Diagnostic and Reasoning from an FNP perspective part 1

1
Diagnostic and Clinical Reasoning Paper Assignment
The purpose of this assignment is to provide you the opportunity to expand the scope of your
clinical documentation and your thought processes relative to complex patient care cases.
1. Select a patient encounter from dysmenorrhea,PCOS,OVarian Cysts,abnormal
Pap,infertility,amenorrhea)
2. The patient encounter you select should be one of the more complex patient cases that
you have experienced with your current clinical patient population. Given that you are to
select complex cases, this assignment may not be completed for a ‘general health, well
child, well woman, routine OB, routine physical exam (etc.)’ type of encounter.
You will need to identify which patient encounter you are expanding your documentation
for by including the Typhon Case ID # under your name on the title page of your paper.
3. For this assignment you will utilize the same SOAP format that you do for your
‘expanded’ Typhon encounters. Construct this assignment ensuring that you adhere to
the writing guidelines provided in the 6th edition APA manual.
Below is the overview of the required elements for this assignment:
*Title Page (Page 1): Follow APA guidelines for running head on page 1, and include
Medical Diagnosis, Student Name, Typhon Case ID #, and Date.
*Subjective (Start of Page 2): Follow APA guidelines for running head on page 2 and
subsequent pages.
CC: chief complaint – What are they being seen for? This is the reason that the patient sought
care, stated in their own words, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and
documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
2
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV
risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact
health and illness. Financial resources.
Click on the link below to explore the CDC’s information on the ‘social determinants of health’.
https://www.cdc.gov/socialdeterminants/
Family history: Use terms like maternal, paternal and the diseases and the ages they were
deceased or diagnosed if known.
Health Maintenance/Promotion: Immunizations, exercise, diet, etc. Remember to use the
United States Clinical Preventative Services Task Force (USPSTF) guidelines for age
appropriate indicators. This should reflect what the patient is presently doing regarding the
guidelines.
Click on the link below to access information about current guidelines.
https://www.uspreventiveservicestaskforce.org/
Review of Systems (ROS): this is to make sure you have not missed any important symptoms,
particularly in areas that you have not already thoroughly explored while discussing the history
of present illness. You would also want to include any pertinent negatives or positives that would
help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore
throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list
below is provided for your convenience it is not to be considered all-encompassing and you are
expected to include other systems/categories applicable to your patient’s chief complaint.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
GI: gastrointestinal
GU: genito-urinary
PV: peripheral vascular
3
MSK: musculoskeletal
Neuro: neurological
Endo: endocrine
Psych:
*Objective:
Physical Examination (PE): either limited for a focused exam or more extensive for a
complete history and physical assessment. This area should confirm your findings related to the
diagnosis. For acute episodic (focused) visits (i.e.GYN, Rectal, Abd, etc.) you may omit other
assessments. All SOAP notes however should have physical examination of CV and lungs.
While the list below is provided for your convenience it is not to be considered all-encompassing
and you are expected to include other systems/assessments applicable to your patient’s chief
complaint. Ensure that you include appropriate female specific physical assessments when
applicable to the encounter. Your physical exam information should be organized using the
same body system format as the ROS section. Appropriate medical terminology describing the
objective examination is mandatory.
VS: vital signs, height and weight, BMI
Gen: general statement of appearance, if there is any acute distress.
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Psych:
4
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that
ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
*Assessment: (number each diagnosis)
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each
diagnosis. A statement of current condition of all other chronic illnesses that were addressed
during the visit must be included (i.e. HTN-well managed on medication). Remember the S and
O must support this diagnosis. Pertinent positives and negatives must be found in the write-up.
*Plan: (number each plan specific to each diagnosis)
These are the interventions that relate to the above diagnosis and address the following aspects
(they should be separated out as listed below):
Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter
that you plan to review/evaluate relative to your work up for the patient’s chief complaint.
Therapeutic: changes in meds, skin care, counseling
Educational: information clients need in order to address their health problems. Include followup care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no
referral made was there a possible referral you could make and why? Advance care planning.
