Unit 8 Assignment – Anxiety Case Study

 

Instructions

Read the case study as listed and complete a SOAP note for an intake.  What additional information do you need for subjective and objective data?  Next, design a treatment plan based on the information you have available; include pharmacological, non-pharmacological, patient education, referral, and follow-up.

Milton is a 68-year-old Asian American male who reports that his biggest problem is worrying non-stop.  He worries all of the time and about “everything under the sun and beyond.”  For example, he reports equal worry about his wife who is undergoing treatment for breast cancer, and whether he returned his book to the library yesterday to maintain a good patron status.  He recognizes that his wife is more important than a book and is bothered that both cause him similar levels of worry even when he tries to rationalize the differences.  Milton is unable to control his worrying with current mechanisms that he lists as distraction or self-talk.  Supplementary, this excessive and uncontrollable worry is creating difficulty falling asleep and staying asleep, constant impatience with others, difficulty focusing at work, and significant back and muscle tension.  Milton has had a lifelong problem with worry, recalling that his mother called him a “worry wart as a child.”  His worrying does “wax and wane”, and worsened when his wife was recently diagnosed with breast cancer.  He feels he is at a loss for what he can do to control it and relax.

Symptoms:

  • Anxiety
  • Concentration Difficulties
  • Irritability
  • Sleep Difficulties
  • Worry

Vitals:

132/80 BP

72 HR

20 R

98.8 T

98% 02

Ht. 5’5”

Weight 149

Rubric

NU673 Unit 8 Assignment – Anxiety Case Study Rubric

NU673 Unit 8 Assignment – Anxiety Case Study Rubric

CriteriaRatingsPts

This criterion is linked to a Learning OutcomeSubjective Data

10 pts

Level 5

Includes all relevant subjective data necessary for differentiation of the client’s problem. Data is presented in a systematic, organized manner consistently.

7 pts

Level 3

Includes most subjective data with omission of two minor details or one major detail. Most data is presented in a systematic, organized manner.

4 pts

Level 1

Includes subjective data but omits four minor details or two major details. Some data is presented in a systematic, organized manner.

0 pts

Level 0

Does not meet the Section

10 pts

This criterion is linked to a Learning OutcomeObjective Data

10 pts

Level 5

Objective data is complete and consistently presented in an organized manner.

7 pts

Level 3

Objective data is complete and presented in an organized manner most of the time.

4 pts

Level 1

Objective data is not complete or is not presented in an organized manner.

0 pts

Level 0

Does not meet the Section

10 pts

This criterion is linked to a Learning OutcomeAssessment

10 pts

Level 5

Assessment, including differential and/or diagnosis (if appropriate), is complete and appropriate to client. Diagnostics are complete and appropriate to clients.

7 pts

Level 3

Assessment, including differential and/or diagnosis (if appropriate), is complete but some may not be appropriate for clients.

4 pts

Level 1

Assessment, including differential and/or diagnosis (if appropriate), is not complete but is appropriate.

0 pts

Level 0

Does not meet the Section

10 pts

This criterion is linked to a Learning OutcomePlan

10 pts

Level 5

Plan includes all relevant measures 95% to 100%. Pharmacologic Non-pharmacologic Education Referral Follow-up

7 pts

Level 3

Plan includes all relevant measures 89% to 94% Pharmacologic Non-Pharmacologic Education Referral Follow-up.

4 pts

Level 1

Plan includes four of the five relevant measures, but the four are complete.

0 pts

Level 0

Does not meet the Section

10 pts

This criterion is linked to a Learning OutcomeProfessional Application

10 pts

Level 5

Case incorporates four evidence-based practice articles.

7 pts

Level 3

Case incorporates three evidence-based practice articles.

4 pts

Level 1

Does not include an evidence-based practice article but has two or more advanced practice articles.

0 pts

Level 0

Does not meet the Section

10 pts

This criterion is linked to a Learning OutcomeCollege-level academic writing

10 pts

Level 5

Includes no more than three grammatical, spelling, or punctuation errors that do not interfere with the readability. Meets the assignment length requirements.

7 pts

Level 3

Includes no more than four grammatical, spelling, or punctuation errors that do not interfere with the readability. Meets the length requirements.

4 pts

Level 1

Includes five or more grammatical, spelling, and punctuation errors make understanding parts of assignment difficult but does not interfere with readability. Meets the length requirements.

0 pts

Level 0

Does not meet the Section

10 pts

Total Points: 60

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