Instructions FOR PATIENT MANAGEMENT PAPER
You will develop a case study (no more than 8 pages no less than 6 pages excluding title and reference page(s) on a topic that will fuse nurse practitioner management. References for this paper must be recent (within the past 5 years).
Purpose: The purpose of this paper is to promote scholarly thought and writing. Writing this paper will increase your critical thinking skills, writing abilities, and will encourage you to incorporate published evidenced based literature in your practice. This paper will allow you to examine the patient management process based on a real person you have had the privilege of interacting with in the clinical setting.
Topic: The topic comes from an actual patient observation. Choose the patient and topic. Caution, since you may see the patient only once, be sure to get complete information from the chart, such as lab values, treatments, medications, etc.
Section I: Introduction
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Objective |
Points |
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One or two paragraphs identify the purpose/objective of the paper include an introduction of the patient and describe the diagnosis |
5 |
Section II: Review Treatment Guidelines/ Present Evidence
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Objective |
Points |
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An Introduction is presented which discusses how the Guideline / evidence was obtained |
5 |
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2 to 3 paragraphs discussing the nature of the problem/diagnosis use of a literature search used to discuss the problem/diagnosis |
20 |
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One paragraph discussing the literature related to the management of the patient |
5 |
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Identify measurable and realistic short and long term goals fort this patient problem. Review appropriate medication intervention Report possible side effects of medication Discuss patient teaching related to the diagnosis Discuss any referrals this patient may need Report any assessment tools used to assess the patient |
25 |
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Plan addressed all of the following areas: social, ethical, legal, economic, spiritual or cultural influences. |
10 |
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Criteria |
Points |
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Review teaching needs for the patient & family with the diagnosis presented. Provide a rationale for each of the teaching needs |
15 |
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Criteria |
Points |
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In summation/closing paragraph discuss how this paper and treatment will guide your practice when evaluating a patient with the final diagnosis |
5 |
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Criteria |
Points |
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Follow APA Guidelines for the whole paper |
10 |
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Provide a title page |
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Pages are numbered |
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APA format for Refrences |
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Minimum of 5 Citations No Spelling errors/grammar errors |
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You must Achieve > 80% to pass |
Total Points = 100 |
ELEMENT FOR CASE STUDY. TAKEN FROM PATIENT CHART
Information Obtained From: Client , Record Referral Source: Other
Chief Complaint: Suicide Ideation, Voices that Patient cannot longer control
History of Present Illness
CJ is a 38 year old Hispanic female that was brought to our attention because of suicide ideation and plan to strangle self. The patient is currently in day 2 recovery. She has no medical Hx and has Psychiatric Hx of Unspecified Psychosis. She has NKDA, and lab were all negatives.
At the time of the present visit, the patient was sitting outside on a chair in the day room. To the question what brings you in she responded; “suicide” How often does that happen? “Often”. Are you on court orders for treatment?” yes, I am on medication and medications does not seem to help well”. Do you hear voices? ” yes, more when I am off medications”. How often do you hear voices when you are on medication?” once every two weeks only”. Do you have a plan to kill yourself?” Yes because life is too hard”. Any plan to kill any other person? “No, Cymbalta is not working”. Have you ever try Zoloft? “yes Zoloft was pretty good, it works for me, I have been on Cymbalta for 3 months and the suicide thoughts are the same, the suicide thought are getting worse and I cannot longer block them”. do you have any children?” Yes I have a 15 year old and I have not seen him in a while, heis with his dad”.
Psychiatric Review of Symptoms :
Depression, Mania, Psychosis, Anxiety Depression: DeniesSymptoms
Anxiety: Restlessness Mania: Denies Symptoms
Psychosis: Auditory Hallucinations Medications: Yes
Current Medications:
BENZTROPINE MESYLATE, 1 MG TABLET, ORAL, 1 Tablet Twice a Day, Start
Date: 10/02/2020
CYMBALTA(DULOXETINE HYDROCHLORIDE),60MG”CAPSULE, DELAYED
RELEASE”, ORAL, 1 Capsule Daily, Start Date: 10/02/2020
MILK OF MAGNESIA, 400 MG/5 ML SUSPENSION, ORAL, 30 Milliliter Every 6
Hours, As Needed, Start Date: 10/02/2020
IBUPROFEN, 200 MG TABLET, ORAL, 2 Tablet Every 6 Hours, As Needed, Start Date: 10/02/2020
NICOTINE, 21 MG/24 HR “PATCH, EXTENDED RELEASE”, TRANSDERMAL, 1 Patch
Once a Day, As Needed, Start Date: 10/02/2020 MAALOXADVANCED(ALUMINUMHYDROXIDE-MAGNESIUM
HYDROXIDE-SIMETHICONE), ORAL, 30 Milliliter Every 4 Hours, As Needed, Start Date: 10/02/2020
PEPTO-BISMOL(BISMUTHSUBSAUCYLATE), 262 MGTABLET, ORAL, 2Tablet
Every 4 Hours, As Needed, Start Date: 10/02/2020
TRAZODONE HYDROCHLORIDE, 100 MG TABLET, ORAL, 1 Tablet At Bedtime, As
Needed, Start Date: 10/02/2020
HYDROXYZINE PAMOATE, 25 MG CAPSULE, ORAL, 1 Capsule Threelimes a Day, As Needed, Start Date: 10/02/2020
Histories
Past Psychiatric History (previous hospitalizations, med trials, outpatient treatment, court ordered treatment, suicide attempts, etc):
IP: multiple admits. Last admit x 5 months ago
OP: LFC
SA: Slit wrists 10 years ago with intention of dying; sought medical care s/p attempt
TBI/SZ/LOC: Denies
Was this information reviewed and/or updated?: Yes
Medical History: Denies
Surgeries: Denies
Allergy: NKDA
At Risk for Pregnancy: Yes
Social Hx
From Tucson. Divorced. Has 3 children (although psychsocial states 5). Dropped out of HS in 9th grade. No GED. Denies h/o trauma/abuse. Denies legal issues.
