-General Usual weight, recent weight change, weakness, fatigue, o.docx

-General Usual weight, recent weight change, weakness,
fatigue, or fever
-Skin Rashes, lumps, sores, itching, dryness, changes in color,
changes in hair or nails, changes in size or color moles
-Head, Eyes, Ears, Nose, Throat (HEENT):
-
Head: Headache, head injury, dizziness,
lightheadedness.
Eyes: Vision, glasses or contact lenses, pain, redness,
excessive tearing, double or blurred vision, spots, specks,
flashing lights, glaucoma, cataracts.
Ears: Hearing, Tinnitus, Vertigo, earaches, infection,
discharge, If hearing is decreased, use or nonuse of hearing
aids,
Nose and Sinuses: Frequent colds, nasal stuffiness,
discharge, or itching, hay fever, nose- bleeds, sinus trouble.
Throat (
or mouth and Pharynx): Condition of teeth and gums,
bleeding gums, dentures, if any, and how they fit, sore tongue,
dry mouth, frequent sore throats, hoarseness.
-Neck “Swollen Glands,” goiter, lumps, pain, or stiffness in the
neck.
-Breast Lumps, pain, or discomfort, nipple discharge
-Respiratory Cough, sputum (color quantity; presence of blood
or hemoptysis), shortness of breath (dyspnea), wheezing, pain
with a deep breath (Pleuritic pain).
-Cardiovascular “Heart trouble”; high blood pressure;

rheumatic fever; heath murmurs; chest pain or discomfort;
palpitations; shortness of breath; need to use pillows at night to
ease breathing (orthopnea); need to sit up at night to ease
breathing (paroxysmal nocturnal dyspnea) swelling in the hands
, ankles, or feet (edema).
-Gastrointestinal Trouble swallowing, heartburn, appetite,
nausea. Bowel movements, stool color and size, change bowel
habits, pain constipation, diarrhea. Abdominal pain, food
intolerance, excessive belching or passing of gas. Jaundice,
liver, or gallbladder trouble.
-Peripheral Vascular Intermittent leg pain with exertion
(Claudication); leg cramps; varicose veins; past clots in the
veins; past clots in the veins; selling in claves, legs, or feet;
color change in fingertips or toes during cold weather; selling
with redness or tenderness.
-Urinary Frequency or urination, polyuria, nighttime urination
(nocturia), urgency, burning or pain during urination, blood in
the urine (hematuria), urinary infections, kidney or flank pain,
kidney stones, ureteral colic, suprapubic pain, incontinence; in
males, reduced caliber or force of the urinary stream, hesitancy,
dribbling.
-Genital
Male: Hernia, discharge from or sores on the penis, testicular
pain or masses, scrotal pain or swelling, history of sexually
transmitted infection and their treatments. Sexual interest
(Libido), function, satisfaction
Female: Menstrual regularity, frequency, and duration of
periods, amount of bleeding; bleeding between periods or after
intercourse, dysmenorrhea, premenstrual tension. Menopausal
symptoms, post-menopausal bleeding. Vaginal discharge,

itching, sores, lumps, sexually transmitted infection, and
treatments. Sexual interest, satisfaction, any problems,
including pain during intercourse (dyspareunia)
-Musculoskeletal Muscle or joint pain, stiffness, arthritis, gout,
backache. If present, describe the location of affected joints or
muscles, any swelling, redness, pain , tenderness, stiffness,
weakness, or limitation of motion or activity; include timing of
symptoms (e.g., morning or evening), duration, and any history
of trauma. Neck or low back pain. Joint pain with systemic
symptoms such as fever, chills, rash, anorexia, weight loss, or
weakness.
-Psychiatric Nervousness, tension, mood, including
depression, memory change, suicidal ideation, suicide plans or
attempts.
-Neurologic Changes in mood, attention, or speech; changes in
orientation, memory, insight, or judgment; headache, dizziness,
vertigo, fainting, blackouts; weakness, paralysis, numbness, loss
of sensation, tingling or “pins and needles,” tremors or other
involuntary movement seizures.
-Hematologic Anemia, easy bruising, or bleeding
-Endocrine Heat or cold intolerance, excessive sweating
,excessive thirst (polydipsia), hunger (polyphagia), or urine
output (polyuria).
-Physical Examination
General Survey: MN is a short, overweight middle-aged
female, who is animated and responds quickly to questions. Her
hair was well groomed. Her color is good, and she lies flat.

