| Course | NR 580 Adult-Gerontology Primary Care Capstone and Intensive |
|---|---|
| Week | 3 |
| Paper type | Comprehensive case write-up |
| Length | About 1,180 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Primary Care NP (AGPCNP) |
| Updated | October 2026 |
Free sample paper for NR 580 Week 3
Comprehensive Case Write-Up: One Visit for a 76-Year-Old With Low Sugars, Falls, Kidney Disease and Heart Failure, Argued From the Medicines Actually Taken to a Return Visit With a Purpose
Student Name
College of Nursing, Chamberlain University
NR 580: Adult-Gerontology Primary Care Capstone and Intensive
Instructor Name
Month Day, Year
Comprehensive Case Write-Up: One Visit for a 76-Year-Old With Low Sugars, Falls, Kidney Disease and Heart Failure, Argued From the Medicines Actually Taken to a Return Visit With a Purpose
Why the History Runs Long
The presenting problem was two falls and three low sugars in six weeks. The history below is longer than that complaint needs, because the plan depends on questions the complaint alone would not prompt: which tablets are actually taken and when, what the patient eats overnight, who is at home at night and what the patient wants from treatment.
History
The patient, a composite drawn from my capstone clinic, is 76, a retired bus mechanic who lives with a spouse in a ranch-style home. Type 2 diabetes was diagnosed 21 years ago. Insulin glargine was started six years ago, when kidney function was better, and the dose has not been reduced since. Glipizide has been taken for 15 years. Heart failure with reduced ejection fraction was diagnosed two years ago after a hospital admission; the cardiologist started carvedilol and sacubitril with valsartan, and the doses have been kept low because of dizziness. Kidney disease has been at stage 3b for a year.
Medication history taken from the bottles, not the list: all six medicines are taken as prescribed by the spouse's account, except the furosemide, which the patient sometimes skips on days with errands. The glipizide is taken at breakfast and at supper. The glargine goes in at 22:00. The patient eats supper at 17:30 and nothing afterward.
Low sugars: three, all between 03:00 and 07:00. The patient woke sweaty and shaky twice; the third was found on a routine check after the morning fall.
Falls: one before dawn heading to the toilet, glucose afterward 58; one mid-afternoon getting off the couch, glucose 142.
What the patient wants: "To stop falling. I don't care if the number's a bit higher."
Examination
Weight 82 kg, stable. Blood pressure lying 128/72, standing at one minute 108/66, and 104/64 at the three-minute mark, the patient lightheaded; resting pulse regular at 64. No leg swelling; lungs clear; no raised jugular venous pressure. Feet: monofilament sensation reduced at both great toes; no ulcers. Gait slow but steady with eyes open; sways with eyes closed. Cognition: no formal testing today; conversation appropriate.
Social and Functional History
Lives with a spouse who manages the pillbox and drives. Walks around the block most days but not since the morning fall. No alcohol. Former smoker, quit 20 years ago. Independent in bathing and dressing; the spouse handles shopping and bills. Two grown children, both within an hour's drive, visit at weekends; one has offered to drive to appointments if the spouse cannot.
Results
A1c 6.4%. Estimated filtration rate 38, potassium 4.8. Ejection fraction 35% eight months ago.
Problem List, Each With Its Disposal
1. Recurrent nocturnal hypoglycemia. Older adults on insulin or sulfonylureas with tight targets are a common pattern of possible overtreatment (Lipska et al., 2015). Cause: glipizide with long-acting insulin dosed for better kidney function and a tight target. Disposal: glipizide stopped; glargine reduced to 16 units; target A1c below 8%; overnight checks twice a week for two weeks. In older adults with several conditions, intensive targets bring hypoglycemia without matching benefit; a large trial of intensive glucose lowering was stopped early because of excess deaths in the intensive group (Action to Control Cardiovascular Risk in Diabetes Study Group, 2008).
2. Falls, two in six weeks. Causes: hypoglycemia for one, orthostatic hypotension for the other. Disposal: problem 1 addresses the first; problem 3 addresses the second; physical therapy referral for balance; advice to sit before standing.
3. Orthostatic hypotension, meeting the consensus definition at a 24-point drop sustained at three minutes (Freeman et al., 2011). Cause: likely the heart failure medicines and the diuretic, with possible autonomic neuropathy from diabetes. Disposal: no dose increases today; furosemide continued at the same dose; reassess standing pressures in two weeks.
4. Heart failure with reduced ejection fraction, medicines below target doses. Disposal: no change today; discussion with the cardiologist about adding an SGLT2 inhibitor at the two-week return, if by then the overnight lows have ceased.
5. Chronic kidney disease, stage 3b. Disposal: stable; recheck in three months; the glargine reduction accounts for reduced insulin clearance.
6. Reduced foot sensation. Disposal: podiatry referral and foot care teaching; recorded so it is not lost among the urgent problems.
7. Mild cognitive impairment. Disposal: the spouse already helps with medicines; no change today; recorded because it affects the safety of insulin self-management.
The Patient's Priorities in the Plan
The patient's priority, to stop falling, ranks the problems. Hypoglycemia comes first because it caused one fall and can cause more tonight. Orthostatic hypotension comes second because it caused the other. The heart failure medicines come after those, not because they matter less over years but because raising them now would work against the first two priorities. This ordering was explained to the patient, who agreed with it.
What Was Deliberately Not Done
No new medicine was added. The heart failure doses were not raised. No referral to endocrinology was made, because the change needed was a reduction, which primary care can manage. Not doing these things is part of the plan, recorded so the next clinician does not read them as omissions.
