Title:

Documentation of problem based assessment of the cardiac system.

 

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of cardiac system. Identify abnormal findings.

 

Course Competency:

Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.

 

Instructions:

 

Content: Use of three sections:

· Subjective

· Objective

· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

 

Format:

· Standard American English (correct grammar, punctuation, etc.)

 

Resources:

Chapter 5: SOAP Notes: The subjective and objective portion only

Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book].

 

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30.

 

Documentation Grading Rubric- 10 possible points

Levels of Achievement
Criteria	Emerging	Competence	Proficiency	Mastery
Subjective (4 Pts)	Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.	Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
	Points: 1	Points: 2	Points: 3	Points: 4
Objective (4 Pts)	Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”.	Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings.	Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information	Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information
	Points: 1	Points: 2	Points: 3	Points: 4
Actual or Potential Risk Factors (2 pts)	Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion.	Brief description of one or two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.	Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.	Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
	Points: 0.5	Points: 1	Points: 1.5	Points: 2

lobal Public Health Nursing: Population Health Around the Globe

Community health nurses work with populations that vary from country to country, and to serve them appropriately requires an understanding of the ways in which the context in which they are located interacts with their health status and health histories. Student nurses are spending a month in Africa reviewing global health and international community health nursing.

1. The student nurses are required to examine the population in Africa to assess the kinds of health conditions the population experiences. What is the context and framework for delivering community-based nursing within the context of international community health nursing?
2. The student nurses are examining the population to assess the kinds of health conditions the African population experience. The international community health nurses suggest using the three eras and the three P’s as helpful guides in this assessment. What are the three eras and the three P’s that the student nurses need to consider?
3. What major international, national, regional, and local organizational structures and organizations affect the ways in which community health nursing is practiced?

NUR2488 Module 07 Borderline Personality Disorder Case Study

 

 

S.is a 48-year-old divorced woman with one adult daughter and three grandchildren. She is currently working as an LPN part-time in a nursing home and works at a convenience store one or two days per week. She has had many jobs over the last 22 years, usually changing every one or two years to a new job. S notes that she has been called less often to work in the convenience store and worries that they don’t like her anymore. She reports being written up several times for arguing with customers. She also reports that she liked her supervisor at; first; she says, “Now I hate her; she’s trying to get me fired.” S. reports that she has tried to get full-time jobs five times in the last four years was hired for three but only lasted one or two weeks at each one.

 

S. reports that she is currently not talking to her daughter because “she is mean to me and she needs to apologize, or I won’t talk to her again.” She is upset that she hasn’t seen her three small grandchildren in about a year. She sends them presents and cards frequently that say “I still love you! Grandma” but hasn’t called them since she stopped talking to her daughter. She is considering reporting to the county that her daughter is keeping her grandchildren from her.

 

S. is very unhappy that she isn’t in a relationship. She was abused by her ex-husband and had a pattern of meeting and dating men who eventually abused her. She states that her last relationship was very good; the man was not abusive, and “I loved him very much.” The relationship ended for reasons that S. doesn’t understand. However, she does report many arguments that ended in “scenes,” such as her throwing chairs, stomping out of the house, making crank phone calls to his family, and calling the police with false reports. But S. also reports that she “couldn’t have loved him more, and I showed it.” She gives examples of going to her boyfriend’s place of work with flowers, buying him expensive presents, surprising him with tickets to Mexico at the last minute – she was very upset that he wasn’t willing to drop everything and go with her. S. reports asking him why he didn’t love her and what she was doing wrong regularly. When the boyfriend asked to break up, S. reported sitting outside his house for weeks, crying; she called his mother, called his boss, and called and texted him until he filed a restraining order. This occurred about four months ago.

 

S. admitted herself to the mental health unit when she felt suicidal. She reports that she had stopped her psychotherapy three months ago and stopped going to DBT. She also stopped her anti-depressant at that time, as she felt it wasn’t working, and missed her last two psychiatrist appointments.

Q1:This is from Chapter 13/Critical Thinking:

Gary suffers from alcoholism and pays no attention to his diet. In addition to the detrimental effects on the liver, excess alcohol consumption can cause deficiencies in certain B vitamins.

Explain why this problem can occur.  Do you have any suggestions how Gary could improve his health?

Q2:

After reading the chapter on trace minerals and the Academy of Nutrition and Dietetics’ Position on Vegetarian Diets, which nutrients do you think vegans might lack in their diets and what recommendations would you make to compensate for these deficiencies? Do you feel that being a vegan is a healthy lifestyle choice? Why or why not? Remember that vegans eat only plant based foods, no animal and dairy

Do you consider yourself or have you thought about becoming a pescatarian, lacto-ovo vegetarian, pollotarian, flexitarian, or vegan? Why of why not?  (if you don’t know the meanings, google the