Adult Comprehensive History & Physical Assessment

Lewis University

College of Nursing and Health Professions Department of Graduate Studies

Integrated Advanced Pathophysiology, Pharmacology and Physical Assessment

Case Study Rubric 30-537

The use of advanced nursing science, including illness prevention, health promotion and wellness will be applied in this case study. Advanced assessment skills are evaluated when you present your patient; identify the normal assessment findings as well as the abnormal findings. Once identified, you are asked to develop a treatment plan specific to your patient’s demographic information which includes, but is not limited to their age, race, gender, ethnic background, socioeconomic status and present physical wellbeing. Utilizing current, evidence-based guidelines and research create a treatment plan tailored to your specific patient (taking into consideration a holistic approach to their care- religion, resources, support). Once you have reviewed treatment options, choose one treatment (medication, physical therapy, homeopathic medicine etc) and develop a plan of care based on your choice of treatment. How will you evaluate the effectiveness of your treatment plan? Will you use a current tool (CQI, QSEN, PDSA etc)? What barriers does your patient/treatment plan have for success? (too costly, no current resources available, patient not willing to be compliant, no means of transportation) And finally, what patient education will you provide to promote your treatment plan. Don’t forget to include the family!

System Overview with Disease History (identify the system and present the history of disease such as onset of symptoms, diagnosis, and current treatment) 10 points

Assessment: Provide Normal findings and disease specific abnormal findings 25 points

Treatment Options- (Traditional, Cultural based, Holistic, Evidence based/safety, homeopathic) Provide an overview of treatment options available, then choose one treatment and continue through the rubric based on 1 treatment 15 points

Evaluation- How will you evaluate the treatment plan? How do you think your treatment plan will affect the disease process? Can you identify possible conflicts to obtaining your desired goal? Outcome- Try to Link to specific CQI tool; core measure assessment; PDSA and or QSEN 10 points

Patient Education- Evidence based, Age specific, Include Diagnosis, treatment plan, list of medications, dose, route, information/ precautions Health Promotion- What are some interventions that you can teach/ implement to help prevent the disease process or to promote health? Think of appropriate Health Screenings, Patient education to ensure compliance of the treatment plan, proposed follow-up; what services are available in your community to assist the population/ disease that you have chosen for your case study? How would one access these services? 30 points

References- Peer reviewed, scholarly, current articles, books, resources to help support your case study. You may use your books. Please follow APA format for the reference page. 10 points