Expert answer:case study
Solved by verified expert:Assignment 2: Comprehensive Plan of Care and Paper
Overview/Description:
You have been provided with case studies in Week 4 and Week 5 that focused on genitourinary, and musculoskeletal disorders. You will pick one of these cases to analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.
Criteria:
•SOAP note
•Evaluation of priority diagnosis
•Facilitators and barriers to disorder management
Submit your document to the W4 Assignment 2 Dropbox by Tuesday, October 31, 2017.
Assignment 2 Grading Criteria
Maximum Points
Introduction
The submission included a general introduction to the priority diagnosis.
10
Subjective Data
The submission included the patient’s interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.
15
Objective Data
The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination as well as laboratory and diagnostic testing results.
15
Assessment
The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.
20
Plan of Care
Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.
25
Evaluation of Priority Diagnosis
The plan chose the priority diagnosis for the patient and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
25
Facilitators and Barriers
The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.
20
Conclusion
The submission included what should be taken away from this assignment.
10
APA/Style/Format
The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style.
Utilized proper format with coversheet, header.
10
Total
150
week_5_musculoskeletal.docx
week_4___genitourinary_clinical_case.docx
Unformatted Attachment Preview
Week 5: Musculoskeletal Clinical Case
HPI
A 40-year-old Asian American male, who works as a roofer, complains that three days ago he
was lifting a heavy object at work, following which he got low back pain. The pain is in the
middle of the back near his waist. The pain increases when he bends forward and he is
experiencing numbness and tingling in the toes of his right foot. He has had similar symptoms
before, but it has not been so bad in the past. This is the worst he has had because in the earlier
instances, he has never had the tingling sensation in his right foot before.
In the past, he got better with rest and some Ibuprofen. He is worried that he will not be able to
continue his work and make money. He is out of work as a result of the pain. He has a lot of
difficulty getting sleep at night. He has started taking some of his friend’s medication and it
seems to help.
He has pain in the mid lumbar area, which radiates to the right buttock. He also has numbness
and tingling down the back of his right thigh to his toes. The pain and numbness has been
increasing since the problem started three days ago. He has tried over-the-counter Ibuprofen
and some stretching exercises, but it does not seem to help. He has not sought any medical care
yet. In the past, the pain had just gone away, but this time the pain is persistent. There is a
gradual worsening of his symptoms and he is concerned about the pain that has been
increasing steadily over the past three days. He is wondering whether he has a herniated disc.
His major concern is that he has no health insurance and will be missing work.
PMH
He has had similar pain in the past, but it was not so severe. He saw a chiropractor around two
or three years ago and that gave him some relief. Otherwise, the patient has no chronic medical
problems. He does not seek medical care on a routine basis.
He has had no diagnostic measures in the past. He has never had any blood work reports, CT
scan reports, X-ray reports and so forth done in the past. He has been gaining weight over the
past few years and does not do any stretching exercises before
work. Patient does not have any other risk factors. There are no records of any past surgeries. He
has neither had any significant illnesses in the past nor any hospitalizations.
ROS
Pain in the mid lumbar area radiating to the right buttock. There is a tingling sensation that goes
down the back of his right thigh to the toes. He does not have urinary or bowel incontinence.
No nausea, vomiting, or fever. He denies abdominal pain and pain with urination. There is no
gross hematuria.
Page 1 of 4
NSG6001 — Advanced Nursing Practice I
©2015 South University
NSG6001 — Advanced Nursing Practice I
Week 5: Musculoskeletal Clinical Case
MEDICATIONS
Patient does not take any prescription medications, only over-the-counter Ibuprofen. He is using
800mg of Ibuprofen every four hours. Patient is compliant with the prescribed regimen; in fact,
he could be using too much. Patient is seeking care because of the increasing pain. He has tried
chiropractic manipulations in the past for low back pain.
ALLERGIES/REACTIONS
He is allergic to Penicillin. It has caused a rash in the past.
SOCIAL HISTORY
This patient works for a local roofing company and makes $30,000.00 per year, which is just a
little over the minimum wage. He has a high school education certificate and makes just enough
money to get by. He has no health insurance. The patient feels that the last thing that he wants
to do is spend money on healthcare. He feels his body will get better on its own, and so he can
just keep working. He made the appointment at this outpatient clinic because his friends told
him about it. He was not sure where to go for help. He has decreased access to healthcare
because he is not aware of the services available. The patient has had essentially no healthcare
to date. The patient states that he is starting to realize that his body will not last forever at his
current position as a laborer.
