Assignment : Case Study Assignment: Assessing Neurological. 

 

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.

In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

 

To Prepare

By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

 

The Case Study Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template.

Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.

List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 

 

CASE STUDY

 

Neurological Cases for Week 9

Case 1: Drooping of the face: A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.
THIS IS THE LINK TO DOWNLOAD THE BOOK:

 

https://www.sendspace.com/file/wd7quh

NOTE: Check the assignment for plagiarism

Episodic/Focused SOAP Note Exemplar

Focused SOAP Note for a patient with chest pain

S. CC: “Chest pain”  HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years  ROS    General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema  Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis

O.

VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the

second right inter-costal space which radiates to the neck.

A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel

sounds are normal in quality and intensity in all areas; a

bruit is heard in the right para-umbilical area. No masses or

splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

A.

Differential Diagnosis:

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Florida National University NUR3826

Course Reflection

Guidelines

Purpose

The purpose of this assignment is to provide the student an opportunity to reflect on selected RN-BSN competencies acquired through the NUR3826 course.

Course Outcomes

This assignment provides documentation of student ability to meet the following course outcomes:

· Identify the different legal and ethical aspects in the nursing practice (ACCN Essential V; QSEN: patient-centered care, teamwork and collaboration).

 

· Analyze the legal impact of the different ethical decisions in the nursing practice (ACCN Essential V; QSEN: patient- centered care, teamwork and collaboration).

 

· Understand the essential of the nursing law and ethics (ACCN Essential V; QSEN: patient-centered care, teamwork and collaboration).

 

Points

This assignment is worth a total of 100 points (10%).

Due Date

Submit your completed assignment under the Assignment tab by Sunday 11:59 p.m. EST of Week 15 as directed.

Requirements

1. The Course Reflection is worth 100 points (10%) and will be graded on quality of self-assessment, use of citations, use of Standard English grammar, sentence structure, and overall organization based on the required components as summarized in the directions and grading criteria/rubric.

2. Follow the directions and grading criteria closely. Any questions about your essay may be posted under the Q & A forum under the Discussions tab.

3. The length of the reflection is to be within three to six pages excluding title page and reference pages.

4. APA format is required with both a title page and reference page. Use the required components of the review as Level 1 headers (upper and lower case, centered):

Note: Introduction – Write an introduction but do not use “Introduction” as a heading in accordance with the rules put forth in the Publication manual of the American Psychological Association (2010, p. 63).

a. Course Reflection

b. Conclusion

Preparing Your Reflection

The BSN Essentials (AACN, 2008) outline a number of healthcare policy and advocacy competencies for the BSN-prepared nurse. Reflect on the NUR3826 course readings, discussion threads, and applications you have completed across this course and write a reflective essay regarding the extent to which you feel you are now prepared to:

1. “Demonstrate the professional standards of moral, ethical, and legal conduct.

2. Assume accountability for personal and professional behaviors.

3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession.

4. Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers.

5. Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice.

6. Reflect on one’s own beliefs and values as they relate to professional practice.

7. Identify personal, professional, and environmental risks that impact personal and professional choices, and behaviors.

8. Communicate to the healthcare team one’s personal bias on difficult healthcare decisions that impact one’s ability to provide care.

9. Recognize the impact of attitudes, values, and expectations on the care of the very young, frail older adults, and other vulnerable populations.

10. Protect patient privacy and confidentiality of patient records and other privileged communications.

11. Access interprofessional and intra-professional resources to resolve ethical and other practice dilemmas.

12. Act to prevent unsafe, illegal, or unethical care practices.

13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development.

14. Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care.” (p. 28).

Reference:

American Association of Colleges of Nursing [AACN]. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.

