NRNP 6541 Pediatric Nursing Ihuman Case Study

NRNP 6541 Management Plan Template– must include these headings

1. Problem Statement – 5 pts (simply write see problem statement written in iHuman section. Please note that the problem statement that I grade is the one written in the “Problem Statement” section within the iHuman. Submitted below

2. ¬¬Primary Diagnosis, Differentials & Coding—10 points (all areas must be addressed)
• What is the primary dx ICD-10 code (1/1 point) (Needs ICD-10 code) Ankle fracture

• What is your rationale for arriving at this primary diagnosis? You must integrate the pertinent finding and support your rationale with evidence-based literature (resources) (4/4 points). You came to the result because of ……..and the patient;s symptoms – SEE PROBLEM STATEMENT ABOVE

Include CPT codes, and any procedural codes (such as nurse lab draws, vaccinations ¬¬¬given, biopsies) (2 points): **You must write the name of the test & the code next to it. DO NOT JUST WRITE THE CPT CODE w/o THE NAME OF THE TEST.
• See x-rays below.

¬Differential diagnoses (ddx)with rationale and resources. Minimum of 3-5 differentials (primary dx does not count as a differential. For well-child visit, if there are no other health issues, then differentials are not needed. (3 points) The differntials you will use are listed below

Sprain/strain
Contusion
Musculoskeletal Pain

i. DDx#1- Explain as to why you chose this ddx based on the patient’s clinical findings and how did you rule it out. Make sure to support your statements with peer reviewed literature.
ii. DDx#2- Explain as to why you chose this ddx based on the patient’s clinical findings and how did you rule it out. Make sure to support your statements with peer reviewed literature.
iii. DDX #3- Explain as to why you chose this ddx based on the patient’s clinical findings and how did you rule it out. Make sure to support your statements with peer reviewed literature.

3. Medications: (10 points)- MUST BE WRITTEN AS A PRESCRIPTION; include any vaccinations and OTC meds here. See Uploads for help.
Minocycline (tetracycline) 100 mg po QD for acne. OTC Benzoyl peroxide cleanser QD 5% topically; salicylic acid QD topically for cystic acne and Motrin OTC for ankle pain
MED:
Sig (latin for instructions):
Disp: Instructed to buy OTC.
RF (refills):

4. Treatment plan / SDOH / Health Promotion – 20 pts
• Treatment plans-should be supported by clinical guidelines (10 points)

• SDOH: address all 6 areas of social determinants of health (5 points)
• Economic Stability- The patient is 16 years old and does not work. Both of her parents work long hours and have no health insurance. They are paying cash for the visit.
• Neighborhood- The apartment building she lives in allows smoking which may be contributing to her asthma flare up.
• Education-She is in High school and has A grades.
• Food Access-
• Community and Social Context:
• Healthcare System: She has no health insurance.

• Health Promotion/Anticipatory guidance: (5 points)
Must list a minimum of 5 related to child’s age. Do not simply write f/u on vaccinations, be specific. Use your Bright Futures to help you with this area.

5. Pt. education (10 points)- – Educate parent and patient about today’s visit/diagnosis/meds etc. Must list a minimum of 5 patient education regarding today’s visit.

6. Follow up- 10 pts
a. Timing/when: (2 points)

b. Instructions: (4 points) (list minimum of 2-4)

c. Symptom to watch for that will prompt a return (red flags): (list at least red flags/4 points)

d. References – 5 pts
a. *In text citations- (1 point)
b. *Min 3 evidence-based references ( 3 points)
c. *Clinical guidelines cited in treatment plan- ( 1 point)

REFERENCES (USE APA)

REFERENCES (USE APA)
Must have 3 and must show that it is cited within your text. Please understand that references provide the information necessary for readers to identify and retrieve each work cited in the text. If your references are not cited within your text, then points will be deducted.
**NO MAYO CLINIC, no healthykids.org, no pt. education websites(such as clevelandclinic), CDC should only be for stats. REFERENCES must be peer-reviewed literature. Please utilize the Walden Library. Use primary sources.

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