*Clinical Decision Making
The next section summarizes your critical thinking, decision-making and diagnostic reasoning
skills that provides you the platform to expand on your identified Typhon patient encounter. It is
a reflection of the thought process you used in caring for the patient. Follow the directions under
each section and label each area as appropriate. All information should be in your own words.
Pathophysiology:
Include information in regard to the pathophysiology related to the main diagnosis or illness
process. This will help to understand how the S and O supported the diagnosis you assigned.
5
Do not copy and paste from credible sources. Paraphrase source information as you construct
your discussion of the pathophysiology and ensure that you provide in-text and reference
citations for the source.
Pharmacology: OR (***Alternate – Therapy information):
Choose one drug that was prescribed at this visit or that is taken chronically by the patient to
review. Please include the name of the drug (generic and brand), class, action, excretion, side
effects and interactions, why this particular drug is being prescribed for this particular patient,
what is this drug intended to treat, (specifically antibiotics, what organisms are we treating?).
What other drug could be chosen instead that would work, if any? Keep in mind the cost and
convenience for the patient.
***NOTE: Since the patient encounter you select for this assignment is supposed to be one of
the most complex encounters you have with this course population, the likelihood exists that you
will have a pharmacologic agent to discuss for this assignment requirement. However, if there
are no pharmacologic agents to utilize then choose a non-pharmacologic element of the
therapeutic plan (e.g. this could be hyperbaric therapy, water therapy, relaxation training,
biofeedback, PT, OT, Counseling [e. g. nutritional, emotional, behavior modification, etc.]or a
Complementary Alternative Medical regimen [e.g. nutritional therapy, a spiritual intervention,
Emotional Freedom Therapy (EFT), journaling, visual imagery, progressive relaxation, Cranial
Electrical Stimulation (CES), etc.]
Do not copy and paste from credible sources. Paraphrase source information as you construct
your discussion and ensure that you provide in-text and reference citations for the source.
Clinical Diagnostic Reasoning:
Include in this section:
1. Differential diagnoses
Include a list of all of the diagnoses you considered for your list of ‘differential
diagnoses. This list may extend beyond the diagnoses identified in the ‘A’ section of the
paper.
2. Priority diagnosis discussion
Discuss the key assessment [history and physical exam] findings that resulted in the
identification of the priority diagnosis/diagnoses indicated in the ‘A’ section of the paper
3. Rationale for key elements of the plan of care
As an advanced practice student you need to explore the evidence relative to the patient’s
care needs and be able to document the rationale for the elements of the plan.
6
Briefly provide rationales for the key elements of the plan of care [e.g. if a particular
HTN medication is prescribed then reference the current JNC guidelines, if a particular
antimicrobial is prescribed provide the source referenced for the decision, etc.]
Provide a rationale for any care aspect included in the plan that is not consistent with the
care approaches found in your course materials, EBP, CPGs or encompassed in the
‘community standard of care’.
When using credible sources to support your discussion do not copy and paste from the sources.
Paraphrase source information as you construct your discussion and ensure that you provide intext and reference citations for the source.
Ethical and or Cultural Concerns:
Identify any ethical or cultural issues related to this patient’s care. Include how these concerns
were addressed.
Discuss the following:
1. Review the provisions of the ANA Code of Ethics
Choose at least one of the provisions of the Code and discuss how your experience with
the patient encounter aligns with the tenants of the provision OR how you advocated for
the patient during the encounter to ensure your actions aligned with the tenants of the
provision.
Link to gain access to the ANA Code of Ethics – you will need to scroll down to ‘Select
One’ [option] to progress to the page where you will have full access to the Code:
https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethicsfor-nurses/
2. Discuss actual or potential cultural implications for this encounter – from the
patient’s cultural perspective or your cultural perspective
Links to articles that explore the issue of cultural concerns in health care:
https://www.redorbit.com/news/health/1372127/transcultural_nursing_its_importance_in
_nursing_practice/
https://journals.lww.com/academicmedicine/Fulltext/2003/06000/A_Strategy_to_Reduce
_Cross_cultural.6.aspx
https://pdfs.semanticscholar.org/3e50/d2758210e1bd345ccf16fcf8dfcd2b1b5ec9.pdf
7
Barriers to Care:
Construct a discussion that summarizes the barriers/potential barriers your patient faces relative
to their ability to seek or receive healthcare services and exploration of at least 3 of the
applicable ‘social determinants of health’ for your patient.
