Module 07 Content

1. You will perform a history of a neurologic problem that your instructor has provided you or one that you have experienced and perform an assessment of the neurologic system. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

  

Title:

Documentation of problem based assessment of the neurological system.

Purpose of Assignment: 

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

Course Competency:

Apply assessment techniques for the neurological and respiratory systems.

Instructions:

Content: Use of three sections: 

o Subjective

o Objective

o 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

      

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.

      

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 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.

   

 

Module 07 Discussion – New Admit

Discussion Topic

Activity Time:

2 hours; Additional Time for Study, Research, and Reflection: 1 hour

Scenario

As a nurse on a general medical floor, the RN has received a new admit. Review the client data provided.

• Richard Henderson
• 58 years old
• Male
• Admit diagnosis: GI bleed
• History: no surgical history
• Medical history: Gastritis & GERD
• Medications: Prilosec 40 mg PO daily, Atenolol 25 mg PO BID, Fiber daily, Alka Seltzer PO – states he takes this at least daily.

Report from physician’s office: Mr. Henderson arrived to the physician’s office today for a complaint of increasing abdominal pain. He states that he is now throwing up coffee-ground emesis. He states that he didn’t take his BP medication this morning because he was dizzy. The physician is admitting him with a diagnosis of GI bleed with an EGD scheduled for tomorrow. He is NPO, and has a 22G IV lock in the left forearm. Last set of vital signs BP 106/60 mm Hg, HR 98 beats/min, RR 20 breaths/min, Temp. 98.8 degrees F, P.O. 90% on room air. He last vomited about 45 minutes ago with a small amount of dark coffee-ground emesis. His pain is 4/10 at present. No pain medication is ordered at this time.

• Lab assessments ordered: CBC and chemistry panel
• CT of the abdomen shows no signs of free air (no perforation)

When he arrives to the floor, he is pale, nauseous, and his skin is cool and clammy. When he is transferred to the bed from the stretcher, he vomits a large amount of coffee-ground emesis and loses consciousness.

Instructions

In the discussion post, address the following:

1. While receiving report, what concerns do you have regarding the client report?
2. What type of shock is occurring?
3. What stage of shock is the client experiencing?
4. What is your next intervention and why?
5. What additional lab assessments would you anticipate?
6. Provide additional thoughts and insights.

In the initial posting provide one additional resource other than the required reading

Nurses often become motivated to change aspects within the larger health care system based on their real-world experience. As such, many nurses take on an advocacy role to influence a change in regulations, policies, and laws that govern the larger health care system.

For this assignment, identify a problem or concern in your state, community, or organization that has the capacity for advocacy through legislation. Research the issue and use the “Advocacy Through Legislation” template to complete this assignment.

You are required to cite to a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice. 

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. 

  Describe one internal and one external method for the dissemination of your evidence-based change proposal. For example, an internal method may be the hospital board, and an external method may be a professional nursing organization. Discuss why it is important to report your change proposal to both of these groups. How will your communication strategies change for each group? 

Changing My Diet     For the life of me, I couldn’t figure out why I had been feeling so tired and irritable lately. I have a hectic schedule with school and work, but I have always been a healthy guy. I don’t smoke, drink alcohol, or do drugs. And I’m not overweight. So when I fell asleep during a test last month, I decided it was time to take action. I made an appointment to see my doctor the same day.     After running several tests to rule out some medical conditions, we talked about my diet. That’s when I had to admit that I ate out almost every day. When I told my doctor about the kinds of foods I ate every day, such as Bavarian cream and jelly doughnuts for breakfast, triple cheeseburgers and chili fries for lunch, and supreme pizzas and cola for dinner, she explained that my diet was the problem.     I really wasn’t so “healthy” after all. Nearly everything I ate had extremely high levels of sugar, fat, calories, cholesterol, salt, and caffeine. I was hardly getting the nutrients my body needed to function properly.     During the visit, my doctor told me about healthier food choices that included good sources of protein, folic acid, and vitamins A and C. She even shared a few of her favorite quick and wholesome recipes. She also suggested that I exercise for at least 20 minutes every day and follow up with a nutritionist.     After a few weeks of playing basketball at the gym and making healthier eating choices, I feel like myself again. I have lots more energy. During class, I remain focused. I’m not so moody or cranky either. You know, changing my diet was one of the best choices I could have ever made!

1. Anthony thought he was healthy because he didn’t smoke, drink alcohol, do drugs, or carry too much weight. What does being healthy mean to you?
2. Monitoring your portion size, or the amount of a food that you eat at one time, is just as important as choosing the right kinds of foods. Why is this true?
3. Anthony chose basketball as his form of exercise. Do you need to join a gym to get enough exercise? What kinds of exercise can you participate in? Explain.