Your patient is a 23-year-old female. She presents with coughing and wheezing which she stated started about three weeks ago. She is currently 25 weeks pregnant. Her last prenatal visit was one month ago in another state. She has an appointment with the prenatal care provider next week, however her respiratory symptoms brought her to your office today.
History – Chickenpox as a child. Asthma as a child, diagnosed at age 8 for which she used a SABA when needed. She has not had the need to use an inhaler since she was 19. She takes only her prenatal vitamin. No other acute or chronic problems. She advises you that she is up to date on all immunizations except she has not had a flu shot (it is October).
Social – Non-smoker, no drug use. She relocated to your state two weeks ago to get away from an abusive domestic situation. She has no support network in this area and has not yet found employment. She has no medical insurance.
HPA – Non-productive cough x 3 weeks. Wheezing audible from across the room. She states it is like this all day and wakes her from sleep every night. She reports that she is fatigued even in the morning. No other complaints.
PE/ROS – Pt appears disheveled but clean. Wheezing in all lung fields. T 98, P 82 regular, R 28 no stridor. FH 130 regular. The remainder of the exam is WNL.
02 98% and FEV 70%
Directions:
- Construct a narrative document of 4-5 pages (not including cover page or reference page)
- Diagnose the patient based on the above findings and provide your rationale for how you arrived at the diagnosis.
- Develop a treatment plan specifically for this patient, pharmacologic and non-pharmacologic.
- Describe community resources (using your own community) currently available in your state/city to support this patient.
- Provide a communication plan that you will use to ensure the patient is an active participant in the treatment plan. Refer to therapeutic communication concepts.
- Utilize national standards, your pharm and/or patho book, and medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts.
- Use references to support your concepts. Utilize correct APA formatting (7th edition) and mechanics of professional communication.
Rubric Title: MN553 Unit 4 Assignment Rubric
| Assignment Criteria | Level III | Level II | Level I | Not Present |
| Criteria 1 | Level III Max Points Points: 10 | Level II Max Points Points: 8 | Level I Max Points Points: 6 | Not Present 0 Points |
| Diagnosing the patient | An accurate diagnosis with correct staging is providedRationale for arrival at the diagnosis with support from national guidelines is provided | An accurate diagnosis is provided with staging that may not be correctRationale for the diagnosis is provided without support | An accurate diagnosis is provided with staging that may not be correctRationale for the diagnosis is provided without support | Does not meet the criteria |
| Criteria 2 | Level III Max Points Points: 10 | Level II Max Points Points: 8 | Level I Max Points Points: 6 | Not Present 0 Points |
| Providing pharmacologic intervention | Correct medications are prescribed to treat the diagnosisRational for medications prescribed adheres to national guidelines | 50% of correct medications are prescribedRational to support prescribed medications is provided and adheres to national guidelines | Less than 50% of the correct medications are prescribedRational to support the prescribed medications is not present or does not adhere to national guidelines | Does not meet the criteria |
| Criteria 3 | Level III Max Points Points: 5 | Level II Max Points Points: | Level I Max Points Points: | Not Present 0 Points |
| Providing non-pharmacologic interventions | Five or more non-pharmacologic interventions are provided | Three or four non-pharmacologic interventions are noted | One or two non-pharmacologic interventions | Does not meet the criteria |
| Criteria 4 | Level III Max Points Points: 10 | Level II Max Points Points: 7 | Level I Max Points Points: 0 | Not Present 0 Points |
| Writing a communication plan | A communication plan which includes principles of therapeutic communication is developed | A communication plan that does not include principles of therapeutic communication is developed | Does not meet the criteria | Does not meet the criteria |
| Criteria 5 | Level III Max Points Points: 10 | Level II Max Points Points: 7 | Level I Max Points Points: 4 | Not Present 0 Points |
| Community Resources | Three or more local community resources are provided | Two local community resources are provided | One local community resource is provided or:Resources are provided but they are not local to the community | Does not meet the criteria |
| Criteria 6 | Level III Max Points Points: 10 | Level II Max Points Points: 8 | Level I Max Points Points: 6 | Not Present 0 Points |
| College-level academic writing | Professional, peer-reviewed, advanced practice references are usedGrammar and mechanics of writing demonstrate graduate level workAdheres to page number requirements | The majority of references used are professional, peer-reviewed and advanced practiceErrors in grammar or mechanics of writing are present but do not interfere with readabilityAdheres to page number requirements | The majority of references used are professional, peer-reviewed and advanced practiceErrors in grammar or mechanics of writing are present but do not interfere with readabilityDoes not adhere to page number requirements | Does not meet the criteria |
| Maximum Total Points | 55 | 44 | 33 | 0 |
| Minimum Total Points | 45 points minimum | 34 points minimum | 1 point minimum | 0 |