Discuss the Following:
1. The actual and potential barriers you identified for your patient
Your discussion needs to include observations about access to care, financial barriers, and
non-financial barriers beyond access. Be sure to provide in-text citations as appropriate
for APA style guidelines in your discussion to support the literature that you reviewed in
identifying the actual/potential barriers.
Links to article exploring barriers
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3393009/
https://academic.oup.com/fampra/article/23/3/325/475515
https://www.careatc.com/ehs/3-common-barriers-to-quality-medical-care
2. Three priority social determinants of health for your patient
Your discussion needs to include exploration of the three social determinants of health
that you identified as having the most significant impact on your patient’s health care and
health status. Be sure to provide in-text citations as appropriate for APA style guidelines
in your discussion to support the literature that you reviewed in identifying the social
determinants of health.
Link to CDC’s information on Social Determinants of Health
https://www.cdc.gov/socialdeterminants/
3. Health care policy or advocacy initiatives relevant to your patient’s care
Include in your discussion at least one health care policy or initiative that you identified
in the literature as having the potential to positively impact the identified actual/potential
barriers or priority social determinants of health for your patient.
Resources for your ‘search’ include the Herzing Library, Google Scholar, PubMed,
and/or the Virginia Henderson Repository https://www.nursingrepository.org/
8
*Evidence based practice:
Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence,
coupled with clinical expertise. As such it enables health practitioners to address healthcare
questions with an evaluative and qualitative approach. EBP allows the practitioner to assess
current and past research, clinical guidelines, and other information resources in order to identify
relevant literature while differentiating between high-quality and low-quality findings. EvidenceBased Practice includes the application of evidence and the evaluation of the outcomes to guide
future practice.
This section is a 1-2 paragraph summary of all the scholarly evidence utilized to complete this
assignment. New resources, topics or ideas should not be introduced.
Discuss the following:
1. Formulate a well-built question.
What clinical questions and terms did you use to direct your search in the library database?
2.
Identify articles and other evidence-based resources that answer the question.
Identify all sources (APA citations) used that informed your decision making in this
particular case.
3. Critically appraise the evidence [research study, evidence based or clinical practice
guidelines, published care standards, etc.] to assess its validity.
Comment on the quality of the research or evidence based practice guidelines used. What is
the level of evidence? How credible is it? Is it a just a recommendation or an expected
standard of care?
4. Apply the evidence and evaluate for areas of improvement.
How valuable was the evidence in understanding and directing the care in this case? How
did it influence your decision making? Were you able to assess the outcome? If so, are
changes needed?
*Self-Reflection:
Reflection on decision making: This is an area where you look over the data gathered and after
a careful review of the available resources (i.e. text books, reference readings) will provide a
reflection of what might have been added or deleted that would have made this note more
conclusive or complete. This is not an area to critique the preceptor. Discuss areas could you
have changed? What areas might you have added, perhaps additional questions you should have
asked in the ROS, or additional areas you may have assessed for in the PE?
Advanced Practice Practitioner Role Analysis: Identify the specific person that drove this
plan of care and developed the management, while including detail in how you advocated for the
9
patient. It is entirely possible, and desirable, that you drove the development of the plan of care.
Include how an individualized approach was applied to this patient’s care. Also include how you
identified your advocacy for the role of the Nurse Practitioner.
*Reference Page: Follow APA guidelines for constructing all reference page citations and
ensure you used APA style for all in-text citations.
