help with home work
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files (2)NU552Jornal9note.docx
NU552_Unit_9_Journal_Template.docx
NU552Jornal9note.docx
All components of the subjective interview should be included in the documentation. Build your HPI and ROS considering the patient's current diagnoses and one complaint.
Consider family history, and risks based on age and sex. Do not video the subjective portion, but complete it; document it. The journal exam documentation and commentary section also need to be completed.
The video will be you introducing yourself and beginning the physical exam. You do not need to verbalize why you are performing assessment techniques in this journal as in other evaluations. You will use a live person volunteer, not a patient, and conduct the examination as a professional medical provider. The patient is to be considered an older adult. Speak to the patient naturally as you would in an exam. Memorize assessment steps. Prepare in advance. Be sure to read the required readings and watch the videos assigned.
Your final production video should be about 15 minutes. Do not exceed 20 minutes. Your preparation and succinctness in the process and moving the patient through the exam is important. Consider how you will divide your time as you begin to prepare and practice. Your communication should be clear and concise with regards to any adaptation for an older adult.
Follow the pattern and process for the exam. Plan the flow of your head to toe assessment. Consider the rubric. Patient position changes should be limited, but with position changes as required.
Your video demonstration should align with the objective documentation for this examination of an older adult.
· Your video journal should be of the objective examination
· Complete head to toe examination in a systematic way.
· The breast and genitourinary exam are deferred for the purpose of this journal.
· Document the full subjective and objective assessment in the journal template.
· If your video does not include the required volunteer consent to participate and be videoed, or if it is over duration in length, or if the diagnostic reasoning scenario content is not completed, it will not be accepted. It is your responsibility to check this before you submit it.
· Complete the assessment and the documentation in a systematic way.
· Complete the questions at the end of the journal demonstrating clinical judgement and diagnostic reasoning.
I will do the video assessment:
NU552_Unit_9_Journal_Template.docx
NU552 Journal Templates
Unit 9 Journal.
Complete the full subjective and objective assessment below. Your subjective interview responses should lean toward some topics related to an older adult and the typical ROS. Your video is the objective portion only. It should align with the objective documentation. Do not video the subjective portion, but complete it. The breast and GU exam are deferred for this journal.
You should practice several times in preparation, memorizing steps and processes to present a smooth and accurate demonstration of skills in your submitted video. The student is to confirm volunteer verbal consent for video participation. Only adults are accepted as volunteers. Shirts on for the competency though in a clinical exam the patient would be draped and skin exposed.
Copy and paste your completed template into the text box along with embedding your Kaltura video. View the grading rubric.
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Unit 9 Journal NU552 |
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Your Name |
Date |
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Patient MRN: |
Verbal consent for volunteer participation and video (adults only permitted), obtained by student and demonstrated on video. Yes ☐ No ☐ |
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Date: |
Age: |
Sex: |
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SUBJECTIVE |
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CC:
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HPI:
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Medications:
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Allergies: NKDA
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Past Medical History: (include DX, and 2-3 preventive screenings due or recently had)
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Family History
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Social History
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ROS |
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General: |
Peripheral Vascular: |
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Skin: |
Urinary: |
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HEENT: |
Genitalia/Reproductive: |
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Neck: |
Musculoskeletal: |
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Breasts: |
Neurologic: |
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Respiratory: |
Hematologic: |
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Cardiovascular: |
Endocrine: |
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Gastrointestinal: |
Psychiatric: |
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OBJECTIVE |
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Weight 180 |
Ht 5’6’’ |
BMI 29 |
SPO2 96% |
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B/P |
P |
R |
Temp 98 F |
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General Appearance
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Skin
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HEENT
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Cardiovascular
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Respiratory
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Abdomen
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Breast DEFERRED |
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Genitourinary DEFERRED |
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Musculoskeletal/Spine
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Neurological
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Psychiatric
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Complete two (2) scenarios. Once from each section. If you completed one of these in the discussion you may use that content for the related scenario and complete a new one from the other section below. Otherwise follow the directions and complete one from each group.
Complete one of these scenarios.
· Consider the chief complaint of worsening memory in a 78-year-old. Existing diagnosis of Alzheimer’s or · Consider the chief complaint of mid back pain in an 82-year-old. Existing diagnosis of osteoporosis. or · Consider the chief complaint of swelling in ankles in a 67-year-old. Existing diagnosis of hypertension
And then one of these scenarios.
· Consider the chief complaint of constant crying in a 6 week old child, of migrant worker parents. or · Consider the chief complaint of prolonged sadness in a pregnant woman at 32 weeks gestation. or · Consider the chief complaint of shortness of breath in a 77-year-old recent widower.
Demonstrate clinical judgment regarding the chief complaint by including this content: Complete one of the three scenarios:
· What pertinent information collected from the history would impact your assessment? · What other systems need assessment due to the symptoms of the patient? · What would be pertinent positives or pertinent negatives found in the exam? · Include at least three differentials. · Include which diagnostics you would order based on your differentials and why. · How might a final diagnosis be determined? · Address a possible brief management plan.
Finally address the relationship between compassion and clinical judgment for all patients and for special populations.
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