Vital Signs: Ht(without shoes) 157 cm (5’2”). Wt (dressed) 65
kg (143 lbs) . BMI 26, BP 164/98 right arm supine; 160/96 left
arm, supine; 152/88 right arm, supine with wide cuff. Heart rate
(HR) 88 and regular. Respiratory rate (RR) 18. Temperature
(oral) 98.6F.
Skin: Palms cold and moist, but color good. Scattered Cherry
angiomas over upper trunk. Nails without clubbing , cyanosis.
Head, Eyes, Ears, Nose, Throat (HEENT): Head; hair of average
texture, Scalp without lesions, normocephalic/ atraumatic
(NC?AT).
Eyes; Vision 20/30 in each eye.
Visual fields full by confrontation. Conjunctive pink; sclera
white. Pupils 4 mm constricting to 2 mm, round, regular,
equally reactive to light. Extraocular movements intact. Disc
margins sharp, without hemorrhage, exudate. No arteriolar
narrowing or A-V nicking.
Ears: Cerumen partially obscures right tympanic
membrane (™); Left canal clear, ™ with good cone of light.
Acuity is a good to whispered voice. Weber midline. AC>BC.
Nose Mucosa pink, septum midline. No sinus
tenderness.
Mouth:Oral mucosa pink. Dentition is good. Tongue
midline. Tonsils absent. Pharynx without exudates.
Neck: Neck Supple. Trachea midline. Thyroid isthmus barely
palpable, lobes not felt.
Lymph Nodes: No cervical, axillary, or epitrochlear nodes.
Thorax and Lungs: Thorax Symmetric with good excursion.
Lungs resonant on percussion. Breath sounds vesicular with no
added sounds. Diaphragms descend 4 cm bilaterally.

Cardiovascular: Jugular venous pressure 1 cm above the sternal
angle, with the head of the examining table raised to 30 degrees.
Carotid upstrokes brisk, without bruits. Apical impulse discrete
and tapping, barely palpable in the 5th left interspace, 8 cm
lateral to the midsternal line. Good S1,,.S2,: no S3 or S3,. A
II/VI medium-pitched midsystolic murmur at the 2nd right
interspace; does not radiate to the neck. No diastolic murmurs.
Breast: pendulous, symmetric.. No masses; nipples without
discharge.
Abdomen: Protuberant. Well-healed scar, right lower quadrant.
Bowel sounds active. No tenderness or masses. Liver span 7cm
in right midclavicular line; edge smooth, palpable 1 cm below
right costal margin (RCM). Spleen not felt. No costovertebral
angles tenderness (CVAT).
Genitalia:
Female External genitalia without lesions. Mild cystocele at
introitus on straining. Vaginal mucosa pink. Cervix pink,
parous, and without discharge. Uterus anterior, midline, smooth,
not enlarged . Adnexa is not palpated due to obesity and poor
relaxation. No cervical or Adnexal tenderness. Pap Smear taken.
Rectovaginal wall intact.
Male External genitalia without discharge or lesions. No scrotal
or testicular mases or swelling, no hernia.
Rectal: No external hemorrhoids, tight sphincter tone, rectal
vault without masses, stool brown negative for occult blood.
Extremities: Bilateral upper extremities warm. Bilateral lower
extremities; no edema. Calves supple, symmetric, temperature
intact bilaterally with negative Homan's sign.

Peripheral vascular: No varicosities in lower extremities. No
stasis pigmentation or ulcers Pulses. (2+ = normal)
_____________________________________________________
____
Radial Femoral Popliteal Dorsalis Pedis
Posterior Tibial
_____________________________________________________
____
Rt 2+ 2+ 2+ 2+ 2+
_____________________________________________________
__
Lt 2+ 2+ 2+ 2+ 2+
Musculoskeletal: No joint deformities or selling on inspection
and palpation. Good range of motion in hands, wrists, elbows,
shoulders, spine, hips, knees, ankles.
Neurologic: Mental Status: Alert and cooperative. Thought
processes are coherent and insight is good. Oriented to person,
place, and time. Cranial
nerves: II to XII intact.
Motor: Good muscle bulk and tone.
Strength: 5/5 bilaterally in deltoids, biceps, triceps,
hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior,
and gastrocnemius.
Cerebellar: Rapid Alternating movements (RAMs) and
point-to-point movements intact. Gait stable, fluid.
Sensory: Pinprick, light touch, position sense,
vibration, and stereognosis intact. Romberg negative.
Reflexes: Bilateral triceps, brachioradialis, patellar and
Achilles deep tendon reflexes intact. Bilateral plantar reflex
intact. Babinski response is negative.

