NURS 6512 Week 7 I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM

NURS 6512 Week 7 I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM
i-Human Case Week #7
56 y/o
5′ 5″ (165 cm)
188.0 lb (85.5 kg)
Reason for encounter

Blood pressure recheck

Location
Outpatient clinic with laboratory capabilities

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Key Findings
Prior elevated blood pressure reading without diagnosis of HTN
Asymptomatic
High-fat, high-salt diet
Physical inactivity
PMH of hypothyroidism
Family history of heart disease
Denies polyuria, polydipsia, polyphagia
Vital signs within normal limits
Obese BMI
Xanthoma, arcus senilis
Remaining physical exam unremarkable
Medications/Allergies
Additional social history
ROS: Inquiry into constitutional symptoms
ROS: Inquiry into endocrine symptoms
ROS: Inquiry into gastrointestinal symptoms
ROS: Inquiry into respiratory symptoms
Communication: Elicit the patient’s perspective

 

Case: Problem Statement
This patient is a 56-year-old obese female with a PMH of hypothyroidism who presents for a blood pressure recheck after attending a workplace health fair 3 weeks ago (BP reading was 132/74). She is asymptomatic and reports consuming a high-fat, high-salt diet, physical inactivity, and a family history of heart disease. She denies polydipsia, polyuria polyphagia, chest pain, and shortness of breath. Physical exam shows stable vital signs with BP 118/72, bilateral eye xanthoma, and arcus senilis. The remaining physical exam is unremarkable

 

Rubric

NURS_6512_Week 7_Assignment_Rubric
NURS_6512_Week 7_Assignment_Rubric
Criteria Ratings Pts

History: Complete an appropriate health history. (Scores are automatically calculated in the i-Human platform.)

20 pts

Excellent
Achieves a score of 85–100%

15 pts

Good
Achieves a score of 84–75%

10 pts

Fair
Achieves a score of 74–65%

5 pts

Poor
Achieves a score of 64–55%

0 pts

Unsatisfactory
Achieves a score of 54% or below
20 pts

Physical Exam: Complete an appropriate physical exam. (Scores are automatically calculated in the i-Human platform.)

20 pts

Excellent
Achieves a score of 85–100%

15 pts

Good
Achieves a score of 84–75%

10 pts

Fair
Achieves a score of 74–65%

5 pts

Poor
Achieves a score of 64–55%

0 pts

Unsatisfactory
Achieves a score of 54% or below
20 pts

EMR Documentation History of Present Illness: 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Subjective findings only

10 pts

Excellent
Complete HPI meeting all 5 criteria.

8 pts

Good
4 requirements are met.

6 pts

Fair
3 requirements are met.

4 pts

Poor
1–2 requirements are met.

0 pts

Unsatisfactory
No requirements are met.
10 pts

EMR Documentation Subjective Data Document Current Medications, Review of System: 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Subjective findings only

10 pts

Excellent
Complete HPI meeting all 5 criteria.

8 pts

Good
4 requirements are met.

6 pts

Fair
3 requirements are met.

4 pts

Poor
1–2 requirements are met.

0 pts

Unsatisfactory
No requirements are met.
10 pts

EMR Documentation Objective Data Document Physical Exam Findings: 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Objective findings only

10 pts

Excellent
Complete HPI meeting all 5 criteria.

8 pts

Good
4 requirements are met.

6 pts

Fair
3 requirements are met.

4 pts

Poor
1–2 requirements are met.

0 pts

Unsatisfactory
No requirements are met.
10 pts

Key Findings: Organize the key findings with the most important first and least important last. NURS 6512 Week 7 I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM

5 pts

Excellent
The key findings are complete and appropriately organized.

4 pts

Good
The key findings are complete but the organization is not correct.

3 pts

Fair
There are 1–2 key findings missing or organized inappropriately.

2 pts

Poor
There are 3 key findings missing and organization is incorrect.

0 pts

Unsatisfactory
There are more than 3 key findings missing and organization is incorrect.
5 pts

Problem Statement: Document a brief and accurate problem statement using professional language that includes the following: 1.) Name or initials, age; 2.) Chief complaint; 3.) Positive and negative subjective findings; 4.) Positive and negative objective findings.

5 pts

Excellent
All requirements are met.

4 pts

Good
3 requirements are met.

3 pts

Fair
2 requirements are met.

2 pts

Poor
1 requirement is met.

0 pts

Unsatisfactory
No requirements are met.
5 pts

Management Plan: Use the expert diagnosis provided to create a pertinent, comprehensive, evidenced-based management plan. Address the following criteria in the plan: 1.) Diagnostic tests; 2.) Medications (write out a complete order, even for OTC meds); 3.) Suggested consults/referrals; 4.) Patient education; 5.) Follow-up, including time interval and specific symptoms to prompt a return visit sooner; 6.) Provide rationales for each intervention and include references to support your plan. Clinical practice guidelines should be utilized as applicable.

15 pts

Excellent
All requirements are met.

13 pts

Good
5 requirements are met.

10 pts

Fair
4 requirements are met.

7 pts

Poor
1-3 requirements are met.

0 pts

Unsatisfactory
No requirements are met.
15 pts

References and Format: Current APA citations for references in management plan. Use of clinical practice guidelines when applicable.

5 pts

Excellent
0–1 errors Clinical practice guidelines used when applicable.

4 pts

Good
2–3 errors Clinical practice guidelines used when applicable.

3 pts

Fair
4–5 errors Clinical practice guidelines not used when applicable.

2 pts

Poor
6–7 errors Clinical practice guidelines not used when applicable.

0 pts

Unsatisfactory
More than 7 errors; clinical practice guidelines not used when applicable.
5 pts
Total Points: 100 NURS 6512 Week 7 I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM
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+1 (442) 290-4086
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We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work.


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