Advanced Nursing Clinical Research Paper

Advanced Nursing Clinical Research Paper

Patient’s Headache Case Study B

Important Instruction about the Assignment

· You will then formulate your differential diagnoses list, develop a plan of care, and submit a written clinic note documenting your care of this patient. Your differential diagnoses list should consist of 4 diagnoses, including 1 of which is your final diagnosis.

· Please briefly describe your rationale and reasoning for why you would include or rule out a diagnosis in your working diagnosis list. Provide 6 research nursing and medical references for your rationale.

· The paper should always have an introduction statement that explains what the paper will entails.

· Remember to include a cover page and use the most recent update APA formatting for references.

· Refer to the SOAP NOTE TEMPLATE for details on how this assignment will be graded.

· For this paper, you must provide 12-15 pages well written evidence-based research paper according to the rubric guidelines, follow the APA format formatting for references and support your paper with at least 5 to 7 nursing or medical evidence-based research articles not older than 7 yrs.

· please take time to read and review it, if the paper is not up a master’s degree level standard, I will not accept the work. I just want to be clear about that before I assigned it to anyone. This is an advanced degree work that requires a very strong writer with the background and experience in Nursing and Medical field and a very well-developed English and written expertise.

Patient’s Headache Case Study B

The patient is a young sixteen-year-old female who came to the clinic with complaint of

of an increased frequency of longstanding, stable-character, severe headaches. Episodes are preceded by bilateral blurred vision and are accompanied by nausea and vomiting.

Chief Complaint:

Beth Brown reports “I’ve been having pain in my stomach for several weeks.” She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.

Reliability and Source of History:

The patient is alert and oriented and able to answer most of the questions.

Subjective and Objective Data.

Documented in the I-Human Dashboard.

Hint 1 (Patient primary diagnoses is Migraine with aura) other potential diagnoses are:

· Cluster headache

· Tension-type headache

· Head injury/Concussion

Hint 2 (patient treatment plan which should include the up-to-date treatment for headache

Assessment

Typing Template for SOAP notes:

Assessment

This is the differential diagnosis section. List FOUR differential / working diagnoses. One of this will be your final diagnosis. For EACH of your diagnoses list a brief rationale indicating why this diagnosis should be considered or not considered as the final diagnosis. Include references used to guide your thinking.

1.

2.

3.

4.

Final Diagnosis:

Plan

All plans until you graduate contain the following elements. If an item does not apply to the particular situation, please indicate- not applicable or not needed at this time. If it’s not indicated it is assumed to not have been addressed.

Pharmacology Medications both prescription and OTC go here. Write out your prescription meds just like a prescription.

Non-Pharmacology What non-pharmacologic interventions do you recommend for your patient?

Diagnostics Are there any lab tests, radiology or other diagnostics you would like to order? Remember to think primary care. No troponins or bedside stat echos in the office.

Consults / Referrals Would you like to phone a friend? Should they follow up with a specialist for additional or further care?

Patient Education What important information do you need to make certain they know? Don’t forget about serious medication interactions or OCP.

Follow Up Think about how much leeway you want to give this patient before someone lays eyes on them again? One week? Two? What should they do if they experience new or worsening symptoms?

Plan (Here is how this needs to look on iHuman submissions)

Pharmacology:

· Ramipril 10mg 1 tablet PO QD

· Norvasc 5mg 1 tablet PO QHS

· HCTZ 12.5mg 1 tablet PO QAM

· …

Non-pharmacology

· DASH diet

· Lifestyle modifications: exercise, etc

· Avoid caffeine and other stimulants

· ….

Labs

· CBC (anemia, “paleness”, fatigue)

· CMP (liver function, renal function, electrolytes, nutrition status)

· BNP (cardiac dysfunction)

· Microalbumin (kidney function; due annually for htn/dm patients)

· (there are other labs)

Diagnostics

· EKG

· ECHO

· Stress test

· Sleep study

· ….

Patient education

· Compression stockings may help with the edema as will reducing the calcium channel blocker. You need to check your blood pressure twice a day before you take your medications and keep a log. Please bring this log to your appointments.

· Address the benefits and limitations to each medication. Address common side effect and the patient goals. Also, address common education topics.

· …..

Referrals

· Cardiology

· ……

Follow up

· Follow up appointment in 1 week to address medication changes and review additional laboratory results (CITATIONsA, 2020; CITATIONsB, 2020)

References

American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.

Daresh, J. C. (2004). Beginning the assistant principalship: A practical guide for new school administrators. Thousand Oaks, CA: Corwin.

Herbst-Damm, K. L., & Kulik, J. A. (2005). Volunteer support, marital status, and the survival times of terminally ill patients. Health Psychology, 24, 225-229. doi:10.1037/0278-6133.24.2.225

U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. (2003). Managing asthma: A guide for schools (NIH Publication No. 02-2650). Retrieved from http://www.nhlbi.nih.gov/ health/prof/asthma/asth_sch.pdf

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