1
Diagnostic and Clinical Reasoning Paper Assignment 80 Point Rubric
Criterion
Highly Proficient
Points 15
Subjective Data
Proficient
13
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are
adeptly
documented and
demonstrate
consistent
information across
all aspects
represented
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are
appropriately
documented and
demonstrate
consistent
information across
all aspects
represented
Points 15
Objective Data
All elements of
objective data are
adeptly
documented and
demonstrate
consistency
relative to the
13
All elements of
objective data are
appropriately
documented and
demonstrate
consistency
relative to the
Marginally
Proficient
11
Approaching
Proficiency
9
Not Proficient
Not evident
7
0
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are
satisfactorily
documented but
do not
demonstrate
consistent
information across
all aspects
represented
11
All elements of
objective data are
satisfactorily
documented but
do not
demonstrate
consistency
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are
either not
satisfactorily
documented or do
not demonstrate
consistent
information across
all aspects
represented
9
All elements of
objective data are
either not
satisfactorily
documented or do
not demonstrate
consistency
All elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health Promotion,
and ROS) are not
satisfactorily
documented and
do not
demonstrate
consistent
information across
all aspects
represented
7
All elements of
objective data are
not satisfactorily
documented and
do not
demonstrate
consistency
No elements of
subjective data
(CC, HPI, PMH,
Allergy
identification,
Medication
Reconciliation,
Social History,
Family History,
Health
Promotion, and
ROS) are
provided in the
assignment
0
No elements of
objective data
are provided in
the assignment
Total
Points
2
Assessment
Plan
information
documented in the
CC, HPI, PMH, and
ROS
information
documented in the
CC, HPI, PMH, and
ROS
Points 10
Assessment
designations and
other elements in
this section are
adeptly
documented and
demonstrate
congruence with
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
9
Assessment
designations and
other elements in
this section are
appropriately
documented and
demonstrate
congruence with
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
Points 10
Elements of the
plan are adeptly
documented,
demonstrate
application of
current clinical
practices for the
identified
assessment
designations, and
demonstrate
congruence of
information across
all aspects
represented
9
Elements of the
plan are
appropriately
documented,
demonstrate
application of
current clinical
practices for the
identified
assessment
designations, and
demonstrate
congruence of
information across
all aspects
represented
relative to the
information
documented in the
CC, HPI, PMH, and
ROS
8
Assessment
designations and
other elements in
this section are
satisfactorily
documented but
do not
demonstrate
congruence with
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
8
Elements of the
plan are
satisfactorily
documented but
either do not
demonstrate
application of
current clinical
practices for the
identified
assessment
designations, or do
not demonstrate
congruence of
information across
relative to the
information
documented in the
CC, HPI, PMH, and
ROS
7
Assessment
designations and
other elements in
this section are
either not
satisfactorily
documented or do
not demonstrate
congruence of
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
7
Elements of the
plan are either not
satisfactorily
documented, or do
not demonstrate
application of
current clinical
practices for the
identified
assessment
designations, or do
not demonstrate
congruence of
information across
all aspects
represented
relative to the
information
documented in the
CC, HPI, PMH, and
ROS
6
Assessment
designations and
other elements in
this section are not
satisfactorily
documented and
do not
demonstrate
congruence of
information
documented in the
CC, HPI, PMH, ROS,
and the objective
data
6
Elements of the
plan are not
satisfactorily
documented, do
not demonstrate
application of
current clinical
practices for the
identified
assessment
designations, and
do not
demonstrate
congruence of
information across
0
Assessment
designations
and other
elements in this
section are not
provided in the
assignment
0
Elements of a
plan are not
provided in the
assignment
3
Points 10
Clinical Decision
All elements of
Making
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are
adeptly
documented and
demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
9
All elements of
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are
appropriately
documented and
demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
Points 10
Evidence-based
Elements of
Practice (EBP)
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search for
EBP resources or
CPGs, appraisal of
the evidence
located, analysis of
the applicability of
the EBP or CPG
9
Elements of
