Description
NURS 696 Acute Care Adult and Geriatric Patient: Theory I
Students will provide an oral case presentation of an acute care patient case via video. Students should choose a patient with a cardiac or pulmonary disorder related to the weekly topics covered in Week 3. Students in a concurrent clinical course with a clinical site will present a patient case seen in the clinical setting. Students not placed in a clinical setting by Week 3 should email the instructor for a case assignment. Please use your WCU email address for all communications.
The oral case presentation should follow the SOAP format:
Visit type (H&P, progress note, or consult)
The purpose of the visit (CC and HPI – use OLDCARTS)
Pertinent histories (PMH, PSH, PFH, PSH, etc.)
Medication and Allergies
Pertinent Review of Systems (ROS)
Vital Signs and pertinent physical exam elements
Provide a differential dx of at least 3 diagnoses (2 differentials plus the working diagnosis)
Final (Working) Diagnosis
Treatment Plan
Patient Education
Disposition and Prognosis
Oral assignments should include verbally articulated evidence-based guideline(s) used to prepare the oral presentation. (For example, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America Guidelines for the management of Heart Failure were referenced to prepare this oral presentation).
*Please do not disclose or enter any patient-identifying information except the age/gender of the patient and visit type (H&P, progress note, or consult).
Download the SOAP Note Template and fill it out based on this scenario to guide your oral presentation. No written submission is required for this assignment.
You will use the screen share setting to record yourself.
The presentation should be no longer than 15 minutes.
This is a video presentation. Review the instructions on how to export the presentation with your narration as a video.
Review the rubric to ensure you address all assignment requirements.
Case Study
A 65 years old former garage mechanic presents with a chief complaint of increased shortness of breath and a change in the quantity and color of his sputum for the past week. The sputum is usually scant and clear. However, recently it has become yellow and continues all day. He has had trouble raising sputum in the past year. He has become progressively short of breath over the last five years. He is now dyspneic at rest. He denies asthma, childhood respiratory problems, allergies and any occupational exposures.
Physical Examination:
Obvious respiratory distress with prominent use of accessory muscles.
Temperature 99.5; Blood pressure 140/90; pulse 110; respiratory rate 28.
Head/neck reveal distended neck veins throughout expiration.
Chest reveals increased A-P diameter; reduced chest wall excursion; lungs hyperresonant to percussion; diaphragms low and immobile; auscultation reveals a prolonged expiratory phase with diminished breath sounds and generalized rhonchi.
Heart reveals PMI in epigastrium; heart sounds distant with regular rhythm and no murmurs.
Extremities reveal trace pitting edema of the lower extremities.
Chest x-ray reveals hyperinflation of lungs with an increase in the retrosternal space; low, flattened diaphragms; hyperlucent lung fields with paucity of vascular markings in the periphery but prominent hila and narrow heart silhouette.
EKG reveals low voltage; right axis; peaked P waves and clockwise rotation.
Laboratory reveals WBC 8,500 with normal differential and Hgb 14.7 gm.
ABG’s:
PFT 0100 (RA) 0300 (2 LPM) 0800 (2 LPM) 0800 (RA)
Ph 7.38 7.37 7.42 7.42
Pa02 44 60 62 60
PaC02 58 63 44 36
HC03 (calc) 31 32 30 24
Normal: Ph 7.40+0.05; Pa02 80+10; PaC02 40+4; HCO2 24+2
Video Case Presentation
Video Case Presentation
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeClinical Case Presentation
10 pts
Accomplished
Reports subjective and objective data in an organized and professional manner. Obtains all pertinent data with enough detail to be able to formulate correct diagnosis without extraneous data. Includes all important data (subjective or objective).
7.5 pts
Satisfactory
Reports and organizes subjective and objective data in a professional manner that is mainly focused. Obtains most pertinent data with enough detail to be able to formulate correct diagnosis. May collect a few pieces of extraneous data. Misses no important data (subjective or objective).
5 pts
Needs Improvement
Reports subjective and objective data in a manner that is less organized or professional and less focused. Obtains data that are mostly pertinent with enough detail to be able to formulate correct diagnosis. May collect many pieces of extraneous data. Misses one or two pieces of important data (subjective or objective).
