Case Studies (total 3) (15 % of course grade) This assignment assess intended course outcome(s) #1 Conduct a comprehensive history and physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment on patients across the life span and health-illness continuum. #2 Identify abnormal physical findings and correlate to possible underlying pathological processes to determine interventions that include nursing, pharmacology, medical management, and alternative/complementary therapies. #3 Demonstrate appropriate communication and collaboration skills between the inter- and intra-professional team to promote patient-centered care. #4 Use information found in patients health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patients individual health promotion and disease prevention needs. The case studies are intended to test the students knowledge in applying assessment skills in detecting normal age related variations and pathological presentations. Students will complete three case studies in the Shadow Health program that will test their knowledge on systems and age related findings. You will be expected to conduct a focused history and physical exam; afterwards, you will then enter your documentation in the self-reflection area. Once you submit your attempt you will be taken to the Experience Overview page that will give you your score for the assignment. The grade for the case study will be based on the initial SPI score. Once you complete the case study, please download the lab pass from Shadow Health and submit the lab pass to the appropriate assignment folder in the LEO classroom. These case studies are considered quizzes, therefore only the grade from the first attempt will be used as the grade for the assignment. Students are encouraged to complete the weekly practice modules before attempting the case studies. Written assignments: Assignment #1: Comprehensive Health History with Genogram and Physical Exam with Write-up (30% of course grade) This assignment assess intended course outcome(s) #1 Conduct a comprehensive history and physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment on patients across the life span and health-illness continuum. #3 Demonstrate appropriate communication and collaboration skills between the inter- and intra-professional team to promote patient-centered care. In the Shadow Health lab, students will need to complete a comprehensive history and physical exam on Tina, the virtual patient, in the module titled: Comprehensive Assessment. The health history should incorporate the following: – Biographical Data including allergies – Reason for seeking care – History of Current Illness – Past Medical History – Family History (including Genogram) – Social History/ Functional assessment – Review of Systems Genograms can be created on a word document using shapes under the insert tab, or they can be drawn by hand, scanned and uploaded. Genograms must look professional and neat. If the genogram is turned in and is not legible or professional, the assignment will receive a grade of zero (0) points towards that part of the grade. The genogram is to be included as part of the comprehensive health history. After you have obtained the history, you will then need to complete a physical exam on the Tina the virtual patient. Your exam needs to be comprehensive and include each of the body systems Students will have up to three attempts to obtain a minimum SPI score of 70 on the history and physical exam on the virtual patient in order to pass the Shadow Health part of the assignment. If students do not achieve a minimum SPI score of 70, after three attempts, the student will receive a grade of zero (0) on the Shadow Health part of the assignment. In addition to the findings from the history and physical exam, your write up also needs to include a problem list and an SBAR communication. The problem list should be complete and include all pertinent health concerns that need consideration or intervention. Finally, the findings from comprehensive history, physical exam and problem list should be summarized into an SBAR communication report. The SBAR Communication Report should follow the following format: SBAR Communication Report Situation (one sentence description of need) Background (details that give an assessment) Assessment (your position on the issue) Recommendation (your specific method for solving the problem) After you have completed your write-up of the history,(including genogram), physical exam, problem list and SBAR report, you will need to submit this, along with your Shadow Health Lab Pass, to the Comprehensive Health History and Physical Exam with Write-up section in LEO. When you submit your paper, please use a cover sheet and document your findings in the appropriate format using appropriate terminology. For an example of the proper format of writing your assessment findings, please refer back to the module in Week 1 titled: Communication of Assessment Findings: Preparing the Narrative, as well as the module titled: Communicating the Assessment Findings: SBAR format Please submit your Shadow Health Lab-Pass along with the write up to the Comprehensive Health History with Genogram and physical Exam with Write-Up assignment folder in the LEO classroom. The worksheet for the Comprehensive Health History can be found in week one of the activities section of the LEO classroom. This worksheet contains the information that you will need to obtain for this assignment. Please use this worksheet as a guide throughout the course to help you in obtaining the information you will need in writing your paper as well as writing the SBAR report. Your write up will be evaluated based on the following criteria: Criteria Level 3 Level 2 Level 1 Shadow Health SPI score (15%) 86-100% 71- 85% 70% Biographical Data (3%) Includes age, race and gender. Missing one data item Missing 2 or more data items Chief Complaint (3 %) Clearly states reason for the patient seeking care, including source of history States the reason for patient seeking care, does not include source of history Does not state, or is unclear as to why patient is seeking care, does not include source of history History of current illness (10%) Includes all 8 characteristics in describing the patients chief complaint Missing few of the characteristics of the chief complaint Missing most of the characteristics of the chief complaint Past Medical History (10%) Includes information regarding past medical and history including major childhood and