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Psychosocial Disorders in the Older Population
Walden University
NRNP 6540F Advanced Practice Care of Older Adults
September 13, 2020
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Psychosocial Disorders in the Older Population
As a person ages, many physiologic changes occur. Normal degenerative changes happen
that affect many brain functions. As advanced practice registered nurses, it is crucial that they
perform a comprehensive assessment on their elderly patients to be able to create a treatment
plan that will manage their medical conditions effectively. In this paper, the goal is to present a
detailed subjective, objective, assessment, and plan (SOAP) for an older adult with psychosocial
disorders. The paper also aims to reflect learning points from analyzing the psychosocial
disorders, their respective diagnostic studies, and treatment plans. Functional and behavioral
changes in geriatric patients should alert the providers to carefully evaluate potential medical
conditions and create a plan that will preserve or maintain their health and physical well-being.
Comprehensive SOAP
Patient Information:
Mrs. P, 70, F, White, Female
Chief Complaint: Mrs. Peters was brought to the clinic by her son complaining of acute
confusion (more than usual) and some agitation and restlessness.
History of Present Illness:
Mrs. Peters is a 70-year-old white female who comes to the clinic accompanied by her
son, Jared, with reports of acute confusion that was worse than baseline, agitation and
restlessness. The symptoms were noted two days ago by her son. Yesterday, Ms. P could not
remember where she was in her own room. She was seen three days ago by her primary doctor
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where her blood pressure was noted to be elevated; hence, her prescription for her blood pressure
medication, Hydrochlorothiazide, was increased to 50 mg daily. No contributing trauma nor fall
were reported by son. No changes in diet or routine regimens were reported.
Current Medications:
Multivitamin daily
Losartan 50 mg daily
Hydrochlorothiazide 50 mg daily
Fish Oil 1 tablet daily
Glyburide 5 mg daily
Metformin 500 mg twice a day
Donepezil 10 mg daily
Alendronate 70 mg orally once a week
Allergies: Atorvastatin
Past Medical History:
Dementia, Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis
Immunization status unknown
Last seen by primary physician 3 days ago
Social and Substance History:
Lives at home with son. Unknown tobacco, alcohol, and drug use.
Family History:
Family history unknown
Surgical History:
No surgical history was reported
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Mental History:
She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations.
She has a history of dementia. Two days ago, son noted he is more confused than usual and very
easily agitated. Ms. Peter’s last Mini-Mental State Exam (MMSE) score was 18/30.
Violence Hx:
She denies any issues about personal, home, community, nor sexual violence.
Reproductive Hx:
Postmenopausal
Review of Systems:
General: No fever, chills, weakness, fatigue, or weight loss.
Head: No trauma reported.
Eyes: No blurred vision, double vision or visual loss. Denies eye pain.
Ears, Nose, Throat: No loss or changes in hearing, ringing, and discharges. Balance
issues and some stumbling noted by son. No changes to nose, nasal polyps, nose bleeds,
sinus infections nor difficulty smelling. No chewing or swallowing difficulties. No
changes to voice and taste. No report of dry mouth.
Cardiovascular: No chest pain, palpitations, or heart murmurs. Denies swelling to legs.
No dyspnea on exertion. History of hypertension.
Respiratory: No shortness of breath, cough, hemoptysis.
Gastrointestinal: No reported nausea, vomiting, or abdominal pain. Denies hematemesis
nor blood in stool. Denies unexplained weight loss. No changes in diet. No diarrhea,
constipation, jaundice, or hemorrhoids.
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Genitourinary: No dysuria, hematuria, polyuria, or nocturia. No report of breast changes,
lumps nor nipple discharges. No history of breast cancer. Unknown mammogram history.
Postmenopausal.
Musculoskeletal: No muscle weakness. No problems with range of motion. She denies
any falls, denies any pain. Son reported patient has had some stumbling and balance
issues but no reported falls. History of osteoporosis.
Integumentary: No changes to skin, hair, and nails. Denies rashes or changes to moles.
Neurological: No dizziness, syncopal episodes, and numbness. Denies headache.
Memory changes reported by son as she was unable to remember where she was in her
own room. No muscle tremors, tics and seizures reported. Denies history of stroke.
Hematologic: No anemia, bleeding tendency, easy bruising, blood transfusion and
clotting disorders reported.
Lymphatics: No enlarged nodes or history of splenectomy.
Psychiatric: No history of depression or anxiety. Denies any visual or auditory
hallucinations. Denies any suicidal thoughts or ideations. History of dementia. No
changes in routine was reported.
Endocrinologic: No reports of sweating, cold, or heat intolerance. History of diabetes.
