(Solution) NRNP 6540 Week 2 Assignment: Assessing


COURSE  

NRNP 6540 Advanced Practice Care of Older Adults


Week 2 Assignment; Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.

• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?

• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.

• Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

SOLUTION  

Patient Information: Initials: P, Age: 70-year-old, Sex: Female, Race: AA

Subjective Data

Chief concern (CC) Acute confusion.

History of present illness or problem (HPI)

Ms. Peters is a 70-year-old female who was brought by her son with reports of acute confusion (more than usual) and some agitation and restlessness. She has a known history of dementia, managed with Aricept 10 mg. daily. Her son, Jared, reports that she began to become more confused than usual and very easily agitated two days ago. He notes that yesterday, she couldn’t remember where she was in her own home. She had a doctor’s appointment three days ago, and her HCTZ (hydrochlorothiazide) was increased to 50 mg. due to increased blood pressure issues.

Ms. Peter’s last Mini-Mental State Exam (MMSE) score was 18/30. The assessment was repeated, and the score remained unchanged

Medication:

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