Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Trinity Valley Community College Associate Degree Nursing Program Level I – Well-Elderly Case Study Rubric Student Name: ____________________________________Date: ___________ Total Points: ______/ 26 Name of Facility: Initials of Patient: Area Complete 2 pts Partial 1 pts Section 1. Assessment (Clinical Judgment) 1a. Assessment Fills in blanks with Fills in blanks with Subjective Data appropriate data appropriate data [≤ 4 inappropriate or [5-8 inappropriate missing] or missing] total 4 pts total 2 pts 1b. Assessment Fills in blanks with Fills in blanks with Objective Data appropriate data appropriate data Except ≤ 4 except 5-8 inappropriate or inappropriate or missing missing total 4 pts total 2 pts 1c. Assessment Highlights Highlights Abnormal Data abnormal data abnormal data except ≤ 4 instances except 5-8 instances of highlighting of highlighting normal data or not normal data or not highlighting highlighting abnormal data abnormal data Insufficient 0 pts total 4 pts Section 2. Nursing Dx (Clinical Judgment) 2a. Nursing Dx 3 Nursing Diagnoses Formulate Three each with nursing (Clinical problem and its Judgment) supportive data AND etiology total 2 pts Fills in blanks with appropriate data [>8 inappropriate or missing] total 0 pts Fills in blanks with appropriate data except >8 inappropriate or missing total 0 pts 1 Highlights abnormal data except >8 instances of highlighting normal data or not highlighting abnormal data total 0 pts 3 Nursing Diagnoses Each with nursing problem and its supportive data AND etiology except missing 1 nursing problem and supportive data AND/OR etiology 3 Nursing Diagnoses Each with nursing problem and its supportive data AND etiology except missing >1 nursing problem and supportive data AND/OR etiology total 4 pts 2b. Nursing Dx 3 Nur Dx’s Labeled & Prioritize Prioritized by (Pt Centered Care) Maslow’s Hierarchy total 2 pts 2 Nur Dx’s Labeled & Prioritized by Maslow’s Hierarchy total 0 pts <2 Nur Dx’s Labeled & Prioritized by Maslow’s Hierarchy Total 1 pt Total 0 pts Total 2 pts Weight Points [weight X2] Total Possible: 4 Earned: [weight X2] Total Possible: 4 Earned: [weight X2] Total Possible: 4 Earned: [weight X2] Total Possible: 4 Earned: [weight X1] Total Possible: 2 Earned: 1 Area Complete 2 pts Section 3. Environment (Safety) Environment List of identified (Safety) hazards AND corresponding recommendations. If environment is hazard-free, then writes one paragraph describing the environment Total 2 pts Section 4. Nutrition (Critical Thinking) Nutrition Lists two or more (Critical nutrition Thinking) recommendations. Partial 1 pts Insufficient 0 pts List of identified hazards AND corresponding recommendations, except missing 1 hazard/recommend ation OR 1 inappropriate recommendation. OR If environment is hazard free and environmental descriptive paragraph is two to four sentences. List of identified hazards AND corresponding recommendations Missing ≥2 hazard AND/OR incorrect recommendation OR if environment is hazard-free and descriptive paragraph is less than two sentences. Total 1 pt Total 0 pts Lists one nutrition recommendation Missing nutrition recommendations Total 2 pts Total 1 pt Section 5. Team work & Collaboration (Critical Thinking) Team work & Identifies 5 or more Identifies 3 or 4 Collaboration resources already resources already (Critical available that is used available that is used Thinking) or not used by the or not used by the client. client. Total 0 pts Total 2 pts Section 6. APA References APA References All references alphabetized with APA format:Author, year, title, and journal. Total 1 pt Total 0 pts All references alphabetized with APA format except one or two kinds of errors made of author, year, title, journal. All references unalphabetized and/or with APA format except three or more kinds of errors made of author, year, title, journal. Total 1 pt Total 0 pts Total 2 pts Identifies 2 or fewer resources already available that is used or not used by the client or omits paragraph. Weight Points [weight X1] Total Possible: 2 Earned: [weight X1] Total Possible: 2 Earned: [weight X1] Total Possible: 2 Earned: [weight X1] Total Possible: 2 Earned: 2 Trinity Valley Community College Associate Degree Nursing Program Level I – Well-Elderly Case Study Section 1. Assessment Section 1a. Subjective Data Demographics: Healthcare Concept – Diversity Age: _____ Gender: _____ Race: _____________ Hispanic/Latino Ethnicity: Yes No Unknown Ethnicity: _______________ Religion: ______________Do your spiritual beliefs apply to your health? Affects treatment decisions End-of-life care Special dietary needs Use of Faith/Folk healer Other: __________________________________________________________________________ Education completed: _______________________________________________________________ Social Support Assessment: Healthcare Concept - Coping