Reproductive: Postmenopausal. No reports of vaginal discharge.
Allergies: No history of asthma, hives, eczema. Has history of chronic allergic rhinitis .
Reports allergy to Atorvastatin.
Objective
Physical exam:
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General: Awake, alert but disoriented to place and time. Speech is clear and coherent but
tangential at times. Patient appears easily distracted. Her eye contact is fair. Appears well
groomed and well nourished.
Vital Signs: BP: 120/64 mm/Hg, Heart Rate: 72, Respiratory Rate: 20 and unlabored,
Temperature: 98.1 degrees Fahrenheit.
HEENT:
Head: Normocephalic and atraumatic. Intact facial sensation.
Eyes: Pupils equal, round, and reactive to light and accommodation. No AV nicking or exudates
in fundoscopic exam. Eye brows symmetrical.
Ears: Symmetrical. Patent external auditory canal with no swelling noted. No abnormal ear
discharges noted. Tympanic membranes intact with no erythema or effusion.
Nose: Symmetrical. No nasal deviation or flaring noted. No nasal polyps noted.
Throat: No erythema or exudates noted to oropharynx. Gag reflex intact.
Neck: Supple with full range of motion. Carotid arteries wit no bruits or jugular vein distention.
No masses palpated. No tracheal deviation noted.
Respiratory: Clear lung sounds in all lung fields to auscultation with inspiration and expiration.
Bilateral chest with equal rise and fall upon inspiration and expiration.
Cardiovascular: Heart rate 72, regular rate and rhythm. S1 and S2 noted. No murmurs, gallops,
and rubs. Abdominal aorta with no bruits noted. Peripheral pulses intact. No peripheral edema
noted.
Gastrointestinal: Abdomen soft, non-tender. Active bowel sounds. No organomegaly noted.
Genitourinary: Bladder not distended. No CVA tenderness noted.
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Musculoskeletal: Fully weight bearing with some gait disturbances noted. Full range of motion
to upper extremities, spine, hips, and lower extremities. No joint effusions, clubbing, cyanosis or
edema noted.
Integumentary: No significant rash or lesions observed. Skin color appropriate for age. Skin
warm to touch with skin turgor appropriate for age. No clubbing or cyanosis noted to nails.
Neurologic: CN II – XII grossly intact. Some gait and balance disturbances noted. No unusual
motor movements or tics noted. Pain sensation intact to both arms and legs. Deep tendon reflexes
to both upper and lower extremities 2+.
Psychiatric: Mood and affect are appropriate but appears easily distracted.
Hematologic: No bruising or discoloration noted on exam.
Lymphatics: No enlarged lymph nodes palpated:
Diagnostic results:
1. Chest Radiology – No cardiopulmonary findings. Within normal limits.
2. CT Head – Diffuse cerebral atrophy
3. MMSE – Score 18/30 with primary deficits in orientation, registration, attention and
calculation, and recall at a previous visit. No changes in today’s visit. Score suggests
Moderate Dementia.
4. Labs: Hemoglobin A1C 7.2%
5. Basic Metabolic Panel:
TEST RESULT REFERENCE
RANGE
GLUCOSE 90 65–99
SODIUM 130 135–146
POTASSIUM 3.4 3.5–5.3
CHLORIDE 104 98–110
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CARBON
DIOXIDE
29 19–30
CALCIUM 9.0 8.6–10.3
BUN 20 7–25
CREATININE 1.00 0.70–1.25
GLOMERULA
R FILTRATION
RATE (eGFR)
77 >or=60
mL/min/1.73m2
Assessment
Differential diagnoses:
1. Dementia
Dementia is a medical condition where there is loss of cognition in many cognitive
domains sufficiently severe to disable social and occupational functions of those affected
(Arvanitakis et al., 2019). Dementia is distinguished by a progressive loss of cognition
and functional ability to perform activities of daily living (Arevalo-Rodriguez et al.,
2015). Mrs. Peters showed symptoms of confusion, worse than her baseline, shown by
inability to recognize where she was in her own home, a symptom that may indicate
dementia. Additionally, the patient has dementia in her medical history and takes Aricept.
The MMSE score of 18/30 also confirms this primary diagnosis. Several studies
demonstrate that MMSE is a sensitive test of overt dementia with good inter-rater
reliability (Myrberg et al., 2020). To perform MMSE, 30 questions to test range of daily
mental skills will be asked and a score of 20 to 24 indicates mild dementia, 13 to 20
indicates moderate dementia, and 12 and below suggests severe dementia (Myrberg et al.,
2020). The patient’s MMSE score suggest moderate dementia. Advanced age, recent
memory impairment, and changes in personality – agitation and restlessness, are positive
indicators of dementia.