The Return Arrangement
Two weeks, in clinic, at 10:00 on a Tuesday, when the spouse can come. Purpose: to read the glucose log, repeat standing pressures and decide on the SGLT2 inhibitor. A phone call from the clinic nurse on day 5 to ask about any readings below 70. If a reading below 70 occurs before then, the spouse calls the clinic the same day and the glargine is reduced by a further 4 units.
How This Visit Connects to the Next
The two-week visit has three decisions waiting for it: whether the glargine needs a further cut, whether the standing pressure has improved and whether to start the SGLT2 inhibitor. Each depends on information collected between now and then, which is why the overnight checks and the nurse's call are part of the plan rather than extras.
What Was Said to the Patient and Spouse
I explained that the low sugars came from medicines that were right years ago and are too strong now, and that a slightly higher sugar is safer for someone who has fallen. The patient repeated back the main change: "No more glipizide, and fewer units at night." The spouse asked whether the sugar might go too high; I explained that we would watch the readings and the A1c, and adjust if needed. Both were given a written sheet with the new doses, the overnight check times and the number to call.
References
Action to Control Cardiovascular Risk in Diabetes Study Group. (2008). Effects of intensive glucose lowering in type 2 diabetes. New England Journal of Medicine, 358(24), 2545-2559. https://doi.org/10.1056/NEJMoa0802743
Freeman, R., Wieling, W., Axelrod, F. B., Benditt, D. G., Benarroch, E., Biaggioni, I., Cheshire, W. P., Chelimsky, T., Cortelli, P., Gibbons, C. H., Goldstein, D. S., Hainsworth, R., Hilz, M. J., Jacob, G., Kaufmann, H., Jordan, J., Lipsitz, L. A., Levine, B. D., Low, P. A., . . . van Dijk, J. G. (2011). Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clinical Autonomic Research, 21(2), 69-72. https://doi.org/10.1007/s10286-011-0119-5
Lipska, K. J., Ross, J. S., Miao, Y., Shah, N. D., Lee, S. J., & Steinman, M. A. (2015). Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Internal Medicine, 175(3), 356-362. https://doi.org/10.1001/jamainternmed.2014.7345
NR 580 Week 3 instructions, in plain terms
The Week 3 write-up should read as one argument about a single person rather than as headed sections sharing a name. The history should be as long as the plan needs, because the questions asked early are the ones later decisions depend on. The examination covers what the history made worth examining. Every problem opened in the history or examination needs a disposal in the plan, even if the disposal is to wait. Most rubrics mark down a plan resting on a history nobody took, such as an instruction about a medicine with no record of what the patient actually takes, and a return visit with no stated purpose.
Inside the NR 580 Week 3 example
The write-up begins by explaining why its history is long. The history covers the diabetes, insulin and glipizide histories, the heart failure medicines, the bottles-based medication history, the timing of low sugars and falls and what the patient wants. Social and functional history and a focused examination follow, including standing pressures and foot sensation. Results are listed. Seven problems are each given a cause and a disposal, from nocturnal hypoglycemia to mild cognitive impairment. Sections cover the patient's priorities, what was deliberately not done, how the visit connects to the next and the return arrangement, and close with what was said to the family.
Where the points sit in the NR 580 Week 3 rubric
The costliest fault is a problem opened and never disposed of: a finding named in the list and then absent below, leaving a marker unable to tell judgment from forgetting. Every problem here has a disposal, including decisions to wait. A plan resting on a history nobody took costs nearly as much, and this write-up takes the medication history from the bottles. An examination unrelated to the history loses the focus criterion. A return visit with a purpose and a time earns the follow-up row, and recording what was deliberately not done shows the plan's limits were chosen. Recording what the patient and spouse were told shows the plan reached the people who will carry it out.
Common NR 580 Week 3 mistakes, and how to avoid them
Many NR 580 Week 3 write-ups list problems in the assessment and then drop some of them in the plan. Others give instructions about medicines without checking what the patient takes. Examinations often cover every system without regard to the history. Return visits are set for routine follow-up with no purpose. Some write-ups read as separate sections with no argument connecting them. If your case differs, send the history, the examination and the problem list, and a write-up can be shaped so that every problem opened is disposed of and the plan rests on what was actually found. Write the history to serve the plan, examine what the history points to and give every problem a disposal before you finish.
Get a NR 580 Week 3 example written to your instructions
Send the Week 3 instructions, whatever template your classroom supplies and the case you have been assigned, and a custom example is written into that template and returned inside 24 to 48 hours, the first one free. It comes back complete, disposal lines included, as a finished document to hold your own version up against.
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NR 580 Week 3 questions, answered
How many problems should the case carry?
Enough that the reasoning has somewhere to show and few enough that each one gets disposed of properly. A patient carrying eight problems and a write-up disposing of three scores below a patient carrying four where every entry is answered. Where your section sets a page limit, it is usually the disposal lines that get cut first, and those are the lines the rubric is reading for.
Does every problem need an action this visit?
No, and pretending otherwise weakens the document. A problem the writer decides not to touch today is disposed of properly by saying so and giving the reason, which reads as a judgment made rather than a line missed. What cannot survive is the entry that appears in the list and then never appears again, since a reader has no way to tell whether it was considered at all.
What makes a return arrangement strong?
That it names what it would catch. An interval on its own is a date. An interval attached to the specific thing being watched for, plus the instructions for coming in sooner if a stated change happens, is an arrangement somebody can judge. Where the plan depends on a result arriving first, the arrangement also says who is watching for it and what happens if it does not come.
Where can I find a free NR 580 Week 3 sample paper?
The full comprehensive case write-up for the 76-year-old, with seven problems each disposed of, is published on this page.
What is the purpose of the return visit in the NR 580 Week 3 write-up?
To read the glucose log, repeat standing pressures and decide on an SGLT2 inhibitor, two weeks after glipizide was stopped and insulin was reduced.