A review of literature provides the practicing nurse with the
latest knowledge regarding any aspect of practice. For this
assignment, you will conduct a literature review for a topic of
your choice. I recommend that you choose a topic of interest to
you and one that is relevant to your current practice.
Assignment Guidelines
1. Choose a topic of interest to you and write a research
question to guide your literature review.
2. Locate at least five full-text research articles that are
relevant to your research question.
3. Read each article and note the author, date of publication,
type of study (quantitative or qualitative) and research design,
target population, sample selection method, number of subjects
and demographics of sample, tools used to collect data, methods
of data analysis used and study findings.
4. Write an 8-10 page paper using the following outline:
A. Introduction that includes the reason you chose the topic
and a purpose statement (“The purpose of this paper is…”).
B. A description of each study, including the author, date of
publication, type of study (quantitative or qualitative) and
research design, target population, sample selection method,
number of subjects and demographics of sample, tools used to
collect data, and methods of data analysis used.
C. Discussion of the findings of the five studies, pointing
out differences and similarities of findings, possible reasons for
conflicting findings, and the limitations of the studies.
D. Conclusion that restates the purpose of the paper, a brief
summary of your overall findings from the review of literature,
and whether or not the data is strong enough to support a
change in practice.
E. Reference List

Grading Criteria (20% of final grade)
1. Appropriateness of research question (10 points)
2. Description of each research study (20 points)
3. Discussion regarding strength of evidence and support for
changing in practice (15 points)
4. Discussion of limitation of each study (15 points)
4. Conclusion: (20 points)
5. Writing style: grammar, punctuation, etc. /APA formatting
(20 points)
1
Running head: Intensivist and patient outcomes
11
Intensivist and patient outcomes
Does having a 24-hour intensivist improve the outcomes of

adult patients in the Intensive Care Unit?
Student Name
Abstract
Patients admitted into the Intensive Care Unit (ICU) come in
with complex health issues and more research is needed to
understand patient outcomes when a 24-hour intensivist is
staffed in an ICU. Exploring ways to improve patient outcomes
is the basis of evidence based practice and it is important for
health care professionals to understand what interventions can
help lead to improve patient outcomes.

Does having a 24-hour intensivist improve the outcomes of
adult patients in the Intensive Care Unit?
The purpose of this paper is to examine if there are differences

in patient outcome when a 24-hour intensivist staffing model is
applied. An intensivist is a medical doctor who specializes in
taking care of the critically ill. Patients admitted to an Intensive
Care Unit (ICU) are often dealing with complex, life
threatening illnesses and it is important to provide great care
regardless of the time they are admitted into the unit. Therefore,
it is necessary to evaluate if having a 24-hour intensivist in
ICUs results in better outcomes for this population. If an
intensivist is staffed on the unit 24-hours a day, they could help
implement early interventions that may help improve the
survival rate of this vulnerable patient population. There have
been several studies evaluating the outcomes of having the ICU
staffed 24 hours a day versus ICU units staffed only during the
morning. There have also been reviews on how nurse
practitioners and physician’s assistants can contribute to
staffing in the ICU. The research hypotheses for this paper is
that having a 24-hour intensivist improves the outcomes of adult
patients in the ICU.
Literature review
Van der Wilden, Schmidt, Chang, Bittner, Cobb, Velmahos, &
King (2013) conducted a quantitative retrospective study at a
Massachusetts hospital, and investigated if there were positive
patient outcomes to staffing 24/7 intensivist in a Surgical
Intensive Care Unit (SICU). The 26-month study had a
purposeful sample of total of 2,829 patients (Van der Wilden et
al., 2013). Prior to implementation, this hospital staffed an
intensivist during the day from 7am-5pm, and afterwards they
were on call. At night, this SICU was covered by residents
and/or critical care fellows. This study collected data such
mortality rate, length of stay, readmission rate and days on
mechanical ventilation. They also collected Acute Physiology
and Chronic Health Evaluation II (APACHE II) scores, which
helps estimate the patient’s ICU mortality (Van der Wilden et
al., 2013). This study conducted statistical analysis by using chi
square for category variables, and used
t-tests to compare continuous variables; all values with