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2. Delirium
Delirium is an acute episode of confusion, fluctuating attention, worsening of cognition,
alteration in level of consciousness that results in agitation (Kennedy-Mallone et al.,
2019). Delirium may be a differential diagnosis for this patient because Mrs. Peter’s acute
episode of worsening confusion occurred two days ago. The patient’s son also reported
that the patient was showing symptoms of agitation which is typical in delirium. Pain,
urinary retention, constipation, dehydration, environmental factors, and polypharmacy are
the possible causes of delirium (Rosen et al., 2015). Pain, constipation, and urinary
retention were not reported during the assessment. No signs of dehydration were also
noted. More information should be obtained during assessment to check for
environmental stressors that could contribute to the confusion. The patient is taking
several medications as shown in her medication history; hence, polypharmacy can be
accounted for the patient’s delirium.
3. Alzheimer’s Disease (AD)
AD is type of dementia that is characterized by a progressive loss of episodic memory
and cognitive function, which later causes deficiencies in language and visuospatial
skills, and often accompanied by behavioral disorders such as aggressiveness, apathy, and
depression (Silva et al., 2019). In assessing Mrs. Peters was reported to have stumbling
and balance issues. This could be an indication of a decline in visuospatial skills,
indicating AD. Agitation and restlessness were also noted with the patient which are
positive indicators associated with AD. Current tests performed does not confirm this
diagnosis, thus, tests to check for biomarkers of cerebrospinal fluid and positron emission
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tomography in combination with several relatively new clinical criteria can aid in
confirming this diagnosis.
4. Depression
Depression in elderly patients is a common disorder that affect their quality of life. The
condition contributes to adverse functional and social outcomes of the said population.
Acute confusion that was worse than baseline, agitation, and restlessness are positive
indicators for depression. Confusion or attention problems due to depression may also be
attributed to AD, dementia, or other brain disorders (National Institute on Aging, 2020);
thus, it is crucial to rule out depression to determine the primary diagnosis. The Geriatric
Depression Scale is a self-rated questionnaire, available in long form (30 items) and a
short-form version (15 items) for diagnosing depression with a cutoff score of eleven in
the long form and seven points in the short form (Blackburn et al., 2017). The reliability,
however, decreases with increasing cognitive impairment. The said screening tool will be
included in the plan to rule out the diagnosis of depression.
Plan
1. Order additional diagnostic studies.
a. Complete blood count and urinalysis can help rule out infections that may be causing
the changes in cognition.
b. Cerebrospinal fluid analysis will be ordered to rule out any specific infections
affecting the brain.
c. Toxicology screens for drug and alcohol use will also determine if the patient’s
behavior is related to controlled substances.
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d. Magnetic Resonance Imaging (MRI) can exclude potentially reversible dementia
causes such as hydrocephalus, subdural hematoma, stroke, and intra and extra-axial
tumors (Panegyres et al., 2016). The CT scan shows diffuse cerebral atrophy, but MRI
has a higher resolution that can detect more subtle and anatomical and vascular
changes.
e. Repeat Hemoglobin A1C in 3 months. Current result shows inadequate control of
blood sugar which may be contributing to the changes in the patient’s cognitive and
functional skills.
f. Perform Geriatric Depression Scale to determine depression.
2. Therapeutic interventions:
a. Continue Donezepil 10 mg tablet daily. Donezepil, a cholinesterase inhibitor, is the
recommended therapy for mild, moderate, or severe AD dementia (Panegyres et al.,
2016).
g. Discontinue Glyburide. A careful Assessment of the patient’s medication history is a
crucial component in the management of delirium, dementia, and AD. The American
Geriatrics Society Beers Criteria identifies medications to avoid in geriatric patients.
The Beers criteria strongly recommends glyburide to be avoided in older adults due to
higher risk of severe prolonged hypoglycemia (Al-Azayzih et al., 2019).
Hypoglycemia can alter a patient’s level of alertness. A fall in blood sugar can cause
confusion, which was one of Mrs. Peter’s presenting symptoms. Continue Metformin.
b. Continue the rest of her current medications to maintain control of blood pressure and
diabetes.
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3. Referral for psychiatric Assessment can help determine if delirium, depression or other
mental health condition is contributing to the patient’s symptoms.
4. Education: Health promotion tasks.
a. Proper nutrition to control diabetes and high blood pressure to improve overall health
and reduce risk of worsening neurodegenerative disease.
b. Physical exercise to preserve strength and prevent loss of agility associated with age
and decrease neuropsychiatric symptoms. Less brain atrophy was noted in patients
with AD who had regular exercise (Panegyres et al., 2016).
c. Offer availability of influenza vaccine to patient.
d. Full guardianship is required because her impairment in cognitive and functional
abilities puts the patient at risk for wandering, falls or non-compliance to medications.