2.5 pts
Unsatisfactory
Fails to report subjective and objective data in an organized, professional manner or is not focused. Collects data that does not enable the student to formulate the correct diagnosis. May collect many pieces of extraneous data. Misses significant amounts of important data (subjective or objective) or performs tasks and skills incorrectly.
10 pts
This criterion is linked to a Learning OutcomeClinical Reasoning, Problem-Solving, and Management Skills
30 pts
Accomplished
Synthesizes subjective and objective information in a logical manner and formulates the correct diagnosis and plan that addresses each diagnosis, appropriate dx tests, treatments, pt. education, and referrals. Oral presentation reflects incorporation of current standards of care.
22.5 pts
Satisfactory
Synthesizes subjective and objective in a logical manner and formulates the correct diagnosis and plan that addresses each diagnosis. Plan may be missing one or two minor components from the dx tests, tx, pt. ed, referral or health maintenance). Consults resources (e.g. preceptor & reference materials) appropriately.
15 pts
Needs Improvement
Synthesizes subjective and objective in a manner that leads to an incorrect dx but the differential is correct. Plan fails to address each diagnosis and may be missing two or three minor components from the dx tests, tx, pt. ed, referral or health maintenance). Consults resources (e.g. preceptor & reference materials) appropriately.
7.5 pts
Unsatisfactory
Unable to synthesize subjective and objective data in a manner that leads to correct diagnosis or differential. Plan does not address the diagnosis or may be missing significant components. Does not consult resources (preceptor or references appropriately.
30 pts
This criterion is linked to a Learning OutcomeOrganization and Time Management
10 pts
Accomplished
Oral presentation of patient encounter is well organized and flows. Prognosis and disposition are included. Case presentation is presented within 15 minutes.
7.5 pts
Satisfactory
Patient encounter is mostly organized as far as flow and time management is somewhat well managed. Prognosis and disposition are included. Case presentation is presented within 20 minutes.
5 pts
Needs Improvement
Patient encounter is less organized and does not flow. Prognosis or disposition are missing. Time is not managed well. Case is presented within 25 minutes.
2.6 pts
Unsatisfactory
Patient encounter does not flow and is not organized. Prognosis and disposition are missing. Time is not managed well. Case presentation exceeds 25 minutes.
10 pts
Total Points: 50
Unformatted Attachment Preview
AGAC SOAP Note Template
Use this template for Comprehensive Notes (H&Ps) and Problem-Focused Notes
(Episodic/progress notes). For the Problem-Focused Notes, only include pertinent problemfocused information related to the chief concern (CC).
Specialty: Cardiology, ER, Gerontology, Internal Med, etc – What is the specialty of the
team/preceptor you are rounding with?
Level of Care: Medical-Surgical, ICU, ER, Clinic (Where are you seeing the patient at?)
Hospital Day #: ER patients or Day of Admission ‘Hospital Day #1’, If in Medical – Surgical Floor
for 10 days ‘Hospital Day #10’.
Demographic Data
o
o
Patient age, race, gender at birth and gender identity
MUST BE HIPAA compliant.
Subjective
Chief Complaint (CC)
O
O
Place the complaint in Quotes
Brief description -only a few words and in the patient’s words … “My chest hurts,” “I
cannot breath,” or “I passed out,” etc.
History of Present Illness (HPI) – the reason for the appointment today
O
Use the OLD CARTS acronym to document the eight elements of a chief concern
(CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving
factors, Timing, and Severity)
O Briefly describe the general state of health prior to the problem.
O Are Activities of Daily Living (ADL) impacted by the current problem?
PAST MEDICAL HISTORY:
O
List current and past medical diagnoses
PAST SURGICAL HISTORY:
O
List all past surgeries
FAMILY HISTORY:
O
Include medical/psychiatric problems to include 3 generations (parents, grandparents,
siblings, or direct relatives.
CURRENT MEDICATIONS:
O
Include current prescription(s), over-the-counter medications, herbal/alternative
medications as well as vitamin/supplement use.
ALLERGIES: Include medications, foods, and chemicals such as latex.
IMMUNIZATIONS HISTORY: list current immunization status and address deficiency
PREVENTATIVE HEALTH HISTORY: (See Table below – Appendix A)
SOCIAL HISTORY:
O
Include nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit drug
use), sexual history/preference, financial problems, legal issues, kids, and history of
abuse, including sexual, emotional, or physical.
