Nursing process

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Rubric Detail

 

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Name: NURS_6512_Week_6_Assignment_1_Rubric

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Excellent

Good

Fair

Poor

With regard to the SOAP note case study provided, address the following:

Analyze the subjective portion of the note. List additional information that should be included in the documentation.

10 (10%) – 12 (12%)

The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.

7 (7%) – 9 (9%)

The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

4 (4%) – 6 (6%)

The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation.

0 (0%) – 3 (3%)

The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

Analyze the objective portion of the note. List additional information that should be included in the documentation.

10 (10%) – 12 (12%)

The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.

7 (7%) – 9 (9%)

The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.

4 (4%) – 6 (6%)

The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

0 (0%) – 3 (3%)

The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

Is the assessment supported by the subjective and objective information? Why or why not?

14 (14%) – 16 (16%)

The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.

11 (11%) – 13 (13%)

The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.

8 (8%) – 10 (10%)

The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.

0 (0%) – 7 (7%)

The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

18 (18%) – 20 (20%)

The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.

15 (15%) – 17 (17%)

The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis.

12 (12%) – 14 (14%)

The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.

0 (0%) – 11 (11%)

The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.

·   Would you reject or accept the current diagnosis? Why or why not?
·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

23 (23%) – 25 (25%)

The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature.

20 (20%) – 22 (22%)

The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature.

17 (17%) – 19 (19%)

The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature.

0 (0%) – 16 (16%)

The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature.

Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 (5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 (4%) – 4 (4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 (3%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

0 (0%) – 2 (2%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation

5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

4 (4%) – 4 (4%)

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 (3%) – 3 (3%)

Contains several (3 or 4) grammar, spelling, and punctuation errors.

0 (0%) – 2 (2%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 (5%) – 5 (5%)

Uses correct APA format with no errors.

4 (4%) – 4 (4%)

Contains a few (1 or 2) APA format errors.

3 (3%) – 3 (3%)

Contains several (3 or 4) APA format errors.

0 (0%) – 2 (2%)

Contains many (≥ 5) APA format errors.

Total Points: 100

Name: NURS_6512_Week_6_Assignment_1_Rubric

ABDOMINAL ASSESSMENT

Subjective:

CC: “My stomach has been hurting for the past two days.”

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain. 

PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd,  Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female 

Objective:

· VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs

· Heart: RRR, no murmurs

· Lungs: CTA, chest wall symmetrical

· Skin: Intact without lesions, no urticaria

· Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.

· Diagnostics: US and CTA 

Assessment:

1. Abdominal Aortic Aneurysm (AAA)

2. Perforated Ulcer

3.  Pancreatitis

PLAN:

To Prepare

Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

· With regard to the Episodic note case study provided:

· 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.

· 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 Assignment

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.

2. Analyze the objective portion of the note. List additional information that should be included in the documentation.

3. Is the assessment supported by the subjective and objective information? Why or why not?

4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race


Subjective Data.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

History of Present Illness: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

Past Medical Hx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Social Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Family Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Review Of System: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.


Objective Data.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)


Assessment

.

Differential Diagnoses (list a minimum of 5 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.


Plan.
  

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2021 Walden University, LLC

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The work has to follow the “FOCUS NOTE TEMPLATE” format. So, its like filling in the information as explained in the prompt SUPPLIED IN THE FOCUSE NOTE TEMPLTE. For example, the first information on the focus note template is the “CHIEF COMPLAINT(CC)” and it has some explanation as to what is expected. Another example is the “HISTORY OF PRESENT ILLNESS”

Secondly, we are expected to provide and explain 5 different possible diagnosis for the patient in the scenario and the most accurate diagnosis to be number one, followed by the next possible diagnosis and the next just in that order until the 5th possible diagnosis which should be the least likely diagnosis.

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