Establish a safe environment. The patient may need Helpance with activities of daily
living.
5. Disposition: Follow up in one week for reAssessment. Perform a repeat MMSE to check
for worsening of dementia or AD. For worsening of symptoms or if new acute symptoms
appear, take patient to the emergency department for Assessment and treatment.
Reflection
Evaluating the case study helped the author analyze the importance of obtaining an
adequate information in performing a SOAP note. Many information was missing in the
subjective and objective assessments that could Help in the creation of the assessment and plan.
The race was not discussed. A recent study discussed that disparities in the prevalence of
dementia was not statistically different for whites, blacks, and Hispanics (Chena &
Zissimopoulosa, 2018); however, it is important to note that the combination of socioeconomic
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and cultural factors can affect the compliance of patients in treatment plans. The immunization
history and information regarding the history of eye exam, colonoscopy, pap smear, and
mammogram were not supplied. Annual health screenings help discover diseases before they
worsen, especially with elderly patients who have greater risks due to comorbidities associated
with advanced age. Adherence to medications is particularly important to the older patients as
well. It is important to know when the patient last took her medications to evaluate compliance
to therapy. Literature showed that poor adherence in medication regimen include patients with
many comorbidities and cognitive impairment (Smaje et al., 2018). The patient’s HgbA1c was
elevated and patient showed signs of confusion in her visit. Knowing medication compliance can
determine if the patient’s symptoms were dosage related or a compliance issue to taking her
diabetic and dementia medications. The case study also did not say about Mrs. Peter’s family
history. Although family history is not necessary to develop AD and other dementias, it is
important to note that that when they run in families, genetic factors, environmental factors, or
both may play a role (Panegyres et al., 2016). Safety concerns for patients with dementia, AD,
and delirium would include wandering, fall risks, and inability to perform activities of daily
living; thus, the importance of a good support system is vital to ensure their safety.
Conclusion
Psychosocial disorders in the geriatric population is prevalent and proper assessment and
management are necessary to preserve their functional abilities. As advanced practice nurses, it is
important to obtain adequate information to be able to diagnose and treat them appropriately.
With the anatomical changes related to advanced age, mental function changes along with it.
Trying to find solutions on the challenges faced by older patients with advanced medications and
appropriate psychosocial treatment plans will help them live their remaining years comfortable.
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References
Al-Azayzih, A., Alamoori, R., & Altawalbeh, S. M. (2019). Potentially inappropriate
medications prescribing according to Beers criteria among elderly outpatients in Jordan:
A cross-sectional study. Pharmacy Practice, 17(2), 1439. https://doi.org/
10.18549/PharmPract.2019.2.1439
Arevalo-Rodriguez, I., Smailagic, N., Roque-Fguls, M., Ciapponi, A., Sanchez-Perez, E.,
Giannakou, A., Pedraza, O. L., Bonfill-Cosp, X., & Cullum, S. (2015). Mini-mental state
examination for the detection of Alzheimer’s disease and other dementias in people with
mild cognitive impairment. Cochrane Database of Systematic Reviews,
(3). https://doi.org/ 10.1002/14651858.CD010783.pub2
Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and management of dementia:
Review. Journal of the American Medical Association, 322(16), 1589-
1599. https://doi.org/10.1001/jama.2019.4782
Blackburn, P., Wilkins-Ho, M., & Wiese, B. (2017). Depression in older adults: Diagnosis and
management. BC Medical Journal, 59(3), 171-177. https://bcmj.org/articles/depressionolder-adults-diagnosis-and-management
Chena, C., & Zissimopoulosa, J. M. (2018). Racial and ethnic differences in trends in dementia
prevalence and risk factors in the United States. Alzheimers Dementia, 4, 510-
520. https://doi.org/10.1016/j.trci.2018.08.009
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Advanced practice nursing in the
care of older adults (2nd ed.). F.A. Davis.
Myrberg, K., Hyden, L. C., & Samuelsson, C. (2020). The mini-mental state examination
(MMSE) from a language perspective: An analysis of test interaction. Clinical
Linguistics and Phonetics, 34(7), 652-670. https://doi.org/10.1080/02699206.2019.1687
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National Institute on Aging. (2020). Depression and older
adults. https://www.nia.nih.gov/health/depression-and-older-adults
Panegyres, P. K., Berry, R., & Burchell, J. (2016). Early dementia
screening. Diagnostics, 6(1). https://doi.org/ 10.3390/diagnostics6010006
Rosen, T., Connors, S., Clark, S., Halpern, A., Stern, M. E., DeWald, J., Lachs, M. S., &
Flomenbaum, N. (2015). Assessment and management of delirium in older adults in the
emergency department: Literature review to inform development of a novel clinical
protocol. Advance Emergency Nursing Journal, 37(3), 183–
E3. https://doi.org/10.1097/TME.0000000000000066
Silva, M. V., Loures, C. M., Alves, L. C., De Souza, L. C., Borges, K. B., & Carvalho, M. D.