P <0.05 were considered significant (Van der Wilden et al.,
2013). Implementation of 24/7 staffing did show that patients
received less blood products and imaging, thereby saving
money. However, they were not able to find sufficient evidence
to suggest that 24/7 intensivist staffing improved morbidity or
mortality. Researchers concluded that this might have been due
the “highly structured and protocolized environment” of the
SICU (Van der Wilden et al., 2013). Therefore, all patients that
come in with the same type of diagnosis, such as sepsis, came
with a specific order set. An ICU such as this, already has
several protocols in place that nurses can resort to, therefore,
not requiring the need for an intensivist to be staffed 24-hours a
day.
Reineck, Wallace, Barnato, & Kahn (2013) conducted a
quantitative retrospective cohort study to see if the quality of
end of life care in ICU patients would be different if they had a
24-hour intensivist. The statistical analysis used to compare
hospitals with and without 24hr intensivist for this study was
the Whitney test for continuous variables, and Fisher’s exact for
categorical variables. For patient characteristics, a t-test was
used for continuous variables and chi-square for categorical
variables. All tests used the two- tailed test with a significance
level of 0.05. The researches obtained APACHE II scores from
patients; the study included 64,752 patients from 49 ICUs, after
performing exclusion and inclusion criteria, they were left with
a sample 3,553 (Reineck et al., 2013). They found that during
the night, there was a decrease in the amount of deaths occurred
when the intensivists were staffed for 24-hours. They also found
that there was a 2.5 day decrease from the admission date to
death, meaning that patient died an average of 2.5 days earlier
than those not staffed with an intensivist all day (Reineck et al.,
2013). They also defined death as patients who both were
decreased and opted to go to hospice after their ICU admission.
The researchers attributed this finding to intervening earlier and
discussing end of life issues with the patient and family. In

discussing patient prognosis and end of life issues immediately,
researchers believed that this helped to improve the quality of
life for the patient and helped forgo futile life sustaining
treatments.
Kerlin, Harhay, Kahn, & Halpern (2015) conducted a
quantitative retrospective cohort study to investigate different
night time staffing model on patient outcomes and mortality
risk. The different staffing models were categorized as:
intensivists, non-attending intensivist, trainee (resident or
fellows), and no physicians (Kerlin et al., 2015). They obtained
their purposeful sample from Project International Mission for
Prognosis and Analysis of Clinical Trials database from 2001 to
2008. Kerlin et al., (2015) calculated each patients Mortality
Prediction Model (MPM). After the inclusion and exclusion
criteria there were 270,742 patients that were in the study.
Statistical analysis used was descriptive statistics and chi
square test (Kerlin et al., 2015). Kerlin et al., (2015) found that
there was no difference in mortality or hospital length of stay.
They found that patients were on mechanical ventilation longer
if they were in the group with the attending nonintensivist.
Unexpectedly this study was able to associate lower mortality
risk when there was no intensivist available during the night,
which may be due to differences in how end of life care is
treated. A limitation of this study was that the sample obtained
was older, and the medical technology or practices might have
advanced since that period of time.
Baharoon, Alyafi, Tamim, Al-Jahdali, Alsafi, Al-Sayyari, &
Ahmed (2016) conducted a quantitative retrospective study to
see the impacts on patient outcomes when there was a
mandatory 24-hour intensivist on site versus an on-demand
intensivist. Method of obtaining data was through National
Guard Health Affairs, which is a health care provider in Saudi
Arabia. Researches used two similar ICU units and divided it
into group A and B, one with 24-hour intensivist and the other
with an intensivist that is available during the day and on call at
night (Baharoon et al., 2016). They used Acute Physiology and