Directions and Grading Criteria

Category	Points	%	Description
(Introduction – see note under requirement #4 above)	8	8	Introduces the purpose of the reflection and addresses BSN Essentials (AACN, 2008) pertinent to healthcare policy and advocacy.
You Decide Reflection	80	80	Include a self-assessment regarding learning that you believe represents your skills, knowledge, and integrative abilities to meet the pertinent BSN Essential and sub-competencies (AACN, 2008) as a result of active learning throughout this course. Be sure to use examples from selected readings, threaded discussions, and/or applications to support your assertions to address each of the following sub-competencies: (a) “Demonstrate the professional standards of moral, ethical, and legal conduct. (b) Assume accountability for personal and professional behaviors. (c) Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession. (d) Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers. (e) Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice. (f) Reflect on one’s own beliefs and values as they relate to professional practice. (g) Identify personal, professional, and environmental risks that impact personal and professional choices, and behaviors. (h) Communicate to the healthcare team one’s personal bias on difficult healthcare decisions that impact one’s ability to provide care. (i) Recognize the impact of attitudes, values, and expectations on the care of the very young, frail older adults, and other vulnerable populations. (j) Protect patient privacy and confidentiality of patient records and other privileged communications. (k) Access interprofessional and intra-professional resources to resolve ethical and other practice dilemmas. (l) Act to prevent unsafe, illegal, or unethical care practices. (m) Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development. (n) Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care.” (p. 28).
Conclusion	4	4	An effective conclusion identifies the main ideas and major conclusions from the body of your essay. Minor details are left out. Summarize the benefits of the pertinent BSN Essential and sub-competencies (AACN, 2008) pertaining to scholarship for evidence-based practice.
Clarity of writing	6	6	Use of standard English grammar and sentence structure. No spelling errors or typographical errors. Organized around the required components using appropriate headers. Writing should demonstrate original thought without an over-reliance on the works of others.
APA format	2	2	All information taken from another source, even if summarized, must be appropriately cited in the manuscript and listed in the references using APA (6th ed.) format: 1. Document setup 2. Title and reference pages 3. Citations in the text and references.
Total:	100	100	A quality essay will meet or exceed all of the above requirements.

Grading Rubric

Assignment Criteria	Meets Criteria	Partially Meets Criteria	Does Not Meet Criteria
(Introduction – see note under requirement #4 above)           (8 pts)	Short introduction of selected BSN sub-competencies (AACN, 2008) pertinent to scholarship for evidence-based practice. Rationale is well presented, and purpose fully developed.   7 – 8 points	Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.         5 – 6 points	Little or very general introduction of selected BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.     0 – 4 points
You Decide Reflection                     (80 pts)	Excellent self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) supported with examples.       70 – 80 points	Basic self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Reflection on pertinent BSN sub-competencies (AACN, 2008) not supported with examples.       59 – 69 points	Little or very general self-assessment of skills, knowledge, and integrative abilities pertinent to healthcare policy and advocacy. Little or no reflection on pertinent BSN sub-competencies (AACN, 2008) or reflection not supported with examples.   0 – 58 points
Conclusion             (4 pts)	Excellent understanding of pertinent BSN sub- competencies (AACN, 2008). Conclusions are well evidenced and fully developed.   3 – 4 points	Basic understanding and/or limited use of original explanation and/or inappropriate emphasis on an area.   2 points	Little understanding of pertinent BSN sub-competencies (AACN, 2008). Little to no original explanation; inappropriate emphasis on an area.   0 – 1 point
Clarity of writing                 (6 pts)	Excellent use of standard English showing original thought with minimal reliance on the works of others. No spelling or grammar errors. Well organized with proper flow of meaning.   5 – 6 points	Some evidence of own expression and competent use of language. No more than three spelling or grammar errors. Well organized thoughts and concepts.     3 – 4 points	Language needs development or there is an over-reliance on the works of others. Four or more spelling and/or grammar errors. Poorly organized thoughts and concepts.   0 – 2 points
APA format         (2 pts)	APA format correct with no more than 1-2 minor errors.     2 points	3-5 errors in APA format and/or 1-2 citations are missing.     1 point	APA formatting contains multiple errors and/or several citations are missing.   0 points
Total Points Possible = 100 points

NUR3826 Course Reflection Guidelines.docx 08/21/19

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