1. Subjective data: Chief Complaint Diabetic foot ulcer ; History of the Present Illness (HPI)/ 2months, Demographics 62 yr old white Male, married works in construction; History of the Present Illness (HPI) that includes the presenting problem Right heel pain due to foot ulcer and the 8 dimensions of the problem(8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) ; Review of Systems (ROS Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denie
2. Objective data: Medications 1000mg of metformin, Lorsartan 50mg; Allergies NKA; Past medical history diabetes, HTN; Family history mother and father deceased from lung CA and father from heart attack; Past surgical history none; Social history works in construction, drinks at the bar 4 nights a week, smokes a pack a day; Labs CBC, CMP, wound culture, blood cultures, lactic acid; Vital signs 162/91, RR 22,O2 sat 95% on room air, HR 116, temp 101.1F oral, BGL 363 6.0’ 280lbs; Physical exam Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
3. Assessment: Primary Diagnosis diabetic foot ulcer; Differential diagnosis- sepsis
4. Plan: Diagnostic testing; Pharmacologic treatment plan; Non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan. Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
5. Other: Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner
• formatted, and cited in the current APA style, including citation of references.
• The presentation should consist of 10-15 slides
Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style