Plan of Care for Neurological Disorders
Joan is a 35-year-old woman who presents with a complaint of headaches that have been occurring more frequently over the last 2 weeks. She has never had any problems with headaches before. Rarely, she has had a headache after a stressful day but denies premenstrual headaches or frequent headaches until 2 weeks ago. Her headaches are left sided in the temporal area and are severe (7 out of 10 on a scale of 1–10) and throbbing. They occur 3–5 times each week. She occasionally becomes nauseous but rarely vomits. The headaches tend to last several hours and go away if she is able to get sleep. Joan tries to retreat to a dark and quiet corner when the headaches begin. She sometimes sees “spots in front of her eyes” right before the onset of a headache. Otherwise, she has no trouble with her vision, has had no epistaxis, upper respiratory symptoms, or sinus symptoms. She denies trauma to her head or any neck stiffness. She denies fever, chills, numbness, or weakness.
Past Medical History: Besides the headaches, Joan has been well and denies any previous surgeries or hospitalizations other than for 3 uncomplicated vaginal deliveries.
Family History: Migraine headaches in her mother and sister. Her uncle had a benign brain tumor that has been successfully treated.
Social History: The patient does not smoke, drinks 1 beer 3 times each week, and denies ever using recreational drugs. She is married and works as an administrative assistant in a busy office. She has 1 preteen and 2 teenagers at home. Their behaviors sometimes cause her to have some stress. Her husband is supportive and helpful.
Medications: Joan’s medications include occasional ibuprofen for “aches and pains.” She tried the ibuprofen for the headaches without relief. She takes no other medications. She states that her mother told her that she was allergic to penicillin as a child, but does not know why.
Objective
General: Joan is well groomed. Her manner and speech are appropriate and she is articulate. She is in no apparent distress during this visit.
Vital Signs: The patient is afebrile, B/P 140/90 (which is higher than normal), pulse 86, resp 12.
HEENT: Head atraumatic and normocephalic. PERRLA, sclera clear, conjunctiva without injections. EOM’s intact. No AV nicking or papilledema. Optic disks have clear margins. Nasal mucosa is without erythema or drainage. There is no sinus tenderness to palpation. Cranial nerves II-XII are grossly intact
Cardiac: Unremarkable
Neurological: Sensation and proprioception are grossly intact and the Romberg test is negative. Gait is steady. Brudzinski and Kernig signs are negative.
To view the Grading Rubric for this Assignment, please visit the Course Home.
Assignment Requirements
The finished Assignment should be a care plan, encompassing all required items listed. The viewpoint and purpose of this Assignment should be clearly established and sustained.
KAPLAN SCHOOL OF NURSING
Unit 5 Assignment
Care of Patient with Neurological Disorder Grading Rubric
[Points Total]
| A. Project Content
30 points possible
|
Score | |||||
| Presentation of Case, subjective and objective data | No paper submitted | Only 1 of the two components addressed | Partially addresses Case, subjective or objective data. Only two addressed | Clearly and thoroughly presents Case, subjective | 20 | |
| Objective | No Paper | Only 1 component addressed | Partially Addresses the objective data | Clearly and thoroughly presents the objective data | 20 | |
| Assessment | No paper submitted | Diagnosis incorrect but completed a thorough exam and lab work in order to rule in diagnosis | Diagnosis correct but failed to rule in diagnosis with exams or lab work or other testing in detail. | Correct diagnosis. Ruled in diagnosis with exams, lab work, and other testing. | 25 | |
| Plan | No paper submitted | One to two of the components addressed | Three to five components addressed | Thoroughly addressed diagnostic studies, medications, education, health promotion, follow up, referrals | 25 | |
| Total Points | ___/90 | |||||
| B. Organization and Formatting
20 points possible |
Score | |||||
| Organization | ||||||
| Organizes project and writes well. | No SOAP note/ plan of care submitted. | SOAP note/plan of care was somewhat organized and overall writing left room for improvement | SOAP note/ plan of care was well-organized, but overall writing left room for improvement | SOAP note/plan of care was thoroughly organized and well-written. | ||
| States ideas clearly and logically. | No paper submitted | Some ideas were stated clearly and logically. | Most ideas were stated clearly and logically | All ideas were stated clearly and logically. | ||
| Writes relevant content. | No paper submitted | Project was off topic and not relevant. | Project was mostly on topic and relevant. | Project was thoroughly on topic and relevant. | ||
| Formatting
|
||||||
| Uses Course Policies formatting guidelines. | No formatting guidelines were followed. | Some guidelines were followed.
.. |
Most guidelines were followed. | All formatting guidelines were followed and the template was used. | ||
| .
Avoids spelling and grammatical errors |
Greater than 6 spelling or grammatical errors. | 4 to 6 spelling or grammatical errors | 1 to 3 spelling or grammatical errors.. | No spelling or grammatical errors. | ||
| Total Points | __/10 | |||||
| Total Points: (A +B)= 100 | ___/100 |
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