Chronic Health Evaluation II (APACHE II) to score the illness
of the patient (Baharoon et al., 2016). The descriptive analysis
and outcome variables were assessed with chi-square and
student
t-test, and a statistical significance of P < 0.05 was used
(Baharoon et al., 2016). Baharoon et al., (2016) performed their
statistical analysis using Statistical Analysis Software. There
was purposive sample of 1,921 patients between both units was
obtained from ICU admissions from January 2004 to December
2005 (Baharoon et al., 2016). Results showed that there was a
reduced mortality rate among medical patients but not with
trauma or surgical patients with the 24-hour intensivist. The
limitation of this study is that it may not be applicable to
everyone due to its geographic location. There might be
differences in the way the United States provides care versus
how Saudi Arabia provides care, thus not making it
generalizable to everyone. Baharoon et al., (2016) also
speculated that ICUs that do not have critically sick patients
may not benefit from having an intensivist 24 hours a day, and
those who are really sick may still have poor prognosis despite
having a doctor available 24 hours a day.
Adıgüzel, Karakurt, Moçin, Takır, Saltürk, Kargın, & Güngör
(2015) conducted a retrospective, cross-sectional, observational
study to see if full time ICU staff made a positive impact on
patients who were on mechanical ventilation. They collected
data patient data from a teaching hospital in a level II ICU from
January 2006 to December 2007. They collected APACHE II
scores, and inclusion and exclusion criteria, and they used
stratification to obtain the patient population (Adıgüzel et al.,
2015). Adıgüzel et al., (2015) used the Mann-Whitney-U test,
and Chi-square test, and P value of <0.05 was used for
statistical significance. (Adıgüzel et al., 2015). There was a
total of 425 patients was used and there were two groups, one
with a periodic intensivist, and another group with 24-hour
intensivist (Adıgüzel et al., 2015). The group with the 24-hr

intensivist showed decrease in duration in mechanical
ventilation and length of stay, however, they both showed
similar mortality rates among both groups. Findings suggest that
the decrease in mechanical ventilation was possibly due to
intensivist being able to control ventilation settings throughout
the day versus only once in the morning.
Discussion
Most of these studies discussed in this literature review used a
retrospective design which is considered a limitation due to
poor control and possible confounding research biases. To have
more control and reduce bias of these studies, an experimental
approach is best. Perhaps the researchers used a retrospective
design due to it being readily available and because it’s more
cost effective. Another limitation of some studies is that the
geographic location, environment of the ICU, and the protocols
in each of the ICUs differ. Therefore, it is difficult to measure
outcomes such as mortality rates when each ICU may evaluate
and perform tasks differently. All of the studies had inclusion
and exclusion criteria to help with the selection of the patient
population. Inclusion criteria included variables such as
diagnosis and age. A limitation of the samples used in these
studies discussed is that most of them used purposeful
sampling. Purposeful samples are generally a disadvantage due
to bias and generalizability.
Some other similarities are that all of the researchers used ICU
patients as their target population. Also, most findings of these
studies suggest that there is no difference in mortality rates in
ICU patients when the unit is staffed all day with intensivists
versus those that are staffed part of the day. Although, most
studies found that there is no difference in mortality rates, there
was a decrease in average length of stays, blood products
administered, imaging orders, and reduced days on mechanical
ventilation. Therefore, having an intensivist staffed on the unit
24 hours a day helps with properly assessing the patient, and
making appropriate adjustments to their plan of care. This is a
positive outcome that helps reduce unnecessary health care

expenditures, thereby, improving the quality of the patient. The
study conducted by Baharoon et al., (2016) had conflicting
findings of mortality rates compared to the other studies. A
possible reason may be that this study took place in Saudi
Arabia, where their medical practices may differ. It can also be
due to the type of illnesses encountered and the general health
of that geographic location. Other limitations of these studies
is that that most researchers collected their data from early
2000s, and much of the medical technology might have changed
by now. Therefore, it is possible that patient outcomes may
differ due to technological advancement and through evidence
based practice guidelines that have been implemented since the
study came out.
Another strength of all the studies is that they used a p value of
0.05 to measure whether an outcome was significant. Other
similar findings from all the studies is that they used a scoring
criteria to predict the severity of the ICU patient. The scoring
that 4/5 studies discussed in this paper used APACHE II, and
the other study used the MPM to predict the outcomes for each
patient. According to Salluh, & Soares (2014), “ICU scoring
systems provide a valuable framework to characterize patients’
severity of illness for the evaluation of ICU performance, for
quality improvement initiatives and for benchmarking
purposes.” By including the APACHE II and MPM scores,
researchers were able to include, exclude, and evaluate their
findings to see if results were due to patients having a higher
risk associated due to their APACHEII or MPM scores.
Conclusions
Taking care of ICU patients is complex, comprehensive, and
timing is often crucial for survival for this vulnerable
population. Differences in patient outcomes can be influenced
by individual differences, practices, resources, and protocols
employed by the institutions and doctors. There have been many
studies that have mixed findings on the 24-hour staffing of
intensivist, many mention that it does not improve mortality