The patient is divorced and thinks he was a failure as a husband. He is behind in alimony
payments. His wife is alive and well without any medical problems. They do not communicate
anymore. They have no children. He would like to try and get back together with her, but she
refuses to speak to him. He has been holding himself back from expressing the amount of stress
he has in life for many years. He thinks he is becoming depressed as a result of this. His parents
still live in the area and he sees them every weekend. He has friends from work and they do
social things together. The patient has not sought any emotional support from anybody. There
is no element of family dysfunction. He becomes easily stressed out. He lives in social isolation
from his community. The patient has always taken his health for granted and not thought much
about it in the past.
HABITS
Smoking: Non smoker
Alcohol: Drinks at bars on weekends to excess with his friends
Substance abuse: He smokes marijuana.
DIET HABITS
He skips breakfast and eats at fast food restaurants twice every day. He sips coffee and
caffeinated beverages throughout the day. The patient feels that his job gives him enough
exercise and so he need not do anything else. He plans to go on a “diet” soon to lose the weight
he has gained over the past few years, but is not sure about the diet he is going to follow.
WORK HABITS
The patient works as a roofer. He has had other labor-intensive jobs in the past that do not
require an
NSG6001 — Advanced Nursing Practice I
Week 5: Musculoskeletal Clinical Case
educational background. He does not enjoy his job. He knows it is a dead end job and wants to
go to school. He is originally from United States and lives in a suburban community where
resources are easily accessible, but he is not aware of them.
FAMILY HISTORY
Both parents have hypercholesterolemia. His 65-year-old father has prostate cancer. Both
parents are being treated with medications for their high cholesterol levels. He has no siblings.
There is a remote history of heart disease in his relatives.
PHYSICAL EXAMINATION
Vital Signs: Ht: 6’; Wt: 220; WC: 40; BP: 120/78; T: 97 po; P: 92 and regular; R: 18 non-labored
HEENT: WNL
Lymph Nodes: None
Lungs: Clear
Heart: RRR without murmur
Carotids: Not examined
Abdomen: Android obesity, otherwise benign
Rectum: Not examined
Genital/Pelvic: NA
Extremities, Including Pulses: 2+ pulses in the lower extremities
Neurologic:
Mental Status: Alert and oriented
Cranial Nerves: II – XII intact
Motor Strength: Upper extremities equal strength 5/5.
Lower extremities: decreased strength of right leg with resisted extension; patient complains of
pain in posterior thigh.
Sensation (light touch, pin prick, vibration, and position): Decreased sensation of right leg along
L5 : S 1 dermatome to pin prick stimulation compared with the left.
Reflexes: DTRs 2+ in upper and lower extremities
Cerebellar function intact—Romberg test is negative; heel-to-toe walking is steady.
Postive straight leg raise on the right at 20 degrees.
NSG6001 — Advanced Nursing Practice I
Week 5: Musculoskeletal Clinical Case
LAB RESULTS/RADIOLOGICAL STUDIES/EKG INTERPRETATION
Lab Results
CBC: WNL
UA dip stick: WNL
Radiological Studies
Plain film of lumbar spine: loss of disc height at L5 to S1. Mild degenerative changes of
lumbar vertebrae.
MRI: moderate disc bulge at L5: S1.
EKG: Not performed
Week 4: Genitourinary Clinical Case
© 2016 South University
2 Week 4: Genitourinary Clinical Case
Patient Setting: 28-year-old female presents to the clinic with a 2 day history of frequency,
burning and pain upon urination; increased lower abdominal pain and vaginal discharge over
the past week. HPI Complains of urinary symptoms similar to those of previous urinary tract
infections (UTIs) which started approximately 2 days ago; also experiencing severe lower
abdominal pain and noted brown fouls smelling discharge after having unprotected intercourse
with her former boyfriend. PMH Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1;
Gravida IV Para III Past Surgical History Tubal ligation 2 years ago. Family/Social History
Family: Single; history of multiple male sexual partners; currently lives with new boyfriend and 3
children. Social: Denies smoking, alcohol and drug use. Medication History None Trimethoprim
(TOM)/ Sulfamethoxazole (SMX) -Rash ROS Last pap 6 months ago, Denies breast discharge.
Positive for Urine looking dark. Physical exam BP 100/80, HR 80, RR 16, T 99.7 F, Wt 120, Ht 5’
0” Gen: Female in moderate distress. HEENT: WNL. Cardio: Regular rate and rhythm normal S1
and S2. Chest: WNL. Abd: soft, tender, increased suprapubic tenderness. GU: Cervical motion
tenderness, adnexal tenderness, foul smelling vaginal drainage. Rectal: WNL.
Page 2 of 3 Advanced Nursing Practice I ©2016 South University
3 Week 4: Genitourinary Clinical Case
EXT: WNL.
NEURO: WNL.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many,
Lkcs 10-15, RBC 0-1
Urine gram stain – Gram negative rods
Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities
pending
Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative
Page 3 of 3 Advanced Nursing Practice I ©2016 South University
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