(2019). Alzheimer’s disease: Risk factors and potentially protective measures. Journal of
Biomedical Science, 26(33). https://doi.org/10.1186/s12929-019-0524-y
Smaje, A., Weston-Clark, M., Raj, R., Orlu, M., Davis, D., & Rawle, M. (2018). Factors
associated with medication adherence in older patients: A systematic review. Aging
Medicine, 1(3), 254-266. https://doi.org/10.1002/agm2.12045
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—–Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
• Location: Head
• Onset: 3 days ago
• Character: Pounding, pressure around the eyes and temples
• Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
• Timing: After being on the computer all day at work
• Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
• Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).
ROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
• General:
• Head:
• EENT (eyes, ears, nose, and throat):
• Etc.:
Note: You should list these in bullet format, and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
• Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
• Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O (objective)
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A (assessment)
Differential diagnoses: List a minimum of three differential diagnoses. Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P (plan)
Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Also included in this section is the reflection. Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.
Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).
References
You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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NRNP_6540_Week9_Assignment_Rubric
• Grid View
• List View
Excellent Good Fair Poor
Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications, checked against Beers Criteria
• Allergies
• Patient medical history (PMHx)
• Review of systems 9 (9%) – 10 (10%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. 8 (8%) – 8 (8%)
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. 7 (7%) – 7 (7%)
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing. 0 (0%) – 6 (6%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 9 (9%) – 10 (10%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 8 (8%) – 8 (8%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 7 (7%) – 7 (7%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 0 (0%) – 6 (6%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
In the Assessment section, provide:
• At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. 23 (23%) – 25 (25%)
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected. 20 (20%) – 22 (22%)
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected. 18 (18%) – 19 (19%)
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 0 (0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned. 27 (27%) – 30 (30%)
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. 24 (24%) – 26 (26%)
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking. 21 (21%) – 23 (23%)
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics. 0 (0%) – 20 (20%)
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. 9 (9%) – 10 (10%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions. 8 (8%) – 8 (8%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions. 7 (7%) – 7 (7%)
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan. 0 (0%) – 6 (6%)
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
Written Expression and Formatting—Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.
Purpose, introduction, and conclusion of the assignment is vague or off topic. 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.
No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)
Uses correct APA format with no errors. 4 (4%) – 4 (4%)
Contains a few (one or two) APA format errors. 3 (3%) – 3 (3%)
Contains several (three or four) APA format errors. 0 (0%) – 2 (2%)
Contains many (≥ five) APA format errors.
Total Points: 100
Name: NRNP_6540_Week9_Assignment_Rubric
—–Samples
1 Psychiatric Disorders in the Elderly
NRNP 6540F Advanced Practice Care of the Elderly
13 Sept 2020
2 Psychosocial Disorders in Seniors
Many physiologic changes occur with age. Normal aging affects several brain functions. To properly manage their senior patients’ medical conditions, advanced practice registered nurses must conduct a thorough assessment. Goal of this paper is to offer a complete SOAP for an older adult with psychosocial issues. The paper will also include key takeaways from examining psychosocial illnesses, diagnostic research, and treatment methods. Changes in aging patients’ functional and behavioral abilities should warn doctors to investigate probable medical issues and devise a plan to preserve or maintain their health.
SOAP vs.
Patient Info:
Mrs. P., 70, White, F.
Mrs. Peters was brought to the clinic by her son, who reported her being quite confused, agitated, and restless.
Illness History:
Mrs. Peters, a 70-year-old white woman, presents with worse-than-normal disorientation, agitation, and restlessness, accompanied by her son, Jared. Her son first noticed them two days ago. Ms. P had no idea where she was in her own room. Her primary doctor 3 saw her blood pressure was high and upped her prescription for Hydrochlorothiazide to 50 mg daily. Son claimed no trauma or fall. No dietary or habit changes were reported.
Medications:
DAILY VITAMIN
50 mg Losartan
Fish Oil 1 pill daily
5 mg Glyburide
500 mg twice daily
10 mg donepezil
70 mg alendronate once a week
Atorvastatin Allergy
Diabetes, Osteoporosis and Chronic Allergic Rhinitis
Unknown Immunization
Primary doctor last seen 3 days ago
Social and drug history: Son lives at home. Use of unknown drugs and tobacco.