rates, but it does show improvements in other areas such as,
reducing amount of days on mechanical ventilation. Although
these studies do not show a reduction in mortality, they also do
not show a negative correlation to patient outcomes when
staffed 24-hours a day. Instead, these studies help with
reducing orders for imaging or labs. Therefore, there are still
some positive outcomes that are being shown. However, there is
still not strong enough data to support a mandatory change for
24-hour intensivist in the ICU.
It is also important to discuss that even though 24-hour
intensivists may be something that all hospitals may want to
implement they may not be able to financially employ 24-hour
intensivists, therefore, even if studies are showing there are can
be some improvements in patient mortality and outcomes, it
may not be feasible to attain in most hospitals. The
implementation of protocols such as the ones Van der Wilden et
al., (2013) mentioned and can help those hospitals with limited
financial resources. Studies such as Van der Wilden et al.,
(2013) did bring up that the reason why the study did not show
significance in mortality rates with 24-hr versus day versus day
time intensivists may have been due to the highly structured
ICU and intense protocols. This may be an option for ICUs to
adopt, as it may be cost effective and can reduce the need to
implement 24-hour intensivists. Nurses could follow an
evidenced based protocol that outlines parameters that is
initiated by intensivist. Within the protocol, nurses would then
need to notify MD after patient meets certain parameters or it
patient not improving after implementation of the protocol.
In addition to financial constraints, there may also be a limited
number of doctors trained in critical care medicine, therefore,
even if staffing the hospital with 24-hour intensivist was
obtainable, there may not be enough doctors available to
provide this service. An option for these hospitals would be to
employ ICU staff with nurse practitioners trained in critical
care. A literature review conducted by White, Kokiousis,
Ensminger, & Shirey (2017), found that supplementing

intensivist staffing with nurse practitioners can positively
impact patient outcomes (in terms of mortality, patient
satisfaction and length of stay) and it could help reduce stress
and burnout for intensivists. Additionally, Scherzer, Dennis,
Swan, Kavuru, & Oxman (2017) found that there was no
difference in patient mortality between a nurse practitioner and
resident. Gershengorn, Wunsch, Wahab, Leaf, Brodie, Li, &
Factor (2011) also found that nurse practitioners and physician
assistants in a medical ICU are able to provide safe quality care
and are a great alternative to staffing an ICU.
In order to gain more understanding the effects of 24-hour
intensivists, more studies need to examine the relationship
between adverse effects and positive outcomes. In light of the
findings from these articles, it would also be equally important
to investigate protocols in the ICU the benefits to patients. This
could help potentially help those hospitals that may not be able
to financially afford, or those that are located in areas where not
many intensivists reside. If more studies are able to find that it
is beneficial to have someone on staff 24-hours a day, hospital
administrators can also start to think about hiring nurse
practitioners and physician’s assistants to help fill any shortage
that the area may be experiencing. After being trained in
specialty areas such as critical care, studies have shown that
nurse practitioners help promote positive outcomes in the ICU
and produce similar outcomes or better than residents. In order
to find evidence based practice, it is essential to have research
proven strategies to help identify and promote quality care for
all patients.
References
Adıgüzel, N., Karakurt, Z., Moçin, Ö. Y., Takır, H. B., Saltürk,
C., Kargın, F., & Güngör, G.
(2015). Full-Time ICU Staff in the Intensive Care Unit: Does It
Improve the Outcome?

