| Course | NR 601 Primary Care of the Maturing and Aged Family Practicum |
|---|---|
| Week | 3 |
| Paper type | Chronic care note |
| Length | About 860 words, 4 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Family Nurse Practitioner (FNP) |
| Updated | October 2026 |
Free sample paper for NR 601 Week 3
Chronic Care Note: R.D., 81, Where the Blood Pressure Target That Protects the Kidneys Is the Target Producing Dizziness on Standing, and the Choice Made
Student Name
College of Nursing, Chamberlain University
NR 601: Primary Care of the Maturing and Aged Family Practicum
Instructor Name
Month Day, Year
Chronic Care Note: R.D., 81, Where the Blood Pressure Target That Protects the Kidneys Is the Target Producing Dizziness on Standing, and the Choice Made
Interval History
Fourteen days since the comprehensive assessment. No falls since, but lightheaded on standing most mornings, worst within an hour of the morning tablets. Nights still broken by two or three trips to pass urine. The daughter now fills the pill organizer on Sundays; this week's organizer was correct. Home physical therapy has started.
What Is Actually Taken
Checked against the organizer and bottles, morning slot: lisinopril (20), hydrochlorothiazide (25), metformin (1,000), omeprazole (20), oxybutynin ER (10), aspirin (81), calcium with vitamin D. Evening slot: metformin (1,000) and atorvastatin (40). Taken separately: diphenhydramine 25 most nights, acetaminophen when the knees ache. All doses in milligrams.
Data Used
Blood pressure: seated 136/74; standing at 1 minute 114/70; standing at 3 minutes 110/66, with lightheadedness.
Home readings from the daughter's cuff, mornings: seated average 132/72.
Basic metabolic panel, last week: sodium 133; potassium 4.1; creatinine 1.1; estimated glomerular filtration rate 52.
Hemoglobin A1c, last month: 6.4%.
Urine albumin to creatinine ratio: 45 mg/g.
Assessment
1. Hypertension with orthostatic hypotension. Seated pressure is at the guideline target for a patient with diabetes and kidney disease, but standing pressure falls by 26 systolic with symptoms.
2. Recurrent falls, two in six months, with orthostatic hypotension a likely contributor. Status: no falls in two weeks, symptoms persist.
3. Chronic kidney disease stage 3a with moderate albuminuria. Status: stable.
4. Type 2 diabetes. Status: A1c 6.4%, at or below target for age; no hypoglycemia risk from metformin alone.
5. Mild hyponatremia, sodium 133, likely from hydrochlorothiazide.
The Collision
The blood pressure target that protects R.D.'s kidneys and heart over the coming years is the same target producing the drop on standing and, very likely, the falls. Intensive pressure lowering in adults over 75 reduced cardiovascular events in a large trial, but that trial excluded people with standing systolic pressure below 110 and many people with recent falls, so its results do not describe R.D. (Williamson et al., 2016). In a nationally representative group of older adults taking blood pressure medicines, serious fall injuries were more common among those on moderate or high intensity treatment, particularly with a prior fall (Tinetti et al., 2014).
I am choosing to accept a higher seated pressure to reduce the drop on standing. A hip fracture this year is a larger and nearer threat to R.D. than the cardiovascular and kidney benefit of a lower target, which would accrue over years. R.D. agreed after we discussed it, saying, "I'd rather not fall again."
Plan
Stop hydrochlorothiazide. This also removes a cause of the low sodium and may reduce nighttime urination. Continue lisinopril 20 mg, which protects the kidneys and causes less orthostatic drop than the thiazide.
Accept seated pressure up to 145/85 at home, with a standing systolic pressure above 110.
The daughter to record seated and standing readings each morning for two weeks, using the method shown in clinic.
Repeat sodium and potassium in two weeks.
Rise slowly, sit on the bed edge for a minute before standing at night; physical therapy to reinforce.
Left for Next Time
Diphenhydramine and oxybutynin, which add sedation and anticholinergic effects at night, will be addressed at the next visit in a deprescribing review; altering three drugs in a single visit would leave no way of knowing which alteration did what.
Omeprazole without a current indication, and aspirin for primary prevention at 81, are noted for later review.
Vision referral was made at the last visit; appointment pending.
Why Not Lower the Lisinopril Instead
Lowering lisinopril would also reduce the drop on standing, but lisinopril reduces albumin in the urine and slows kidney decline in diabetes, a benefit specific to R.D.'s conditions. Hydrochlorothiazide offers no such extra benefit, lowers sodium and adds to nighttime urination. Stopping it first keeps the medicine with the most to offer.
What R.D. Was Told
R.D. was told that the pressure would be allowed to run a little higher sitting down so that it would not fall so far on standing, that this was a deliberate choice and that the daughter's readings would show whether it was working. R.D. repeated the plan back correctly, and the daughter wrote it on the calendar.
How the Choice Will Be Judged
At the next visit, success means fewer mornings of lightheadedness, a standing systolic pressure above 110 on most readings, no falls and a seated average that has not risen above 145. Falls are often the result of several risks acting together (Tinetti & Kumar, 2010), so a fall would not by itself mean the choice was wrong, but it would prompt a fresh look at every contributor.
