally
GENITOURINARY: no CVA tenderness; not examined
MUSCULOSKELETAL: Heberden's nodes at the DIP joints of all
fingers and crepitus of the bilateral knees on flexion and extension with
tenderness to palpation medially at both knees. Kyphosis and gait slow, but
steady.
PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9
score is 22.
SKIN: Sparse hair noted on lower legs and feet bilaterally
with dry skin on her ankles and feet.
Labs:: Hgb 12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230,
Triglycerides 188, HDL 37, LDL 190, TSH 3.7, glucose 98 BUN 12 Cr 0.8
A:
Primary Diagnosis:
Congestive Heart Failure (CHF) (150.9)
Secondary Diagnoses:
Primary Hypertension (I10)
Depression F32.3:
Obesity (E66):
Osteoarthritis (OA) (715.90)
Differential Diagnosis:
Peripheral Vascular Disease (PVD) (173.9)
P:
Medications:
Sertraline 25 mg. Take 1 tab PO QD disp#30, 1 refill
Tylenol 650 mg PO Q4 hours as needed for arthritis pain
Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH.
12-lead EKG, Chest X-ray; Initial 2D echo with Doppler;
Ankle-brachial index
Education:
Congestive heart failure is caused by the inability of your
heart to pump blood effectively enough to meet the demands of your body. If you
think of your body as any other pump, if fluid does not move well through the
system, then it will back up into other spaces. When blood backs up it puts a
lot of pressure on the blood vessels, which forces fluid to leak out into the
nearby tissue. With CHF, this fluid usually moves into your lungs, legs, or
abdomen.
The signs of worsening CHF include decreased energy level,
shortness of breath during your normal routine, increased swelling to your legs
and feet, your clothes feel tight, or a wet sounding cough. Call the office if
these symptoms occur.
Weigh yourself every morning at the same time. If you have a
3 pound weight gain in 24 hours, or a 5 pound weight gain over a week, you
should call the office.
Exercise and maintaining a normal weight is very important.
You should try to exercise at least 20-30 minutes a day, more if possible.
Start slow with walking.
Decrease your salt intake. Do not add any extra salt to
foods. Salt makes you retain fluid, and it makes you want to drink more fluid.
Avoid fast food and prepared food as they are usually very high in sodium.
If you notice your legs swelling, elevate them up and rest.
Do not drink alcohol and continue to avoid smoking or second hand smoke.
Take your medications as directed, with water. Do not stop
them abruptly or skip doses.
I have started you on a medication for depression. It can
take 2 weeks to start to feel it working and up to a month until you can fell
the real benefits.
If you start to feel more depressed, like you want to harm
yourself or others, please contact me right away or got to the ER.
Referrals: may refer based on lab results
Follow up: return to office in 2 weeks
Additional lab results:
Echo results: LVEF 39%
BNP - 682 pg/ml
Questions: You determine the medications for CHF/ASCVD
According to the ACC/AHA Guidelines, what is BJ's heart failure
stage?
According to the ACC/AHA Guidelines, what medications should
BJ be prescribed?
Does she need any additional medication given her history of
MI?
Write her complete prescriptions using the prescription
writing format.
DQ2 Polypharmacy Discussion
Polypharmacy is a common concern, especially in the elderly.
List the definitions of polypharmacy you encounter in your
readings. There is more than one.
Discuss three risk factors that can lead to polypharmacy.
Explain the rationale for why each listed item is a risk factor. This is
different than adverse drug reactions. ADRs can be a result of polypharmacy,
and is important, but ADRs are not a risk factor.
Discuss three action steps that a provider can take to
prevent polypharmacy.
Provide an example of how your clinical preceptors have
addressed polypharmacy.
NR601 Primary
Care of the Maturing and Aged Family
Week 3
Discussion
DQ1 Geriatric Assessment Tools
Review the course library page list of available screening
tools. Link to Library (Links to an external site.)Links to an external site.
Scroll down and look on the left hand side of the screen:
Geriatric Assessment tools
Choose two assessment tools that are appropriate for primary
care (excluding depression, anxiety and pain screening tools) and discuss the
following:
explain the purpose of the tool
scoring guidelines
how you apply the assessment in practice
*If you would like to present a screening tool that is not
listed, contact your instructor for approval.
