| Course | NR 569 Differential Diagnosis in Acute Care Practicum |
|---|---|
| Week | 6 |
| Paper type | Reasoning journal |
| Length | About 1,120 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Acute Care NP (AGACNP) |
| Updated | October 2026 |
Free sample paper for NR 569 Week 6
Reasoning Journal, Hospital Days 1 to 4: Five Dated Entries on One Patient After Gastric Bypass, Each With the Running List as It Stood
Student Name
College of Nursing, Chamberlain University
NR 569: Differential Diagnosis in Acute Care Practicum
Instructor Name
Month Day, Year
Reasoning Journal, Hospital Days 1 to 4: Five Dated Entries on One Patient After Gastric Bypass, Each With the Running List as It Stood
Entry 1: Hospital Day 1, 21:40
I meet the patient in the emergency department hallway, on a stretcher, with the sibling holding a plastic bag of medicine boxes. I am three hours into the shift and this is my first admission of the night. My attention goes first to the numbers: heart rate 112, glucose 61 at triage, potassium 3.0. Three weeks of vomiting explains all of them, and I can feel the explanation settling before I have examined anyone.
Running list at 21:40: 1. Dehydration and electrolyte loss. 2. Low glucose. 3. Leak or abscess. 4. Promethazine. 5. Brainstem or cerebellar stroke. 6. Wernicke. 7. Seizures. 8. Liver.
I write Wernicke sixth, and I write beside it "no alcohol." I notice that I am using that phrase as a reason to rank it low, and I am not sure the phrase deserves that much weight. I leave it there for now.
Entry 2: Hospital Day 2, 07:15
The night produced a CT and a set of glucose checks. The CT shows no leak and a narrowed pouch outlet, which is the best explanation yet for the vomiting. The glucose has stayed between 104 and 138 since the dextrose. The patient is still oriented to name only. So correcting the sugar did not correct the confusion, and the abdomen has explained the vomiting without explaining the brain.
Running list at 07:15: 1. Dehydration and electrolyte loss. 2. Brainstem or cerebellar stroke. 3. Wernicke. 4. Seizures. 5. Promethazine. 6. Liver. 7. Leak or abscess, provisional on cultures. Low glucose is off.
The two neurologic entries have risen because the entries above them fell, not because anything new pointed to them. I note that difference so I do not mistake it for evidence later.
I also look again at the promethazine box. Eight suppositories in ten days, the last one on the evening before admission, by the sibling's account. If the drug were driving the confusion, I would expect some improvement by now, more than a day later. There is none, so I lower it but do not yet remove it, because the count depends on memory.
Entry 3: Hospital Day 2, 15:30
This entry is the longest because this is where the list moves.
At 15:10 I go back to examine the eyes properly, which I did not do last night. Last night I wrote "extraocular movements full to casual tracking," and today I understand what that phrase hid: I watched the eyes follow my face across the room, and I did not ask them to hold a position. Today I hold a finger 30 degrees to the left and wait. The eyes drift back toward the center and jerk out again: nystagmus. The same thing happens on the right. When I ask for a full look toward each ear, neither eye gets all the way; each stops short by a few millimeters. On alternate cover, neither eye jumps vertically. Finger to nose is clumsy on both sides equally.
What arrived: bilateral gaze-evoked nystagmus, bilateral incomplete abduction, no skew, symmetric limb clumsiness. What it did: the deficiency now meets all four of the proposed criteria, diet, eyes, cerebellum and mental state (Caine et al., 1997). The symmetry argues against a single vascular lesion, though it does not exclude a midline one.
Running list at 15:30: 1. Wernicke. 2. Brainstem or cerebellar stroke. 3. Dehydration and electrolyte loss. 4. Seizures. 5. Promethazine. 6. Liver. 7. Leak or abscess, provisional.
I page my preceptor, and the thiamine order is changed to 200 mg by vein every eight hours, with the first dose at 16:00.
Entry 4: Hospital Day 3, 08:30
The MRI was done at 23:20 last night and read at 07:50. FLAIR images show symmetric bright signal in the medial thalami and around the cerebral aqueduct; diffusion images show no restriction in any vascular territory. MRI has a specificity near 93% for this pattern in acute thiamine deficiency (Antunez et al., 1998), and the absence of a vascular lesion moves stroke far down.
At my bedside check, the nystagmus is still present but takes longer to appear, and abduction on the left is nearly full. The patient tells me it is Thursday, which is wrong by one day but closer than yesterday.
I explain the scan to the sibling in plain words: a vitamin the brain depends on ran low during the weeks of vomiting, treatment has started, and some of the damage often improves, but nobody can say how much for several weeks.
Running list at 08:30: 1. Wernicke. 2. Dehydration and electrolyte loss, improving. 3. Brainstem or cerebellar stroke, unlikely. 4. Seizures. Promethazine, liver, and leak or abscess are off; cultures show no growth at 48 hours.
I am uncomfortable with how quickly I took off the hepatic entry on day 2. I removed it on normal liver tests. I have read nothing yet about whether ammonia can rise without liver disease after this operation.
Entry 5: Hospital Day 4, 09:00
The preceptor raises the question I wrote down yesterday: ammonia can rise after a gastric bypass without any liver disease. A systematic review found 33 such patients, most after this exact operation, and most of them had neurologic symptoms such as confusion (Sakran et al., 2023). The entry I removed on day 2 belongs back on the list, not because I think it is the answer, but because I removed it for a reason that does not apply. An ammonia level is drawn on ice and sent at once.
Running list at 09:00: 1. Wernicke. 2. Dehydration and electrolyte loss, improving. 3. Ammonia without liver disease, reinstated, result pending. 4. Brainstem or cerebellar stroke, unlikely. 5. Seizures; a routine EEG yesterday showed diffuse slowing without epileptiform activity.
