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*APA 7
*Please use nursing or medical terminologies, and current scholarly references.
*Please read all instructions carefully.
Getting Started
This discussion is designed to guide you through the process of preparing a case evaluation using the SOAP format. The activities in this forum will form the framework for all the case studies that will be graded each week and many of the discussion topics.
Upon successful completion of the course material, you will be able to:
Start thinking about medications as a prescriber as opposed to a nurse.
Confidently complete case studies in subsequent workshops.
Resources
Textbook: Pharmacotherapeutics for Advanced Practice Nurses and Physicians Assistants
Lexi-Comp (available via Up-to-Date) or other suitable drug/disease reference.
Suggested treatment guidelines/recommendations for this workshop
Workshop One Case Study
Background Information
This activity is broken down into three separate parts: identifying problems, supporting problems with subjective/objective (S/O) information, and planning a course of care (A/P). Your post should include all three elements to receive full credit.
Writing a Case Study: Part One—Identifying Problems
In analyzing your patients that are presented in this class, we will use the problem-oriented approach. The first step is to create a problem list. Problems may be a patient concern, a healthcare professional’s concern, or both. Not all problems are diagnoses. Also, not all items listed in the past medical history need to be addressed as current problems. Problems may be symptoms, abnormal laboratory results, compliance issues, and so on. The problem list may include only one problem, or it may include ten or more. Every patient is different. Each student should try to identify ONE unique problem with patient HG in the case study provided. Although some problems will likely be duplicated, please try to cover all problems.
Instructions
Review the rubric to make sure you understand the criteria for earning your grade.
Navigate to the Writing a Case Study threaded discussion below and make an initial posting by the end of day five of this workshop. If there are no other problems to identify, select a problem that is already completed, but try to identify an alternate therapy. For this assignment, grading will focus on your ability to include all the necessary information as opposed to selecting the “best” therapeutic option. For case studies in future workshops, more emphasis will be placed on appropriate medication selection.
The format that you choose to present your information is completely up to you. One that has suited many students well is the chart format, which might look something like the example below.
Initial posts are due by the end of day five of the workshop. Respond to at least one of your peer’s postings by the end of day seven of this workshop.
Problem
Subjective/Objective
Assessment/Plan
Allergic rhinitis
Pt complaints of runny nose, sneezing and non-productive cough
Swollen nasal membranes
Start patient on loratadine (Claritin®) 10mg daily
Goals: eliminate allergy complaints (i.e. rhinorrhea, cough, swollen nasal membranes)
Monitoring: assess symptoms (rhinorrhea, sneezing, cough, nasal membranes) at 3 month follow up appointment or sooner if symptoms do not resolve with medication.
Patient education: Take medication daily for most effective results. Potential adverse effects include dry mouth, headache, and somnolence.
Heartburn
Pt complains of occasional heartburn, particularly after eating spicy food
Start ranitidine (Zantac®) 150 mg as needed for heartburn symptoms
Goals: eliminate heartburn symptoms
Monitoring: assess for heartburn at 3 month follow up appointment or sooner if symptoms to not resolve with medication
Patient education: Do not take more than 300 mg daily. Potential adverse effects include abdominal pain, constipation, diarrhea, and headache.