NUR 504
Miss Cookie
a year ago
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files (3)NUR504Case2.pdf
NUR504Ass1.pdf
NUR504Dis1.pdf
NUR504Case2.pdf
Case 2 Chief Complaint. (CC). I am here for my annual physical exam and have been having vaginal discharge.”
History of Present Illness (HPI) 32-year-old pregnant lesbian – her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank.
PMH- None
PSH- None
Drug Hx Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion
Allergies-None
Family Hx She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.
Review of Systems (ROS)
General No fatigue, fever, or chills.
Head, Eyes, Ears, Nose & Throat (HEENT)-None
Neck No fatigue, fever, or chills.
Respiratory-None
CV- None
GI-None
GU- None
Integument multiple piercings, and tattoos. Old scars related to “cutting”
MS/Neurono syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.
Objective Data PE B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98
General-None
HEENT Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Lungs CTA AP&L
Card S1S2 without rub or gallop
Abd benign, normoactive bowel sounds x 4
GU external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa
intact.
Ext no cyanosis, clubbing or edema
Integument intact without lesions masses or rashes.
MS-None
Neuro No obvious deficits and CN grossly intact II-XII
NUR504Ass1.pdf
Comprehensive Mental Health Examination
For this assignment, list the parts of a comprehensive mental status examination (MSE) for mental health patients. Give examples of each and describe the significance to the advanced practice nurse.
Submission Instructions
• The paper is to be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
• The paper should be formatted per current APA and 2-4 pages in length, excluding the title, abstract, and references page.
• Incorporate a minimum of 5 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
• This assignment will be assessed through Turnitin.
Mental Exam Rubric Mental Exam Rubric
Criteria Ratings Poi nts
Identificati on of Main Issues/ Problems
Distinguished Identify and demonstrate a sophisticated understanding of the issues/
problems.
20 pts
Excellent Identifies and demonstrate an accomplished understanding of most of
issues/problems.
18 pts
Fair Identifies and demonstrate an an acceptable understanding of most of
issues/problems.
16 pts
Poor Identifies and demonstrate an unacceptable understanding of most of
issues/problems.
8 pts
/20 pts
Analysis and Evaluation of Issues/ Probelms
Distinguished Presents an insightful, thorough analysis and evaluation of issues/problems.
20 pts
Excellent Presents a thorough analysis and evaluation of most of the issues/problems.
18 pts
Fair Presents a superficial or incomplete analysis and evaluation of issues/
problems.
16 pts
Poor Presents unacceptable analysis and evaluation of issues/problems.
8 pts
/20 pts
Demonstr ates a Conceptu al Understan ding
Distinguished Provides a thorough, competent and interpretive responses to all issues/
problems, and shows a high level of conceptual understanding.
20 pts
Excellent Provides a competent and interpretive responses to all issues/problems, and
shows a moderate level of conceptual understanding.
18 pts
Fair Provides a competent responses to all issues/problems, but lacks
interpretation and a moderate level of conceptual understanding.
16 pts
Poor Provides an unacceptable response to all issues/problems, and lacks
interpretation and a moderate level of conceptual understanding.
8 pts
/20 pts
Use of Citations to Course Readings and Additional Research/ Literature
Distinguished Effectively uses the literature and other resources to inform their work.
Exceptional use of citations and extended referencing.
20 pts
Excellent Effectively uses the literature and other resources to inform their work.
Moderate use of citations and extended referencing.
18 pts
Fair Ineffectively uses the literature and other resources to inform their work.
Moderate use of citations and extended referencing.
16 pts
Poor Ineffectively uses the literature and other resources to inform their work. An
unacceptable use of citations and extended referencing.
8 pts
/20 pts
Writing Mechanic s and APA Formattin g Guidelines
Full Marks Demonstrate a high level of clarity, precision, and attention to detail. APA
style is correct and writing is free of grammar and spelling errors.
20 pts
Excellent Demonstrate a high level of clarity. APA style and writing mechanics need
more precision and attention to detail.
18 pts
Fair Demonstrate a moderate level of clarity. APA style and writing mechanics
need more precision and attention to detail.
16 pts
Poor Demonstrates issues in writing and communicating clearly. APA style and
writing mechanics need serious attention.
8 pts
/20 pts
NUR504Dis1.pdf
Cultural, Spiritual, Nutritional, & Mental Health Disorders
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number. Case 2
Case 1 Case 2 Case 3 Subjective Data
Chief Compla int (CC)
“I came for my annual physical exam, but do not want to be a burden to my daughter.”
“I am here for my annual physical exam and have been having vaginal discharge.”
“Annual physical exam”
History of Present Illness (HPI)
At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs.
32-year-old pregnant lesbian – her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank.
23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle.
PMH
Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis
PSH S/P cholecystectomy
Drug Hx
Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.
Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion
Current Meds: denied
Allergie s
No allergies to food or medications.
Family Hx
She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.
He has a family history of diabetes, hypertension, and alcoholism.
Review of Systems (ROS)
General
+ weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills.
No fatigue, fever, or chills.
No recent weight gains of losses, fatigue, fever, or chills.
Head, Eyes, Ears, Nose & Throat (HEENT )
No changes in vision or hearing, no difficulty chewing or swallowing.
Neck No pain or injury No pain or injury Respira tory
CV no chest discomfort or palpitations
GI
GU no urinary hesitancy or change in urine stream
Integum ent
multiple bruises on his upper arms and back.
multiple piercings, and tattoos. Old scars related to “cutting”
history of eczema – not active
MS/ Neuro
+ falls x 2 within the last 6 months; no syncopal episodes or dizziness
no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.
no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements
Objective Data
PE B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8
B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98
B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6
General
23-year-old male appears well developed and well- nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress.
HEENT
Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.
Lungs CTA AP&L CTA AP&L CTA AP&L
Once you received your case number, answer the following questions: Case 2
1. Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
2. Utilizing the five assessment domains, which ones would you utilize on your patients in conducting a comprehensive nutritional assessment.
Card S1S2 without rub or gallop
S1S2 without rub or gallop
S1S2, +II/VI holosystolic murmur; without rub or gallop
Abd benign, normoactive bowel sounds x 4
benign, normoactive bowel sounds x 4
benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
GU
external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact.
Ext no cyanosis, clubbing or edema
no cyanosis, clubbing or edema
no cyanosis, clubbing or edema
Integum ent
multiple bruises in different stages of healing – on his upper arms and back.
intact without lesions masses or rashes.
intact without lesions masses or rashes.
MS
Neuro No obvious deformities, CN grossly intact II-XII
No obvious deficits and CN grossly intact II-XII
No obvious deficits and CN grossly intact II-XII
3. Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?
Submission Instructions:
• Your instructor will assign you your case number and you will post on the case number you have been assigned.
• You will reply to the other two case studies (One of each). • Your initial post should be at least 500 words, formatted and
cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
• All replies must be constructive and use literature where possible.
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