O Employment/Education: occupation (type), exposure to harmful agents, highest
school achievement
*In writing a complete H&P you will need to document everything about the patient’s social
history.
**In writing PF-Notes ONLY DOCUMENT social history pertinent to the patient’s acute problem.
REVIEW OF SYSTEMS:
O
O
O
O
O
ROS:
General:
Eyes:
A ROS is a question-seeking inventory by body systems to identify signs and/or
symptoms that the patient may be experiencing or has experienced that may or may
not correlate with the CC.
*If a + finding is found not related to the cc this may represent an additional
problem that will need to be detailed in the HPI.
Must include any physical complaint(s) by the body system that is relevant to the
treatment and management of the current concern(s). List only the pertinent body
systems specific to the CC.
Remember to include pertinent positive and negative findings when detailing the
ROS related to a chief concern (cc).
Do not repeat the information provided in HPI
Use the format below when detailing the ROS
Ears, nose, mouth & throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Skin & Breasts:
Musculoskeletal:
Allergic:
Immunologic:
Endocrine:
Hematopoietic/Lymphatic:
Genitourinary:
Neurological:
Psychiatric/Mental Status:
Objective
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure. Heart rate (regular or irregular). Respirations. SaO2 (on room air or
O2). Temperature. Weight. Height.
*Document the presence of any internal/external devices (IV, Central lines, NGTs, G-tubes,
Ostomies, urinary catheters, etc.) and dates of placement during the admission.
General:
Eyes:
Ears, nose, mouth & throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Skin & Breasts:
Musculoskeletal:
Allergic:
Immunologic:
Endocrine:
Hematopoietic/Lymphatic:
Genitourinary:
Neurological:
Psychiatric/Mental Status:
Pertinent Diagnostic Test Results: actual labs/ecg/radiology results from that day.
Pertinent hospital medications: Neosynephrine gtt, etc
Assessment (Diagnosis)
Differential Diagnosis (DDx) – including ICD-10 code
O
Include two (2) differential diagnoses you considered but did not select as the final
diagnosis. Why were these 2 diagnoses not selected? Support with pertinent
positive and negative findings for each differential with an evidence-based
guideline(s) (required).
Working or Final Diagnosis:
O Final or working diagnosis (1) (including ICD-10 code)
O Provide a rational explanation supported by evidenced-based guidelines (required).
List the pertinent positive and negative symptoms/signs that support your final
diagnosis.
Plan
Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic
O
O
Pharmacologic -include full prescribing information for each medication(s) ordered
Refill Provided: Include full prescribing information for each medication(s) refilled
and the correlating diagnosis related to the refill.
Patient Education:
O include specific education related to each medication prescribed.
O Was risk versus benefit of current treatment plan addressed for medication(s) and
interventions? Was the patient included in the medical decision making and in
agreement with the final plan
O NPs should not be prescribing non-FDA approved medications or medications
related to off-label use. If a physician prescribed a non-FDA-approved medication for
working diagnosis or recommended off-label use was education provided and was
the risk to benefit of the medication(s) addressed in the patient’s education?
Prognosis Good, Fair, or Poor?
O Indicate the patient’s prognosis: Good, Fair, Poor
O Provide support for your selected prognosis
Consult/Referral/Follow-up
O DID YOU CONSULT OTHER SERVICE?
O Did you recommend follow-up with PCP, or other healthcare professionals?
O
When is the subsequent follow-up?
Disposition:
O Indicate the disposition of the patient.
O Was the patient sent home, Emergency room via EMS, etc.
O Include rationale for the follow-up recommendation or referral
Reference(s)
o Include APA formatted references for written assignments.
o Minimum 2 references are required from evidence-based resources.
o Oral assignments should include verbally articulated evidence-based guideline(s)
used to prepare the oral presentation.
APPENDIX A
PREVENTATIVE CARE SCHEDULE (Example – not all-inclusive)
Preventive
Care
Pap
Mammogram
A1C
Eye Exam
Monofilament
Test
Urine
Microalbumin
Diet/Lifestyle
Modifications
Digital Rectal
Exam (DRE)
PSA
Colonoscopy
or FOBT
Dexa Scan
CXR
BNP
ECG
Echo
Stress
Test
Vaccines
Date
Result
Referrals Made
Purchase answer to see full
attachment