adult diseases, injuries, surgeries, allergies transfusions, medications, alcohol, tobacco and drug use Missing some information regarding medical and social history Missing many parts of the past medical and social history Family History and Genogram (12%) Includes three generations of family members, clearly states relationships and major illnesses, includes ages and names, using appropriate symbols, identifies health risk factors across all generations and all known causes of death Incomplete family structure, less than three generations of family, some errors in demonstrating relationships using appropriate symbols. Some information regarding ages and names of family members are missing, Identifies medical diagnosis of a few family members, does not state causes of death Less than three generations, relationships are unclear, Missing most of the information regarding family member names or ages. Does not state medical diagnosis of family members, does not state causes of death Review of Systems (5%) Completely covers all systems. Identifies co-existing problems, describes positive reactions clearly Missing few systems Missing many systems Social and Functional assessment (5%) Fully assess ability to perform activities of daily living or environmental concerns. Includes information regarding finances, occupation, religion, hobbies, sleep, exercise and diet. Missing information regarding patients ability to perform activities of daily living or environmental concerns Little to no information regarding patients ability to perform activities of daily living, does not address environmental concerns Physical Examination (20%) Complete documentation of each body system examined. Findings are clearly described Some parts of the exam performed are missing, few errors in describing findings Many parts of the exam performed are missing, frequent errors in describing findings Problem List (4%) Lists all pertinent health concerns. Provides a clear picture of the patients health problems that require consideration or intervention Mostly based on history and physical exam findings Little/vague connection to patient history or physical exam findings SBAR communication (10%) Completely documents: situation, background, assessment and recommendations Situation, background, assessment or recommendations are not clearly described. Incomplete documentation, unclear regarding situation, assessment recommendation and/or recommendation Organization, spelling and grammar, terminology (3%) Organized, easy to read, no spelling or grammar mistakes, uses appropriate terminology Organized and easy to read, few spelling or grammar mistakes, few errors in terminology Disorganized, difficult to read, many spelling and grammar errors mistakes. Does not use appropriate terminology Total Points (63-100) Points ( 25-62) Points (0-24) Health Promotion Paper (25% of course grade) This assignment assesses intended course outcome(s) #4 Use information found in Tina’s health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patients individual health promotion and disease prevention needs Students will use the information found in Tina’s history, genogram, and assessment to formulate an individualized health promotion and disease prevention plan of care. Recommendations should be evidence-based and from credible sources. The plan for addressing the health promotion and disease prevention needs for Tina should include: Demographics: Age, gender and race of the patient Education level Health literacy Access to health care Insurance/Financial status Is the patient able to afford medications and health diet, and other out-of-pocket expenses? Screening/Risk Assessment Identified health concerns based on screening assessments and demographic information Nutrition/Activity What is the patients activity level, is the environment where the patient lives safe for activity Nutrition recommendations based on age, race gender and pre-existing medical conditions Activity recommendations Social Support Support systems, family members, community resources Health Maintenance Recommended health screening based on age, race, gender and pre-existing medical conditions Patient Education: Identified knowledge deficit areas/patient education needs (medication teaching etc). Self-care needs/ Activities of daily living * The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references). Your paper will be evaluated based on the following criteria: Criteria Level 3 Level 2 Level 1 Demographics (5%) Includes age, race and gender of patient Missing one data item Missing 2 or more data items Insurance/Financial status (10%) Includes information regarding patients insurance status and ability to afford medications and other out-of-pocket expenses Missing some information regarding insurance status and ability to pay for medications and other out-of-pocket expenses. Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses Screening /risk assessment (10%) Identifies health concerns based on screening assessments and demographic information. Missing some information regarding health concerns, by excluding information from screening assessments and demographics Health concerns are not identified due to information missing from screening assessments and demographics Nutrition/activity (20%) Completely asses patients nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions Most of the information regarding the patients nutrition and activity levels are missing, recommendations are missing or not based on the patients age, race, gender and pre-existing medical conditions Social support (10%) Identifies support systems such as family members and community resources Missing some information regarding support systems such as family members and/or community resources Little to no information regarding social support Health Maintenance (20%) Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions Patient Education (20%) Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living Lacks identification of knowledge deficit areas/patient education needs. Does not consider self-care needs or activities of daily living. Organization, spelling and grammar, APA (5%) Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA Organized and easy to read, few spelling or grammar mistakes, few errors in APA Disorganized, difficult to read, many spelling and grammar errors mistakes. Does not use APA Overall score Points (60-100) Points ( 24-59) Points ( 0-23)
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