Emotional support available: Yes No Support System (Especially when there are problems) Case worker Children Family Friend Guardian Pet Religious leader Sibling Spouse Support group Therapist Other: ___________________________ Health History: Medical History: _____________________________________________________________________ Surgical History: _____________________________________________________________________ Accidents or Injuries: _________________________________________________________________ How do you define health? _____________________________________________________________ View of own health now:_______________________________________________________________ What are your concerns? _______________________________________________________________ What are your health goals? _____________________________________________________________ Allergies: Healthcare Concept - Immunity Comments: ____________________________________________________________ Communicable Diseases: _______________________________________________________________ Childhood Illnesses: ___________________________________________________________________ 3 Immunizations: Shingles vaccine / Date received: ______ Pneumococcal vaccine / Date received: ______ Influenza (flu) vaccine /Date received: ______ Tetanus, diphtheria, pertussis (Tdap) vaccine / Date received: _________ Current Medications: Medication Name Medication Reason Dosage Frequency *Able to verbalize all home medications: Accurately Inaccurately *Manages medication administration: Independently Effectively with assistance Family History Assessment Heart Disease High Blood Pressure Stroke Diabetes Blood Disorders Cancer Sickle Cell Anemia Arthritis Obesity Kidney Disease Tuberculosis Mental Illness Seizures Alcohol/Drug Abuse Self Mother Father Grandparents Siblings 4 Nutritional Screen: Healthcare Concept – Nutrition Usual Weight: ___________ Appetite: Good Fair Poor Other: _________________ Unintentional weight change greater than 10 lbs. in the last 6 months: Yes No Weight gain: Yes __________ No Weight loss: Yes _________ No Diet: NPO Regular Bland Diabetic Dysphagia Ground Kosher Low cholesterol Low fat Low sodium Mechanical soft No added salt Pureed Renal Vegetarian Eating difficulties: Chewing Loose teeth No teeth Swallowing Dentures (poor fitting) If eating difficulties present, describe the problem: ______________________________________________ _______________________________________________________________________________________ Nutritional Risk Factors Constipation Eating Disorder Enteral Feedings Impaired Nutritional Intake Fluid intake < 50% of normal in last three days Nausea/Vomiting/Diarrhea History of Skin Breakdown/Decubitus Ulcers Time Yes If yes, ask and describe history of problem Food Intake History (24-Hour recall) List foods consumed Method of Preparation Serving Breakfast Lunch Afternoon snack Dinner HS snack 5 Functional Assessment: Healthcare Concept – Functional Ability Functional Assessment Bathing Dressing Toileting Transferring Continence Feeding ADL Index Score Independent (2) Requires assistance (1) Dependent (0) Comment Total 12 = Total independence 6 = Moderate independence 0 = Maximum dependence Instrumental Activities of Daily Living (IADL): (The first answer in each case indicates independence, the second capability with assistance, the third; dependence The maximum score is 21. Declining scores over time reveal deterioration) Ability to use telephone: (3) Operates telephone on own initiative; looks up and dials numbers, etc. () Dials a few well known numbers (1) Answers telephone but does not dial (0) Does not use telephone at all Shopping: (3) Takes care of all shopping needs independently (2) Shops independently for small purchases (1) Needs to be accompanied on any shopping trip (0) Completely unable to shop Food preparation: (3) Plans, prepares and serves adequate meals independently (2) Prepares adequate meals if supplied with ingredients (1) Heats and serves prepared meals or prepares meals but does not maintain adequate diet (0) Needs to have meals prepared and served Housekeeping: (3) Maintains house alone or with occasional assistance (2) Performs light daily tasks but cannot maintain acceptable levels of cleanliness (1) Needs help with all home maintenance tasks (0) Does not participate in any housekeeping tasks Laundry: (2) Does personal laundry completely (1) Launders small items; rinses socks; stockings; etc. (0) All laundry must be done by others Mode of Transportation: (3) Travels independently or drives on vehicle (2) Arranges own travel via taxi, but does not otherwise use public transportation (1) Travel limited to Taxi or car, with assistance of another (0) Does not travel at all Responsibility for own medication: (2) Is responsible for taking medication in correct dosages at correct time (1) Takes responsibility if medication is prepared in