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search
for EBP resources
or CPGs, appraisal
of the evidence
located, analysis of
the applicability of
the EBP or CPG
all aspects
represented
8
All elements of
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are
satisfactorily
documented but
do not
demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
8
Elements of
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search
for EBP resources
or CPGs, appraisal
of the evidence
located, analysis of
the applicability of
the EBP or CPG
7
All elements of
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are either
not satisfactorily
documented or do
not demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
7
Elements of
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search
for EBP resources
or CPGs, appraisal
of the evidence
located, analysis of
the applicability of
the EBP or CPG
all aspects
represented
6
All elements of
Clinical Decision
Making
(pathophysiology,
pharm/alternate
therapy,
differential
diagnoses,
ethical/cultural
concerns, and
barriers) are not
satisfactorily
documented and
do not
demonstrate
congruence with
information across
all preceding
sections (SOAP) of
the assignment
6
Elements of
EBP(formulation of
evidence support
question,
demonstration of
the results of a
scholarly search
for EBP resources
or CPGs, appraisal
of the evidence
located, analysis of
the applicability of
the EBP or CPG
0
Elements of
clinical decision
making are not
provided in the
assignment
0
No elements of
evidence-based
practice are
provided in the
assignment
4
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are
adeptly discussed
and demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
Points 5
SelfReflective
Reflection/Critique
discussions of
decision making
and advanced
practice
practitioner role
analysis are
adeptly articulated
and logically flow
from the
discussions in the
preceding sections
(SOAP, Clinical
Decision Making,
and EBP) of the
assignment
Points 5
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are
appropriately
discussed and
demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are
satisfactorily
discussed but do
not demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
4.5
Reflective
discussions of
decision making
and advanced
practice
practitioner role
analysis are
appropriately
articulated and
logically flow from
the discussions in
the preceding
sections (SOAP,
Clinical Decision
Making, and EBP)
of the assignment
4
Reflective
discussions of
decision making
and advanced
practice
practitioner role
analysis are
satisfactorily
articulated but do
not logically flow
from the
discussions in the
preceding sections
(SOAP, Clinical
Decision Making,
and EBP) of the
assignment
4
4.5
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are
either not
satisfactorily
discussed or do not
demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
3.5
Reflective
discussions of
decision making
and advanced
practice
practitioner role
analysis are either
not satisfactorily
articulated or do
not logically flow
from the
discussions in the
preceding sections
(SOAP, Clinical
Decision Making,
and EBP) of the
assignment
3.5
guidelines to this
encounter, analysis
of patient care
values to EBP or
CPGs presented to
them during your
encounter) are not
satisfactorily
discussed and do
not demonstrate
congruence with
information across
all preceding
sections (SOAP and
Clinical Decision
Making) of the
assignment
3
Reflective
discussions of
decision making
and advanced
practice
practitioner role
analysis are not
satisfactorily
articulated and do
not logically flow
from the
discussions in the
preceding sections
(SOAP, Clinical
Decision Making,
and EBP) of the
assignment
3
0
No reflective
discussions are
provided in the
assignment
0
5
Professional
Communication
The discussions
and exploration of
thoughts are
adeptly provided
and demonstrate
sound grammatical
construction
without readily
detectable errors
in application of
APA style
guidelines
The discussions
and exploration of
thoughts are
appropriately
provided and
demonstrate
sound grammatical
construction with
only minor
detectable errors
in application of
APA style
guidelines
The discussions
and exploration of
thoughts are
satisfactorily
provided but
either do not
demonstrate
sound grammatical
construction or
include several
readily detectable
errors in
application of APA
style guidelines
The discussions
and exploration of
thoughts are either
not satisfactorily
provided, or do not
demonstrate
sound grammatical
construction, or
include several
readily detectable
errors in
application of APA
style guidelines
The discussions
and exploration of
thoughts are not
satisfactorily
provided, do not
demonstrate
sound grammatical
construction, and
include several
readily detectable
errors in
application of APA
style guidelines
No discussions
or exploration
of thoughts are
provided in the
submission
Total Score:
XX/80

Purchase answer to see full
attachment