Unknown Family History
No prior surgical history was mentioned.
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She denies having visual or auditory hallucinations. She denies having suicidal thoughts.
Her mother had dementia. Son noticed he’s more confused and irritated than normal. Ms. Peter’s last MMSE score was 18/30.
She denies any personal, domestic, or sexual violence.
Hx Reproduc:
Postmenopausal System Review
Not having a temperature or chills, or feeling tired.
No trauma to the head.
Eyes: No double vision or visual loss. Refutes eye ail
Ears, nose, and throat: No hearing loss, ringing, or discharges. Son notes balance concerns and stumbling. No nose changes, polyps, bleeding, sinus infections, or problems smelling. No issues chewing or swallowing. No voice or flavor changes. No dry mouth reports.
It has no palpitations or heart murmurs. Denies leg swelling.
I don’t sweat much. Hypertension history
No shortness of breath, cough, or hemoptysis.
GI: No nausea, vomiting, or abdominal pain. Disavows hematemesis and scrotal Explicable weight loss denied No diet modifications. Ketosis (no diarrhoea, constipation, jaund
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In the genitourinary system, dysuria is absent. No changes, lumps, or nipple discharges reported. NO HISTORY OF BRUCE No prior mammograms.
Postmenopausal.
No muscle weakness. No range of motion issues. She denies any pain or falls. Son reported patient stumbling and having balance difficulty but no falls. Osteoporosis history.
Skin, hair, and nails are unaffected. No rashes or mole changes.
No dizziness, syncope, or numbness. No headache.
Her memory had changed and she couldn’t remember where she was in her own room. No tremors, tics, or seizures. Denies stroke history
Blood transfusion and coagulation issues have not been recorded.
No enlarged lymph nodes or splenectomy history.
The applicant has no psychiatric history. No visual or audio hallucinations. Denies having suicidal thoughts. Dementia history. Routine remained unchanged.
Intestinal: No sweating, cold or heat intolerance. Diabetes history
Postmenopausal. No vaginal discharge reported.
No asthma, hives, or eczema history. Chronic allergic rhinitis history
Allergic to Atorvastatin.
Objective
Exam: 6
General: Unable to place or time. A little tangential at times. Distracted patient. Her gaze is fair. Appears well-groomed and fed.
Heart rate 72, respiratory rate 20 and unlabored. BP 120/64 mm/Hg.
Normocephalic and atraumatic head Face-sensation intact
Pupils equal, circular, and light reactive. Examined for AV nicking or exudates. symmetrical brows
Symmetrical ear No enlargement in the external auditory canal. No unusual ear secretions. No erythema or effusion on tympanic membranes.
Symmetrical. No nasal flaring or deviation. The nose is clear.
Oropharynx: No erythema or exudates noticed. No gag reflex.
Neck: Flexible with no carotid bruits or jugular vein distention.
No masses felt. Trach deviation absent.
Clear lung sounds in all lung fields on inspiration and expiration.
Bilateral chest with equal rise and fall.
Cardiovascular: 72 bpm, steady beat. S1 and S2. Not even a murmur. Aorta abdominale sans bruits. Intact peripheral pulses Null peripheral edema
Abdomen gentle, non-tender Bowel sounds. Anomalies found.
Bladder not swollen. No CVA tenderness.
7
Fully weight bearing with some gait abnormalities. Upper extremities, spine, hips, and lower extremities. No joint effusions, cyanosis, or edema.
No major rash or sores on the skin. Age-appropriate skin tone Warm skin with age-appropriate turgor. No nail clubbing or cyanosis.
Neurological: CN II–XII intact. Some gait and balance issues. Nothing out of the ordinary here. Both arms and legs still hurt. Upper and lower extremity deep tendon reflexes 2+.
Mood and affect are normal, yet easily distracted.
No bruising or discolouration on exam.
No enlarging lymph nodes palpated:
1. Chest X-ray – No cardiopulmonary findings. Normal limitations.
Atrophic Diffuse Cerebral Tissue
The patient had primary deficiencies in orientation, registration, attention, computation, and recall on the MMSE. No modifications for today. Moderate Dementia Score.