advance in separate dosages (0) Is not capable of dispensing own medication Ability to handle finances: (2) Manages financial matters independently; collects and keeps track of income (1) Manages day-to-day purchases, but needs help with banking, major purchases, etc. (0) Incapable of handling money IADL Total: __________ 6 Sleep Assessment: Healthcare Concept – Sleep Average hours of sleep______ Usual bedtime: _______ Usual awake time: _______ Do you feel rested after you sleep? Yes No Quality of sleep: Poor Fair Good Poor Sleep problems: Difficulty falling asleep Difficulty remaining asleep Night awakenings Nightmares Pain Assessment: Healthcare Concept - Comfort Pain History: Location: Where is your pain? ____________________________________________________________________ Quality: Tell me what your discomfort feels like______________________________________________________ Intensity: On a scale of 0-10 with “0” representing no pain and “10” representing the worst possible pain, how would you rate your pain? ________________________________________________________________________ Pattern: When did or does the pain start? ____________________________________________________________ How long have you had the pain, or how long does it last? _____________________________________________ Do you have pain free periods? When? And for how long? _____________________________________________ _____________________________________________________________________________________________ Precipitating factors: What triggers the pain or makes it worse? __________________________________________ Alleviating factors: What measures or methods have you found helpful in lessening or relieving the pain? _____________________________________________________________________________________________ Effect of pain on: Daily life Sleep Appetite Relationships Emotions Concentration None Very mild Mild Moderate Severe Very Severe 7 Section 1b. Objective Data Height: ________ Weight: ________ Ideal body weight (range): _______________________________ Vital signs: T: _____ P: _____ R: _____ B/P:___________ which arm? ______________________ Sitting: ___________________________________ Standing: ________________________________ General Appearance of the Client Grooming Appearance: Well Fair Poor Disheveled Hygiene Appearance: Posture Appearance: Normal Relaxed Stiff Slumped Speech: Clear Disorganized Dysarthria Expressive aphasia Loud Monotone Rapid Slow Soft Affect: Anxious Depressed Elated Happy Irritable Labile Sad Other: ______________________ Skin & Extremities Assessment - Healthcare Concept - Tissue Integrity Skin Color: Normal for ethnicity Ashen Cyanotic Flushed Jaundice Pale Mottled Other Variations in skin color: Birthmarks Calluses Freckles Moles Stria Other If any variations present, document location: ______________________________________________________ Skin Temperature: Warm Cold Cool Hot Other Skin Turgor: Elastic Tenting Other: ________________________________________________________ Nail Description: Groomed Bruised Clubbed Dirty Yellow Ridged Smooth Thick Thin Brittle Ingrown Inflamed Hair Description: Absent on extremities Absent on head Alopecia Coarse Brittle Dry Fine Oily Shiny Soft Musculoskeletal Assessment: Health Care Concept - Mobility Gait: Steady Asymmetrical Dragging High stepping Jerky Shuffling Spastic Staggering Stiff Unsteady Wide based Unable to assess Other_________________________________________________ Evaluation of bilateral muscle strength LLE LUE RUE RLE Evaluate hand grip strength Strength Muscle Tone Sensation Range of Motion (ROM) Patient follows instructions to release the hand when assessing grip strength: Yes No * ROM – Document Full motion active or passive, limited motion active or passive, pain with movement, unable to move) 8 Asymmetrical Muscle tenderness? If yes, document location and severity: Mild Moderate Severe Joint tenderness? If yes, document location and severity: Spinal Assessment: Activity limitations? Mini Mental Status Exam: Healthcare Concept – Cognition 5.) How old are y 9.) What does it mean to say, “A rolling stone doesn’t grow moss?” 10.) Subtract 3 Mental Status Exam Mini Score = _______________ (0-2 errors = intact, 3-4 errors = mild intellectual impairment, 5-7 errors = moderate, 8-10 errors = severe) *Allow 1 more error if client has no grade school education *Allow 1 fewer error if client has had education beyond High school Sensory Function Assessment: Health Care Concept - Sensory Perception Perform Fingertip-to-nose Touch Test on patient (Estes; p. 752; 1-3 only): Abnormal Comment: 9 Fall Risk Assessment: - Healthcare Concept – Safety Morse Fall Risk Assessment Yes No Response points History of Falling immediate or in the last three months Yes response = 25 Presence of secondary diagnosis Yes response = 15 Use of ambulatory aid Furniture =30 Crutches, cane, walker = 15 IV/Heparin lock