Substance Use History: Denies current illicit substance abuse; endorses remote h/o of opioid abuse but states she has been sober x 4 years. Declines to provide details. Denies ETOH use. Opportunistic use of nicotine (vaping).
Development: Unknown
Review of Systems
System Reviewed: Constitutional Constitutional: Denies Problem
Mental Status Exam
Most Recent Vitals:
Date: 10/03/2020 Time:08:28AM
Blood Pressure: 115/67 mmHg
Heart Rate: 87 bpm Respiration Rate: 16 bpm Temperature: 97.2 Fahrenheit Oxygen Saturation: 98 %
Appearance: Chronological Age, Normal Weight
Attitude: Accessible, Cooperative, Good Eye Contact, Relates Well Muscle Strength/Tone:NormaI
Gait/Station: Steady
Speech: Clear Articulation, Regular in Rate and Rhythm Language: Appropriate Use of Language, English Speaking
Orientation: Fully Oriented.
Affect: Dysphoric, Flattened, Labile
Mood: Depressed
Productivity: Spontaneous Associations:
Goal Directed
Abstract Thinking: Adequate Abstracting Ability Thought Content: Delusions, Illusions
Thought Content Comments: Reported Unspecified voices that she cannot longer blocked as use to do in the past.
Hallucinations reported: No
Suicide ideation reported: Yes Explain:
“I want to end my life because life is too hard”
Homicide ideation reported : No
Estimated Intellectual Functioning: Average Fund of Knowledge: Age Appropriate Memory: NoMemory Impairment Concentration: Adequate
Insight: Moderately Impaired Judgment: Adequate
Pbysical Exam
General: No Distress Neuro: WNL, Gait Normal
Pulm: No Use of Accessory Muscles, Unlabored Derm: WNL
Extremities: No Gross Deformity, Moves Extremities Equally, Normal Range of Motion Back: WNL
Risk Assessment
Estimated Suicide Risk Levels: High ( Schizoaffective disorder, Suicide ideation, worsening Psychotic symptoms as evidenced by the voices she cannot longer block.)
Estimated Violence Risk Level: Moderate
Comment: (Schizoaffective disorder, Suicide ideation, worsening Psychotic symptoms as evidenced by the voices she cannot longer block.)
Estimated Victimization Risk Level: Low Access to Firearms: No
Static Risk Factors: Divorced, Single, Hx of Suicide Attempts, Role of Significant Other Dynamic Risk Factors: Suicide Ideation, Anhedonia, Psychotic Symptoms
Protective Factors: Living with Someone, Social Support
Formulation/DiagnosticSummary(MedicalDecisionMaking):
C J is a 38 year old Hispanic female that was brought to our attention because of suicide ideation and plan to strangle self. The patient is currently in day 2 recovery. She has no medical Hx and has Psychiatric Hx of Unspecified Psychosis. She has NKDA, and lab were all negatives.
Pt is depressed, withdrawn and reported that her antidepressantis not working, express desire to switch from Cymbalta to Zoloft which she indicated has worked in the pass. Pt has symptoms consistent with depression; hopeless. poor sleep hygiene,isolative and has lack of interest in thing that use to be interested in and suicidal. Pt will benefit from addition time to stabilized on antidepressant
10/01/2020 Mental disorder, not otherwise specified
10/02/2020 Mental disorder, not otherwise specified 10/02/2020 Suicidat ideation
10/02/2020 Anxiety 10/02/2020 Suicidal ideations
10/02/2020 Unspecified anxiety disorder
10/02/2020 Unspecified psychosis not due to a substance or known physiological condition
10/02/2020 Schizoaffective disorder
Plan/Recommendations:
Reassess tomorrow Discontinue Cymbalta,
start Zoloft 50 mg PO Q am ( depression)
Will participate in group therapy as appropriate
CM please collaborate with outpatient team on dispo
Referral To: Primary Care Physician
Discussion with Individual: Prognosis, Treatment Options, Importance of Compliance, Risk Factor Reduction, Patient Family Education, Risk, Benefits, Side Effects, At Risk for Becoming Pregnant, Importance of Follow Up, Obtaining Additional Crisis Svcs, After Hours Crisis Resource, Crisis Prevention Plan
Return to Clinic/Crisis Center: 1 Week
Justification for Continued Hospitalization: Patient Remains Suicidal, Patient Remains Psychotic
Inpatient Only – Criteria for Discharge: Individual Will Not Have Suicidal Thoughts or Have Risk of Self-Harm, Individual Will Not Have Homicidal Thoughts or Have Risk of Harming Others, Individual’s Psychotic Symptoms Will Have Improved Sufficientlly to Independently Provide Self-Care and Respond Appropriately to Others
Inpatient Only – Estimated Length of Stay: 3 Days
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