clinical case study (nursing)
clinical case study only part of assignment need to be completed please see assignment doc.
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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. clinical case study (nursing)
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. References not older than 5 years. I only need the Plan of care, Evaluation of priority diagnosis and facilitators and barriers to disorder management part complete I have already done the first part. I have attached an example of the assignment and what I have started, please just add the rest of the assignment to it. Criteria: • SOAP note • Evaluation of priority diagnosis • Facilitators and barriers to disorder management Submit your document to the W4 Assignment 2 Dropbox by Tuesday, April 4, 2017. Assignment 2 Grading Criteria Maximum Points Introduction 10 The submission included a general introduction to the priority diagnosis. 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 15 nurse practitioner.
It included head to toe physical examination as well as laboratory and diagnostic testing results. Assessment The submission included at least three priority diagnoses. Each diagnosis was 20 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. Plan of Care Plan included diagnostic and therapeutic (pharmacologic and nonpharmacologic) management as well as education and counseling provided. 25 The plan was supported by evidence/guidelines, and the follow-up plans were noted. Evaluation of Priority Diagnosis The plan chose the priority diagnosis for the patient and differentiated the 25 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. Facilitators and Barriers 20
The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers. clinical case study (nursing)
Conclusion 10 The submission included what should be taken away from this assignment. 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 Differential Diagnoses: Selecting each diagnosis is similar to a detective, using clues drawn from the patient’s description of symptoms (chief complaint), results of diagnostic procedures, medical knowledge, and additional information attained from assessment tools, you will make a list of all the possible diagnoses that could explain the chief complaint. It is important to note that each chief complaint should have an entirely separate list of differential diagnoses. The decision to select each diagnosis should be supported by pertinent “positive” or negative” findings from the subjective and objective information portion of the note. One by one, using those same findings, you will begin to narrow down the list by finding clues that don’t fit. If you have all of the information, you will be left with one definitive (or primary) diagnosis.
List and number the possible differential diagnoses including rationale (problems) you have identified. **Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es). For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes the diagnosis (es), the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include how diagnostic interpretation results support your chosen diagnosis. clinical case study (nursing)
Final Diagnosis: List the top 3-4 final diagnosis with the appropriate ICD 10 code (in order of priority). Remember your time with the patient will likely only be 15-20 minutes so you will not be able to address more than 3-4 current problems at one visit. You may also include any chronic diagnosis with ICD10 codes. P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include current Evidence Based Practice citations and rationale. Please utilize current national treatment guidelines and standards. Please list the primary diagnosis from above in order of priority and address the following items for each as indicated. 1. Medications: write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications. 2. Additional diagnostic tests: include EBP citations to support ordering additional tests. 3. Education: this is part of the chart and should be brief, this is not a patient education sheet and needs to have an Evidence Based reference.
4. Referrals: include an Evidence Based citation to support a referral. 5. Follow up. Patient follow-up should be specific with the time and plan or circumstances of return. You should provide a reference for your decision on when to follow up. Reflection: While you are in school it is important to reflect on the patient encounter during your practicum experience. This section will be a narrative note discussing if you would have done anything different, whether you agree or disagree with the preceptor’s diagnosis and treatment based on current evidence based guidelines. 03/09/2017 03/09/2017 … clinical case study (nursing)