Turk Toraks Dergisi / Turkish Thoracic Journal,
16(1), 28-32. doi:10.5152/ttd.2014.4317
Baharoon, S., Alyafi, W., Tamim, H., Al-Jahdali, H., Alsafi, E.,
Al-Sayyari, A., & Ahmed, Q.
(2016). Continuous Mandatory Onsite Consultant Intensivists in
the ICU: Impacts on
Patient Outcomes.
Journal of Patient Safety,
12(2), 108-113
Gershengorn, H., Wunsch, H., Wahab, R., Leaf, D., Brodie, D.,
Li, G., & Factor, P. (2011).
Impact of nonphysician staffing on outcomes in a medical ICU.
Chest,
139(6), 1347-
1353. doi:10.1378/chest.10-2648
Kerlin, M. P., Harhay, M. O., Kahn, J. M., & Halpern, S. D.
(2015). Nighttime intensivist
staffing, mortality, and limits on life support: a retrospective
cohort study.
Chest,
147(4),
951-958. doi:10.1378/chest.14-0501

Reineck, L. A., Wallace, D. J., Barnato, A. E., & Kahn, J. M.
(2013). Nighttime intensivist
staffing and the timing of death among ICU decedents: a
retrospective cohort study.
Critical Care,
17(3), R216. doi:10.1186/cc13033
Salluh, J. F., & Soares, M. (2014). ICU severity of illness
scores: APACHE, SAPS and MPM.
Current Opinion in Critical Care,
20(5), 557-565. doi:10.1097/MCC.0000000000000135
Scherzer, R., Dennis, M. P., Swan, B. A., Kavuru, M. S., &
Oxman, D. A. (2017). A Comparison
of Usage and Outcomes Between Nurse Practitioner and
Resident-Staffed Medical ICUs.
Critical Care Medicine,
45(2), e132-e137. doi:10.1097/CCM.0000000000002055
Van der Wilden, G., Schmidt, U., Chang, Y., Bittner, E., Cobb,
J., Velmahos, G., & King, D.
(2013). Implementation of 24/7 intensivist presence in the
SICU: Effect on processes of
care.
Journal of Trauma & Acute Care Surgery,
74(2), 563-567.

doi:10.1097/TA.0b013e31827880a8
White, T., Kokiousis, J., Ensminger, S., & Shirey, M. (2017).
Supplementing Intensivist Staffing
With Nurse Practitioners: Literature Review.
AACN Advanced Critical Care,
28(2), 111-
123. doi:10.4037/aacnacc2017949
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Case Study 3: NUR 631 Lab

Felisha is a 34-year-old female with PMH of asthma,
Hypertension, and dysmenorrhea, who presents to the clinic for
evaluation of “abdominal pain.” She states it started 3 days ago.
She denies any injury to her abdomen. She says it started by her
belly button, then slowly moved to the RLQ and flank. Her
partner Sally, said that on the way to the office, every pothole
they drove over, she complained of pain. She took OTC
Ibuprofen 600mg two days ago, but it just dulled the pain. She
rates the pain currently 8/10 on the pain scale. She reports a
low-grade fever of 37.8 Celsius yesterday but none today. She
has intermittent nausea and admits to vomiting twice over the
past 3 days. She works as a marine biologist, and it has been
very hard for her to swim at work, so she had to call in today to
get to the clinic. She has had decreased PO intake at home. She
admits to smoking 3 cigarettes/day x 10 years. She drinks white
wine socially. She has a mother (58yo HTN, CAD), father (62yo
AFIB, CAD, CVA), Brother 26 (healthy). She takes amlodipine
5mg daily and uses albuterol inhaler as needed for her asthma
control. She has had a PAP smear at age 32, and a LEEP
procedure following with her gynecologist. She denies any
urinary frequency, or blood in her urine. Her last BM was
yesterday.
Vitals 36.8 oral, HR 98, BP 140/45, RR 18, SPO2 99% room air,
Weight 157lbs, 5ft 9in
She is alert and oriented x 3. PERRLA, EOMI. Appropriate
appearance. Oral mucosa dry, pink. Dentition in good repair.
Neck supple, trachea midline, no lymphadenopathy, no JVD.
Chest clear to auscultation. No pain to palpation of chest wall.
Cardiovascular with normal s1, s2. No murmur or gallops
appreciated. Abdomen is soft, BS X 4 quadrants. Pain with
palpation of the right lower quadrant. No suprapubic tenderness.
On GU exam, normal vaginal mucosa, cervical OS closed. LMP
2 weeks ago. Skin no rashes, no joint tenderness. No pedal
edema is noted. ROM is intact in all joints bilaterally. Able to
heel and toe walk. DTR’s 2+ BUE, BLE. Normal rectal tone, no

