N581-19A_20Sep Advanced Practice Nursing I Preceptorship Experience

Discipline: Nursing

Type of Paper: Research paper

Academic Level: Undergrad. (yrs 3-4)

Paper Format: APA

Pages: 5 Words: 1375

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Question

Assignment 3

A 58 year old male patient who is unemployed and overweight presents to the office with complaints of chest pressure and jaw pain that resolved after resting yesterday. He is in a monogamous relationship with a life partner. He admits a history of hypercholesteremia but does not take medications

CC: “I had chest pain when doing laundry yesterday.” Past medical history: Anxiety, hypercholesteremia

Family History- Father died at 60 from a myocardial infarction

Vital signs: Blood pressure: 158/98; height, 5 feet 6 inches; weight, 242 lbs. Lab results:

TC 420

LDL 190

HDL 32

Glucose: 228

Hgb 14

Hct 38

MCV 78

Questions:

1. What additional subjective data do you think the patient will share?

2. What additional objective data will you be assessing for?

3. What National Guidelines are appropriate to consider? What level of evidence supports these guidelines?

4. What tests will you order?

5. Will you be looking for a consult?

6. What are the medical and nursing diagnoses?

7. Are there any legal/ethical considerations?

8. What is your plan of care? medical

nursing

complementary therapies

9. Are there any Healthy People 2020 objectives that you should consider?

10. Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting him and the family involved in the care to reach optimal health?

11. What additional patient teaching is needed?

12. What billing codes would you recommend?

Grading Rubric

Criteria

10 Points

7 Points

4 Points

0 0 Points

Assessment	Develops and demonstrates a clear & precise assessment plan supported with professional literature and includes objective and subjective data.	Develops and demonstrates an assessment plan but not fully supported with professional literature may be missing one important piece of data	Develops and demonstrates a brief & vague assessment plan while missing important details of the assessment data; supported with minimal professional literature.	No paper submitted or content missing	/10
Guidelines/Evidence	Thoroughly describes all relevant practice guidelines. Clearly defines and delineates the levels of evidence that support the guidelines.	Describes relevant practice guidelines and/or describes levels of evidence to support guidelines but does not do both.	Describes a brief & vague treatment plan but lists no guidelines and does not level evidence.	No paper submitted or content missing	/10
Diagnostics	Clearly describes all appropriate diagnostics (including sensitivity and specificity). Clearly differentiates the difference between a positive and a negative finding and APN considerations	Describes all appropriate diagnostics but does not discuss the difference between a positive and negative finding or lacks a discussion of specificity and sensitivity for each diagnostic	Simply lists some diagnostics but does not discuss specificity, sensitivity, negative, or positive and APN considerations	No paper submitted or content missing	/10
Treatment Plan	Develops and provides a clearly written set of orders inclusive of all essential elements in a treatment plan.	Develops a clear set of written orders but omits an important order for the diagnosis	Develops and provides a brief set of orders for the treatment plan with more than one omission.	No paper submitted or content missing	/10
Healthy People 2020 Health Promotion	Develops and demonstrates a clear & precise description of the Healthy People 2020 goals and specifically relates one goal to current case.	Develops a Health Promotion plan and/or discusses Healthy People 2020 and the relation to the case	Describes Health Promotion but does not relate back to the case	No paper submitted or content missing	/10
Evaluation	Develops and demonstrates a clear & precise evaluation plan for the next office visit inclusive of data that will indicate no change necessary in plan or changes necessary in the plan	Develops a evaluation plan for next office visit. Includes data but does not describe predictive changes	Develops a vague evaluation plan. There is no data identified or plan	No paper submitted or content missing	/10
Patient/Family Teaching	Develops and demonstrates a clear & precise educational plan for the patient and family.	Educational topics are described but no plan is developed for the patient and family	A general educational plan is shared but is not specific to the current case..	No paper submitted or content missing	/10
Billing	Discusses all levels of billing that apply to the case and most likely appropriate level for first visit and one follow up visit	Discusses only the billing level that the APN may utilize without rationalization and the differences in initial and follow up	Discusses billing levels however provides inaccurate levels or rationalization	No paper submitted or content missing	/10

Follow up	Develops a follow up plan that specifically identifies the data that will need to be reviewed during the follow up visit. (This may function as communication to the team…i.e. check BP, cholesterol, and EKG next visit)	Discusses a general plan for follow up but no specific data is listed. May not indicate when follow up should occur or why?	Describes a generalized follow up plan that applies to all patients not the specific case.	No paper submitted or content missing	/10
	5 Points	2.5 Points	0 Points
Grammar, spelling, and punctuation	There are no errors in grammar, spelling, and punctuation	There are a few minor errors in grammar, spelling, and punctuation that do not detract from the meaning	There are major errors in grammar, spelling, and punctuation that do not reflect scholarly writing	NA	/5
APA	The paper meets APA format guidelines	There are minor APA format errors	There are significant errors in format	NA	/5
Total Points Possible = 100