DQ2 Psychiatric Disorders and Screening
Anxiety and depression are the most common psychiatric problems
you will encounter in your primary care practice.
Review this case study
HPI: KB, 55 year old Caucasian female who presents to office
with complaints of fatigue. The fatigue has been present for 6 months and seems
worse in the morning, improving slightly through the day. KB reports a lack of
energy and "loss of joy". States" I really don't feel like going
anywhere or doing anything" Reports she often has difficulty staying on
task and completing projects for work. She reports not feeling hungry and does
not feel rested when she wakes up in the morning. KB is a widow for 2 years,
social events that are couples only can make her symptoms worse. She tries to
do at least one social activity a week but it can be really exhausting. Her
husband died in their car while she was driving him to the hospital and
sometimes driving in that car makes all the memories come back. She recently
got a puppy, which she thought would help with the loneliness but the care of
the puppy seems overwhelming at times. Rest and exercise, specifically yoga and
meditation seem to make her feel better. At this time she does not want to do
either. She has not tried any medications, prescribed or otherwise. She reports
drinking a lot of coffee, but that does not seem to help.
Current medications: Excedrin PM about once a week when she
can't sleep, seems to help a bit. NKDA.
PMH: no major illnesses. Immunizations up to date.
SH: widowed, employed full time as a manager. Drinks wine, 1
glass every night. No tobacco, no illicit drugs. Previously married while
living in France, reports an abusive relationship. The French government gave
custody of her son to the ex-husband. She returned to US without her son 10
years ago. She sees her son two times a year, they skype and text "all the
time" but she misses him.
FH: Parents are alive and well. Has one son, age 21, he is
healthy but lives in France with his father.
ROS
CONSTITUTIONAL: reports weight loss of 2-3 pounds, no fever,
chills, or weakness reported
HEENT: Eyes: No visual loss, blurred vision, double vision
or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion,
runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: Reports decreased appetite for about 3
months. No nausea, vomiting or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness or tingling in the extremities. No change in bowel or bladder
control.
GENITOURINARY: no burning on urination. Last menstrual
period 4 years ago.
PSYCHIATRIC: No history of diagnosed depression or anxiety.
Reports great anxiety due to verbal and concern for physical abuse, reports
feeling very sad and anxious when divorcing and leaving her son in France. Did
not seek treatment. She started to feel better after about 4 months.
ENDOCRINOLOGIC: No reports of sweating, cold or heat
intolerance. No polyuria or polydipsia
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Discussion Questions:
1. Research screening tools for depression and anxiety.
Choose one screening tool for depression and one screening
tool for anxiety that you feel are appropriate to screen KB.
Explain why you chose that particular tool for KB. If you
can, attempt to score KB based on the information provided (not all data may be
provided). Include what questions could be scored, and your chosen score.
2. Identify your next step for evaluation and treatment for
KB.
What medication, if any, would you recommend for treatment?
Provide the rationale. This should include the medication class, mechanism of
action of the medication and why this medication is appropriate for KB. Include
initial prescribing information.
If the medication works as expected, when should KB expect
to start feeling better?
NR601 Primary
Care of the Maturing and Aged Family
Week 6
Discussion
Post Menopausal and Sexuality Issues in the Maturing and
Older Adult Discussion
Ageism and gender bias can affect who and how we ask about
sexual health, sexual activity, and concerning symptoms. Depending on your own
level of comfort and cultural norms this can be a tough conversation for some
providers. But this is an important topic and as our videos discussed, women
are wanting us to ask about sexual concerns. This week we also reviewed
sexually transmitted diseases and the effects of ageism on time to diagnosis so
it is necessary to ask these questions and provide good education for all
patients. You will not know any needs unless you ask.
Discussion Questions:
Review the required NAMS videos. What was the most
surprising thing you learned about in the videos? Explain why it was
surprising.
What is GSM? What body systems are involved? How does this
affect a woman's quality of life?
What treatment does Dr Shapiro recommend?
Review one aspect of treatment that Dr Shapiro recommends
and include an EBP journal article or guideline recommendation in addition to
referencing the video in your response.
Sexuality and the older adult
What is your level of comfort in taking a complete sexual
history? Is this comfort level different for male or female patients? If so,
why?