Labs: A1C 7.2 %
5. Metabolic Panel:
TESTS REFERENCES
RANGE
90–99 GLUCOSE
130–146 SODIUM
POTASSIUM CHLORIDE 104 98–110 8 CARBON DIOXIDE 29 19–30
CALCIUM 8.5–10.3 BUN 7–25
CREATININE 0.70–1.25
eGFR 77 >or=60 mL/min/1.73m2
Assessment
Various diagnoses:
Demencia
Dementia is a medical illness characterized by widespread cognitive loss that impairs social and vocational functions (Arvanitakis et al., 2019). Dementia is characterized by a progressive loss of cognition and functional capacity (Arevalo-Rodriguez et al., 2015). Mrs. Peters had worsened bewilderment, as seen by her inability to know where she was in her own home, a hallmark of dementia. The patient also has dementia and takes Aricept.
18/30 on the MMSE supports this initial diagnosis. MMSE is a sensitive and reliable inter-rater test for dementia (Myrberg et al., 2020). A score of 20-24 denotes mild dementia, 13-20 indicates moderate dementia, and 12 and lower indicates severe dementia (Myrberg et al., 2020). It shows mild dementia on the MMSE. Aging, recent memory loss, and personality changes — agitation and restlessness – are all signs of dementia.
9
2. Daze
Delirium is characterized by agitation, fluctuating attention, impaired cognition, and altered degree of awareness (Kennedy-Mallone et al., 2019). Mrs. Peter had an acute bout of growing confusion two days ago, suggesting delirium. The patient’s son noticed agitation, which is common in delirium. Dehydration, pain, urine retention, constipation, environmental variables, and polypharmacy can cause delirium (Rosen et al., 2015). No complaints of pain, constipation, or urine retention were made. There were no evidence of dehydration. During the examination, look for environmental stresses that may be contributing to the misunderstanding. Polypharmacy can explain for the patient’s delirium as evidenced in her drug history.
3. Alzheimer’s (AD)
Progressive loss of episodic memory and cognitive function produces deficits in language and visual skills, and is commonly accompanied by behavioral disorders such as aggression, apathy, and depression (Silva et al., 2019). Mrs. Peters was seen to be stumbling and unbalanced. This could be a sign of Alzheimer’s disease (AD). The patient displayed signs of AD such as agitation and restlessness. Testing for cerebrospinal fluid biomarkers and positron emission tomography, along with numerous new clinical criteria, can help confirm this diagnosis.
4. Sadness
Depression is a prevalent illness that affects the elderly’s quality of life. The condition affects the population’s functional and social consequences.
Acute disorientation, agitation, and restlessness are all signs of depression. Depression can cause confusion or attention issues, which can be mistaken for AD, dementia, or other brain disorders (National Institute on Aging, 2020). The Geriatric Depression Scale is a self-report questionnaire with a cutoff score of eleven in the long form and seven in the short form for diagnosing depression (Blackburn et al., 2017). However, the dependability declines with cognitive impairment. The strategy will incorporate the claimed screening technique to rule out depression.
Plan 1: Order further diagnostic tests.
a. A complete blood count and urinalysis can rule out illnesses causing cognitive abnormalities.
b. A CSF analysis will be performed to rule out any brain infections.
It will also identify if the patient’s conduct is due to controlled substances.
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d. MRI can rule out reversible dementia causes such hydrocephalus, subdural hematoma, stroke, and intra- and extra-axial malignancies (Panegyres et al., 2016). Its increased resolution allows it to detect subtle structural and circulatory changes that a CT scan cannot.
f. Retest A1C in 3 months. The patient’s cognitive and functional skills may be deteriorating due to insufficient blood sugar control.
b. Assess depression using the Geriatric Depression Scale.
2. Continue taking Donezepil 10 mg daily. cholinesterase inhibitor donezepil (Panegyres et al., 2016).
f. Stop Glyburide. Medication history is critical in the management of delirium, dementia, and Alzheimer’s. The American Geriatrics Society’s Beers Criteria lists drugs to avoid in elderly.
To avoid severe persistent hypoglycemia in elderly persons, the Beers criteria strongly advises against glyburide (Al-Azayzih et al., 2019).
Hypoglycemia can impair alertness. A drop in blood sugar might create confusion, which Mrs. Peter had. Metformin.
b. Maintain her existing blood pressure and diabetic meds.
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3. Referral for psychiatric examination can Help diagnose delirium, depression, or other mental health issues.
4. Health promotion tasks:
Controlling diabetes and hypertension improves general health and reduces risk of neurodegenerative disease.
b. Physical activity to maintain strength and agility and reduce neuropsychiatric symptoms. Regular exercise reduced brain atrophy in Alzheimer’s sufferers (Panegyres et al., 2016).
d. Inform patient about influenza vaccine.
d. Full guardianship is required since her cognitive and functional impairment puts her at danger for roaming, falls, and medication non-compliance.
Create a safe space. The patient may need help with daily tasks.
5. Disposition: Reevaluate in one week. Repeat the MMSE to assess dementia or AD progression. Take the patient to the ER if symptoms worsen or new symptoms occur.
