Case Study Assignment
Guidelines with Scoring Rubric
Purpose
The purpose of this case study assignment is to
1) Analyze provided subjective and objective information to diagnose and develop aÂ
management plan for the case study patient.
2) Apply national diabetes guidelines to case study patient management plan.
3) Demonstrate mastery of SOAP note writing.
Course Outcomes
Through this assignment, the student will demonstrate the ability to:
1. Employ appropriate health promotion guidelines and disease prevention strategies in theÂ
management of mature and aging individuals and families.Â
2. Formulate appropriate diagnoses and evidence-based plans of care for mature and agingÂ
individuals and families using subjective and objective data.
3. Incorporate unique patient cultural preferences, values, and health beliefs in the care of matureÂ
and aging individuals and families
4. Integrate theory and evidence based practice in the care of mature and aging individuals andÂ
their families
6. Conduct pharmacologic assessment addressing polypharmacy, drug interactions and otherÂ
adverse events in the care of mature and aging individuals and their families.
7. Apply evidence-based screening tools to perform functional assessments with aging individualsÂ
and their families as appropriate.
Due Date: Sunday 11:59 p.m. MT at the end of Week 5
Total Points Possible: 200 points
PREPARING THE ASSIGNMENTÂ
The assignment is a paper which is to be written in APA format. This includes a title page andÂ
reference page.
Review the attached patient visit information. The patient has presented for an acute care visit. YouÂ
are provided with the subjective and objective exam findings. As the provider, you are to diagnoseÂ
and develop the management plan for this case study patient.Â
Use the categories below to create section headings for your paper.
Introduction: briefly discuss the purpose of this paper.
Assessment: review the provided case study information.
Chamberlain College of Nursing NR601Â
2
Identify the primary, secondary and differential diagnoses for the patient. Use the 601 SOAP noteÂ
format as a guide to develop your diagnoses.
Each diagnosis will include the following information:
1. ICD 10 code.
2. A brief pathophysiology statement which his no longer that 2 sentences, paraphrased andÂ
includes common signs and symptoms of the diagnosis.
3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentenceÂ
statement which links the subjective and objective findings (including lab data andÂ
interpretation).
4. A rationale statement which summarizes why the diagnosis was chosen.Â
5. Do not include quotes, paraphrase all scholarly information and provide an intext citation toÂ
your scholarly reference. Use the Reference Guidelines document for information onÂ
scholarly references.Â
Plan (there are five (5) sections to the management plan)
1. Diagnostics. List all labs and diagnostic test you would like to order. Each test includes aÂ
rationale statement which includes the diagnosis for the test, the purpose of the test andÂ
how the test results will contribute to your management plan. Each rationale statement isÂ
cited.Â
2. Medications: Each medication is listed in prescription format. Each prescribed and OTCÂ
medication is linked to a specific diagnosis and includes a paraphrased EBP rationale forÂ
prescribing.Â
3. Education: section includes detailed education on all five (5) subcategories: diagnosis, eachÂ
medication purpose and side effects, diet, personalized exercise recommendations andÂ
warning sign for diagnosis and medications if applicable. All education steps are linked to aÂ
diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601Â
SOAP note guideline for more detailed information.Â
4. Referrals: any recommended referrals are appropriate to the patient diagnosis and currentÂ
condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale forÂ
orderingÂ
5. Follow up: Follow up includes a specific time frame to return to PCP office for nextÂ
scheduled appointment. Includes EBP rationale with in text citation.Â