How will this information impact the way you will interact
with your mature and elderly clients?
NR601 Primary
Care of the Maturing and Aged Family
Week 7
Discussion
Reflection
Reflect back over the past eight weeks and describe how the
achievement of the course outcomes in this course have prepared you to meet the
MSN program outcome #5, the MSN Essential VIII, and the Nurse Practitioner Core
Competency # 8 Ethics Competencies.
Chamberlain College of Nursing Program Outcome #5
Advocates for positive health outcomes through
compassionate, evidence-based, collaborative advanced nursing practice.
(Extraordinary nursing)
Masters Essential VIII: Clinical Prevention and Population
Health for Improving Health
Design patient-centered and culturally responsive strategies
in the delivery of clinical prevention and health promote on interventions
and/or services to individuals, families, communities, and aggregates/clinical
populations.
Integrate clinical prevention and population health concepts
in the development of culturally relevant and linguistically appropriate health
education, communication strategies, and interventions.
NONPF: #8 Ethics Competencies
Integrates ethical principles in decision making.
Evaluates the ethical consequences of decisions.
Applies ethically sound solutions to complex issues related
to individuals, populations and systems of care
Review the assignment rubric for specific requirements for
this reflection post.
NR601 Primary
Care of the Maturing and Aged Family
Week 5 Case
Study Assignment
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
PREPARING THE ASSIGNMENT
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.
The assignment will be submitted through TurnItIn. Due to
the common language in a large group assignment, it is possible that similarity
scores can exceed 25%. It is the student’s responsibility to review the TII
paper and assure that sections of original work contain low similarity. If
there are concerns, please contact your instructor.
|
Category
|
Points
|
%
|
Description
|
|
Assessment
|
50
|
25
|
Each diagnosis, primary, secondary
and differential includes the ICD10 codes in parentheses next to each
diagnosis. A one to two sentence paraphrased pathophysiology statement
explains the diagnosis. Include pertinent positive and negative findings to
support your diagnoses from the history and physical exam, which links this
diagnosis to your patient. Each diagnoses must include an in text citation to
a scholarly reference. Diagnoses are consistent with the
guideline recommendations or scholarly reference.
|
|
Evidence-Based Practice (EBP)
|
50
|
25
|
National guidelines, including the American
Diabetes Association Standards and Medical Care in Diabetes-2017or later, are used as rationale to support the diagnosis
and develop the management plan. Every diagnoses must include an in text
citation to a scholarly reference. 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.
|
|
Plan: diagnostics
|
10
|
5
|
Each test listed in this
section includes a rationale statement, 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.
|
|
Plan: medications
|
10
|
5
|
Each prescribed and OTC
medication is linked to a diagnosis, and includes a paraphrased EBP rationale
and in text citation. Diagnosis is clearly stated in the rationale statement.
|
|
Plan: education
|
10
|
5
|
All education steps are
linked to a diagnosis, paraphrased, and include an EBP rationale. Section
includes personalized and detailed education on all diagnoses, medications,
diet, exercise, and warning signs.
|
|
Plan: Referrals
|
10
|
5
|
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
|
|
Plan: Follow up
|
10
|
5
|
Follow up includes a
specific time frame to return to PCP office for next scheduled appointment.
|
|
Medication costs
|
10
|
5
|
All prescribed medications
costs, prescribed and OTC, are calculated to evaluate the total monthly
medication cost for the patient. A reflection statement is included.
|
|
SOAP note
|
20
|
10
|
A SOAP note, written on a
separate page, follows the assignment. The SOAP note is located prior to the
Reference section. The SOAP note is written following the provided SOAP note
format. Rationales are not included; this SOAP note is an example of a
patient chart entry.
|
|
Grammar, Syntax, APA
|
10
|
5
|
APA format, grammar,
spelling, and/or punctuation are accurate, or with zero to one errors. All
referenced information is cited, “according to” is not used.
|
|
Organization
|
10
|
5
|
Paper is developed in a
logical, meaningful, and understandable sequence using categories in
instructions as section headings. The paper does not exceed 20 pages.
Each diagnosis and action
step in the plan lists the step followed by the rationale. Rationale length
does not exceed template directions.
|
|
Total
|
200
|
100
|
A quality assignment will meet or
exceed all of the above requirements.
|