Closing Note
Across four days the list moved twice for reasons I can name and once for a reason I am embarrassed by. The confusion that was first explained by numbers was later explained by an eye examination I had skipped. Most necropsy-proven cases of this disease were never recognized during life (Harper et al., 1986), and reading that now, after the fact, I can see how the omission happens: the numbers explained enough that I stopped looking. The ammonia result and the patient's memory over the coming week remain open.
References
Antunez, E., Estruch, R., Cardenal, C., Nicolas, J. M., Fernandez-Sola, J., & Urbano-Marquez, A. (1998). Usefulness of CT and MR imaging in the diagnosis of acute Wernicke's encephalopathy. American Journal of Roentgenology, 171(4), 1131-1137. https://doi.org/10.2214/ajr.171.4.9763009
Caine, D., Halliday, G. M., Kril, J. J., & Harper, C. G. (1997). Operational criteria for the classification of chronic alcoholics: Identification of Wernicke's encephalopathy. Journal of Neurology, Neurosurgery & Psychiatry, 62(1), 51-60. https://doi.org/10.1136/jnnp.62.1.51
Harper, C. G., Giles, M., & Finlay-Jones, R. (1986). Clinical signs in the Wernicke-Korsakoff complex: A retrospective analysis of 131 cases diagnosed at necropsy. Journal of Neurology, Neurosurgery & Psychiatry, 49(4), 341-345. https://doi.org/10.1136/jnnp.49.4.341
Sakran, N., Parmar, C., & Pouwels, S. (2023). Nonhepatic hyperammonemic encephalopathy following bariatric surgery: A systematic review. Obesity Research & Clinical Practice, 17(6), 458-467. https://doi.org/10.1016/j.orcp.2023.11.001
Reading the NR 569 Week 6 instructions
The Week 6 journal asks for several short entries written during the case rather than one essay written after it. Expect each piece to carry a date and time and to run a couple of hundred words. Most prompts want the running list printed in full in every entry so a reader can compare one with the next. The entry where the list moves should be the longest and should say what new information arrived and what it changed. Entries are written in the present tense of the moment. A brief closing note often asks what stayed unresolved. Journals that record feelings without the list, or that never change, usually lose most of the marks. Your section may also limit the number of entries, so check the count before drafting.
How the NR 569 Week 6 example is put together
Each entry in the sample opens with a hospital day and clock time and ends with the running list, using short labels such as Wernicke, seizures and liver so lists can be compared quickly. Entry 1 catches the writer anchoring on the vomiting numbers. Entry 2 records the CT and glucose results and notes that entries rose only because others fell. Entry 3 describes the eye examination step by step, names what arrived and shows the new order. Entry 4 adds MRI findings and early improvement, and the writer explains the scan to the sibling. Entry 5 reinstates an ammonia cause. The closing note names one embarrassing reason and two open questions.
Reading the NR 569 Week 6 grading rubric
The journal earns its marks through movement. A set in which nothing changes, or every entry agrees, suggests it was written in one sitting, so this sample shows the list moving twice for named reasons. Dates and times on every entry carry their own credit because they prove the pieces were written apart. Reprinting the full list in each entry makes the movement checkable, a row many rubrics include. The longest entry should sit where the list turns, and here it does. Honest notes on anchoring and on a hasty removal fit the reflection criterion, while ending with open questions keeps the journal from reading as a summary.
NR 569 Week 6 help: mistakes that cost points
The most damaging NR 569 Week 6 pattern is a journal where every entry repeats the same list, which suggests the reasoning never moved. Undated entries are a close second, since dates are the only evidence the pieces were written separately. Some writers describe only what changed, so the reader cannot reconstruct the full list. Others fill entries with feelings about the shift and none about the list. Padding with unit routine to reach a word count also loses marks. If your case moved differently, send your dated notes and lists; a journal can be shaped around your own turning point, with the full list reprinted each time.
Get a NR 569 Week 6 example written to your instructions
Email over the Week 6 instructions, the number of entries your section wants and any journal template it posts, and a custom example comes back inside 24 to 48 hours, the first one free. Tell the desk roughly when the entries are supposed to fall across the week, because the spacing decides how much can plausibly change between them.
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- NR 567 Week 6: Empiric Antibiotic Rationale
NR 569 Week 6 questions, answered
How many entries does a journal need?
Three to five is the common instruction and the number matters less than the spacing. Two entries an hour apart cannot show much; two entries three days apart can show a great deal. If your section fixes a number, the sample matches it, and if it fixes only a total word count, the desk splits that across enough moments for the list to move twice.
My case never changed. Is there anything to write?
Yes, and it is a legitimate entry set. A list that held through new information is a finding, provided each entry says what arrived and why it did not move anything. What fails is a journal asserting steadiness without testing it. Write the results that came in, the item each one might have touched, and the reason it stayed.
Can the journal follow a classroom case rather than one from the unit?
Where your instructions allow it, yes, and a supplied case is often easier to date honestly because the information arrives in a fixed order. What changes is the source of each entry's new material: a classroom case hands it over on a schedule, while a rotation case gives it to you when it turns up. Send whichever you have and the desk spaces the entries to match.
Where can I find a free NR 569 Week 6 sample paper?
This page holds all five dated journal entries for the patient after gastric bypass, each with its running list, plus margin notes on why the layout scores.
Which entry is the turning point in the NR 569 Week 6 journal?
Entry 3, at 15:30 on hospital day 2, when a gaze-holding eye examination finds nystagmus to both sides and weak abduction, moving thiamine deficiency to the top of the list.