Gait/Transferring Mental Status Points Yes response =20 Impaired = 20 Weak =10 Forgets limitations = 15 Total Score: 0-44 indicates need for standard environmental safety precautions. A score of 45 or > will add a problem “At Risk for Falls” to the problem list. Please initiate the Fall Prevention Plan of Care. Total Assessment of Home Environment for Safety Hazards: Healthcare Concept – Safety If yes; describe: Is furniture Is the Healthcare Concept - Human Development Erikson’s Stage: Give one example of how the patient is meeting the above identified developmental stage: 10 Section 1c. (For sections 1a. and 1b. highlight, with a colored highlighter, each of the abnormal values for the subjective and objective data.) Section 2. Nursing Diagnoses Section 2a. Formulate Three Nursing Diagnoses (RN Dx = P r/t E) 1.) Group the abnormal highlighted data in your assessment to support one problem (P) in the Health and Illness Concepts Problem Table (see table 1-1). That one problem will be used as the “P” in one of the nursing diagnoses.) Healthcare Concept P = Problem (for nursing diagnosis) Diversity Communication: Verbal, Impaired Coping: Family, Compromised Decisional Conflict Human Dignity, Risk for compromised Spiritual Distress (Risk for) Ineffective/Maladaptive Coping Compromised Family Coping Readiness for Enhanced Coping Ineffective Community Coping Ineffective protection Impaired skin integrity Risk for infection Risk for allergy response Knowledge deficit: Immune response Bowel incontinence Constipation Perceived constipation Risk for constipation Diarrhea Dysfunctional gastrointestinal motility Risk for dysfunctional gastrointestinal motility Urinary incontinence Functional urinary incontinence Overflow urinary incontinence Reflex urinary incontinence Stress Urinary incontinence Urge urinary incontinence Risk for urge urinary incontinence Toileting, self-care deficit Impaired urinary elimination Readiness for enhanced urinary elimination Urinary retention Self-care deficit(s) Impaired mobility Impaired wheelchair mobility Coping Immunity Nutrition Functional Ability 11 Sleep Comfort Tissue Integrity Mobility Cognition Sensory Perception Safety Human Development Sleep Pattern Disturbance Sleep Deprivation Readiness for Enhanced Sleep Insomnia Acute pain Chronic pain Impaired comfort Readiness for enhanced comfort Impaired skin/tissue integrity Alteration in comfort, pain Risk for injury Risk for falls Decreased mobility Knowledge Deficit: personal safety or health maintenance or treatment regimen Acute confusion Impaired Verbal Communication Risk for Injury Impaired Social Interaction Sensory Perception Disturbance (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Altered role performance (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Social Isolation (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Body Image disturbance (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Impaired Communication (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Risk for injury Risk for falls Knowledge Deficit: personal safety or health maintenance or treatment regimen Acute confusion Impaired ADL’s Impaired physical mobility Acute confusion Chronic confusion Delayed growth and development Table 1-1 Health and Illness Concepts Problem Table 2.) Next, add the etiology to complete the nursing diagnosis. Section 2b. Prioritize The Three Nursing Diagnoses 3.) Use Maslow’s Hierarchy of Needs Theory to identify which level the nursing diagnosis falls in. 12 4.) Prioritize the Nursing diagnosis as First (most important), second, and third according to Maslow. Do the above steps, one through four, for each nursing diagnosis. You will have a total of three nursing diagnoses. Example: The abnormal data: “I have a hard time moving around due to I have arthritis in both hips” The concept: Healthcare concept – Mobility The Nursing Diagnosis: Decreased mobility r/t joint pain The identification according to Maslow’s Hierarchy: Physiological The prioritization of the Nursing diagnosis: First Section 3. Environment Provide recommendations for all identified safety, environmental and/or hazardous problems from the “Assessment of Home Environment for Safety Hazards” in this case study form. Complete one paragraph describing all hazards identified; if no hazards identified, then writes one summary paragraph. Section 4. Nutrition Critical Thinking Exercise: Analyze the “Food Intake History” that is in this case study form, and make recommendations for healthy food choices. Section 5. Team Work and Collaboration Critical Thinking Exercise: Because of the increasing number of older adults, identify 5 resources already available that are needed in your community in order to assist with this growing population. Section 6. APA Style References For examples and explanations visit the following link: http://owl.english.purdue.edu/owl/resource/560/01/ 13