Follow-Up
Two weeks, or sooner if a fall, fainting or home seated pressure above 160 systolic.
References
Tinetti, M. E., & Kumar, C. (2010). The patient who falls: "It's always a trade-off." JAMA, 303(3), 258-266. https://doi.org/10.1001/jama.2009.2024
Tinetti, M. E., Han, L., Lee, D. S. H., McAvay, G. J., Peduzzi, P., Gross, C. P., Zhou, B., & Lin, H. (2014). Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Internal Medicine, 174(4), 588-595. https://doi.org/10.1001/jamainternmed.2013.14764
Williamson, J. D., Supiano, M. A., Applegate, W. B., Berlowitz, D. R., Campbell, R. C., Chertow, G. M., Fine, L. J., Haley, W. E., Hawfield, A. T., Ix, J. H., Kitzman, D. W., Kostis, J. B., Krousel-Wood, M. A., Launer, L. J., Oparil, S., Rodriguez, C. J., Roumie, C. L., Shorr, R. I., Sink, K. M., ... Pajewski, N. M. (2016). Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: A randomized clinical trial. JAMA, 315(24), 2673-2682. https://doi.org/10.1001/jama.2016.7050
NR 601 Week 3 instructions, in plain terms
The Week 3 note is short. What makes it graduate work is the assessment, where the conflict between conditions is stated plainly: the target that protects one organ is producing harm elsewhere. Pick one and say why. Give the interval history and what the patient actually takes, checked against bottles or the organizer. Include only the data the note uses. Give each problem a status. List what was left for next time. Most rubrics mark down a note that documents both conditions correctly and never admits they conflict, a note that addresses eight problems at one visit and a symptom recorded but never considered as a medicine effect.
How this NR 601 Week 3 example is built
The sample's interval history notes no falls but morning lightheadedness within an hour of the tablets. Medicines are checked by organizer slot. Data are limited to seated and standing pressures, home readings, electrolytes, kidney function, A1c and urine albumin. Five problems get a status. The collision paragraph explains that the lower target protects the kidneys but drops standing pressure, cites a trial that excluded patients like R.D. and a study linking treatment intensity to fall injuries, and records R.D.'s view. The plan stops the thiazide and keeps lisinopril. What R.D. was told, how the choice will be judged, what waits and follow-up close it.
Reading the NR 601 Week 3 grading rubric
The largest single loss is a note that documents both conditions and never admits they are fighting; this note names the collision in its own section. The everything note, addressing every problem at once, costs the next share, while this one defers three medicines to a later visit with a reason. A symptom recorded and never considered as a drug effect loses a row, and the lightheadedness is linked to the morning tablets. Choosing one target, with the patient's view recorded, earns the judgment criterion. Saying how the choice will be judged keeps the decision accountable. Explaining why lisinopril was kept shows the choice between medicines was reasoned. Recording what R.D. was told closes the loop.
NR 601 Week 3 help from the desk
Weak NR 601 Week 3 notes give each condition a tidy plan that contradicts the other. Others address every problem in one visit, which no clinic session allows. Many record dizziness without asking whether a medicine causes it. Long data sections often include results the note never uses. Few state what was left for next time. Name the conflict between your patient's conditions in one paragraph, choose one side with reasons and record what the patient thinks. Keep the note short and list what waits. If your patient differs, send the conditions and medicines, and a matching sample note can be drafted. Write how you will judge the choice at the next visit.
Get a NR 601 Week 3 example written to your instructions
Send the Week 3 case your classroom supplies along with the note format it expects, and a custom example is written to both and returned inside 24 to 48 hours, the first one free. If the case has a conflict buried in it, the example will name the conflict where a grader can find it.
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NR 601 Week 3 questions, answered
Is it acceptable to leave a problem unaddressed?
Yes, when the note says so on purpose. A visit has a length and a patient has an attention span, and a plan that changes six things at once cannot be evaluated when something goes wrong. What loses points is silence. Name the problem, say why it can wait safely, and give the visit at which it returns.
Should guideline targets always be applied?
Guidelines are written for populations and the note is written for one person. Where a target was developed in trials that enrolled few patients over eighty, saying so and adjusting is defensible clinical reasoning rather than a shortcut. What is not defensible is departing from a target silently, since the grader cannot tell a decision from an omission.
How much detail belongs in the objective section?
Only what the assessment will use. A full head to toe examination pasted into a chronic care visit signals that the writer has not decided what the visit was about. Include the systems the problems live in, the vitals the plan depends on, and any finding that would change the decision if it moved in either direction.
Where can I find a free NR 601 Week 3 sample paper?
The full chronic care note choosing between a kidney-protecting blood pressure target and fall risk for R.D. is on this page.
Why stop hydrochlorothiazide rather than lisinopril in the NR 601 Week 3 note?
Lisinopril reduces urine albumin and protects the kidneys in diabetes, while the thiazide adds no such benefit, lowers sodium and adds to nighttime urination.