hemorrhoids, Fecal occult blood negative.
CBC: WBC 21.6, HGB 13.5, HCT 29.0, PLTS 250
Chemistry: Na 135, K 3.5, Mag 2.0, BUN 27, Crea 0.9, glucose
114
Urine HCG: negative
Instructions: Reformat the above data as follows from Bates:
You must include a full ROS and Physical Exam for full Credit
1). CC:
HPI
PMH (include surgeries and traumatic injuries)
Current medications
Allergies
Psychosocial
Family History – genogram (you can draw it and place on last
page, or create in word document)
ROS – complete information
Physical Exam – complete information
2). List 3 Differential Diagnoses in descending order of
suspicion
(Number these as #1, #2, #3, your #1 should be your primary
working DX)
3). List the pertinent positives/negatives to support your
differentials. (at least 3 of each)
4). List additional history data that would support your primary
differential diagnosis and why? (At least 10 history questions
listed)
5). List any additional physical components that would support
your primary differential diagnosis and why? (At least 5 PE
findings that would better help you diagnose your primary
differential)

6). Select your primary differential diagnosis as #1 and include
2 other differentials:
a) Give a brief pathophysiologic description of each disorder
(< 10 sentences)
b) Etiology (primary dx)
c) Usual clinical findings or features (primary dx)
d) Diagnostic criteria (if any) for making the diagnosis
(primary dx)
e) Treatment Plan – include specific treatments like
pharmacotherapy (be specific with doses, amounts, etc) (for
your PRIMARY DX)
The
Basic 7 Questions
1. Where is it located? Where does it hurt the worst?2.
2. Quality: What do you bring up when you cough? How would
you describe the pain? What does it feel like?
3. Severity: How bad is it?
4.Context: How did it happen? When do you notice it?5.
5. Timing: When did it start? or how long have you had it? How
frequently does it happen?6.
Modifying factors:
6. What makes it better? or What have you done about it?
What makes it worse?7.
7. Associated symptoms: What other symptoms are you having
GRADING SHEET FOR NUR 631 WRITTEN CASE STUDY
Student Name:
CCS# _1__

HISTORY DATA- 40 points HX
pts____
Chief Concern (CC) (8) ____
Complete History of Present Illness (HPI)
(12) ____
Pertinent PMH (meds, allergies, social risks)
(4) ____
Review of Systems (Case data documented appropriately)
(12) ____
Family History (with genogram) (4)
____
PHYSICAL EXAM - 40 points PE pts_____
Case data appropriately documented in
FULL PE
DIFFERENTIAL DIAGNOSIS - 10 points
DD pts____
List 3 Differentials to explain primary problem
([email protected]=3) ____
Give a brief
pathophysiologic description of each DD: (3)
Etiology ____
Usual clinical findings or features ____
Pertinent positives/negatives listed to support primary DD
(2) ____
List additional history questions to support primary DD (1)
____
List additional physical findings to support primary DD (1)
____

PLAN OF CARE -5 points Plan
pts___
(specific treatments including meds - be specific with doses,
times)
Pharmacologic (2) ____
Non Pharmacologic (1) ____
Patient Education (1) ____
Follow Up (1) ____
*Neatness, typed, submitted on time, appropriate format,
use of appropriate terminology, references -
5 points Form pts___
Total points _____
Copy the template for ROS and PE from Bates verbatim and
substitute normal for abnormal findings listed in the case
studies. If the finding is normal put "denies". If it is abnormal
put "endorses".
Use the pocket manual for differential diagnosis to look up your
symptoms (presenting) and they will list possible causes.
Narrow the causes down based on 1)your patient's presenting
symptoms and 2) by using the current medical diagnosis and
treatment textbook.
Create a genogram for the family history. Example is in Bates.
Look at the case study rubric and make sure you've met all
requirements.

Pertinent positive: sign/symptom that helps to rule in diagnosis.
Pertinent negative: sign/symptom that is NOT present and
because it is not present helps to rule out an alternate diagnosis.
For example, pertinent positives for pneumonia could be fever
and cough with blood-tinged sputum. These could also be
pertinent positives for TB but if the patient does NOT have
night sweats and weight loss for example, the absence of these
symptoms would be pertinent negatives that would make you
think the patient is more likely experiencing pneumonia (rule
out TB).

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