Reflection
Using the case study, the author learned the value of gathering sufficient information for a SOAP note. The subjective and objective assessments lacked much information that may help create the assessment and plan.
No mention of race. However, it is vital to remember that the mix of socioeconomic and cultural factors can impair patient compliance with treatment programs (Chena et al., 2018). The history of immunizations, eye exams, colonoscopies, pap smears, and mammograms were not provided. Annual health screenings help detect diseases early, especially in the elderly, who have higher risks due to age-related comorbidities. Medication adherence is critical for elderly people as well. To assess therapeutic compliance, know when the patient last took her prescriptions. Patients with several comorbidities and cognitive impairment have poor drug adherence (Smaje et al., 2018). The patient’s HgbA1c was high and she appeared confused. To find out if the patient’s symptoms were due to dosage or non-compliance with her diabetic and dementia meds. There was no mention of Mrs. Peter’s family history. While a family history of AD or other dementias is not required, it is crucial to highlight that genetic, environmental, or both factors may be involved (Panegyres et al., 2016). Wandering, fall risks, and incapacity to conduct everyday chores are all safety problems for persons with dementia, AD, and delirium.
Conclusion
Psychosocial issues in the elderly are common and require thorough assessment and care to maintain functional capacities. As advanced practice nurses, we need to gather enough data to properly diagnose and treat patients.
With the anatomical changes related to advanced age, mental function changes along with it.
Finding answers for elderly patients’ problems using improved drugs and psychosocial treatment plans would help them live more comfortably in their later years.
14 sReferences
Al-Azayzih, A., Alamoori, R., & Altawalbeh, S. M. (2019). Potentially inappropriate medications prescribing according to Beers criteria among elderly outpatients in Jordan: A cross-sectional study. Pharmacy Practice, 17(2), 1439. https://doi.org/ 10.18549/PharmPract.2019.2.1439
Arevalo-Rodriguez, I., Smailagic, N., Roque-Fguls, M., Ciapponi, A., Sanchez-Perez, E., Giannakou, A., Pedraza, O. L., Bonfill-Cosp, X., & Cullum, S. (2015). Mini-mental state examination for the detection of Alzheimer’s disease and other dementias in people with mild cognitive impairment. Cochrane Database of Systematic Reviews, (3). https://doi.org/ 10.1002/14651858.CD010783.pub2
Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and management of dementia: Review. Journal of the American Medical Association, 322(16), 1589- 1599. https://doi.org/10.1001/jama.2019.4782
Blackburn, P., Wilkins-Ho, M., & Wiese, B. (2017). Depression in older adults: Diagnosis and management. BC Medical Journal, 59(3), 171-177. https://bcmj.org/articles/depressionolder-adults-diagnosis-and-management
Chena, C., & Zissimopoulosa, J. M. (2018). Racial and ethnic differences in trends in dementia prevalence and risk factors in the United States. Alzheimers Dementia, 4, 510- 520. https://doi.org/10.1016/j.trci.2018.08.009
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Advanced practice nursing in the care of older adults (2nd ed.). F.A. Davis.
Myrberg, K., Hyden, L. C., & Samuelsson, C. (2020). The mini-mental state examination (MMSE) from a language perspective: An analysis of test interaction. Clinical Linguistics and Phonetics, 34(7), 652-670. https://doi.org/10.1080/02699206.2019.1687 15
National Institute on Aging. (2020). Depression and older adults. https://www.nia.nih.gov/health/depression-and-older-adults
Panegyres, P. K., Berry, R., & Burchell, J. (2016). Early dementia screening. Diagnostics, 6(1). https://doi.org/ 10.3390/diagnostics6010006
Rosen, T., Connors, S., Clark, S., Halpern, A., Stern, M. E., DeWald, J., Lachs, M. S., & Flomenbaum, N. (2015). Assessment and management of delirium in older adults in the emergency department: Literature review to inform development of a novel clinical protocol. Advance Emergency Nursing Journal, 37(3), 183– E3. https://doi.org/10.1097/TME.0000000000000066
Silva, M. V., Loures, C. M., Alves, L. C., De Souza, L. C., Borges, K. B., & Carvalho, M. D. (2019). Alzheimer’s disease: Risk factors and potentially protective measures. Journal of Biomedical Science, 26(33). https://doi.org/10.1186/s12929-019-0524-y
Smaje, A., Weston-Clark, M., Raj, R., Orlu, M., Davis, D., & Rawle, M. (2018). Factors associated with medication adherence in older patients: A systematic review. Aging Medicine, 1(3), 254-266. https://doi.org/10.1002/agm2.12045 16
