HAS108 Health Assessment Case Study Evaluation

Assessment Task

This assessment provides an opportunity for you to demonstrate the theoretical knowledge you have acquired so far in HAS108, focusing on comprehensive history taking and questioning techniques.

Context

This assessment presents a timely opportunity for you to think about how to integrate frameworks of person centred care and partnering with consumers into your nursing practice.

It is important to consider how you could establish a person centred approach to the patient in the scenario you select, and articulate any features about this patient that navigate the direction of questioning or techniques you would utilise in assessment and care planning.

Instructions

1. View the two (2) case scenario videos provided and found in your Assessment 2 area
2. Choose one (1) of these scenarios; David or Theo
3. Read the additional observation data on each character (see Appendix 1 in this document)
4. You are to address a series of short answer questions tailored for the character in the scenario

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This assessment requires you to answer 3 questions. The questions are the same for each character however, given the different circumstances, socio-economic and medical histories of the characters, each case study is to be uniquely considered.

A short introduction (150-200 words) briefly introducing the case study is required.

A short conclusion (150-200 words) will concisely summarise your findings for your chosen case study.

Short Answer Questions:

• Using resources provided in this subject, identify and explain what information is needed to a gain a more comprehensive past history for your chosen video Consider the patients level of health literacy and cultural safety issues in your answer.
• Based on the information given for each character, identify and explain what abnormalities/concerns you can identify in the physical observations and patient
• Identify and explain what additional physical assessments are needed in order to facilitate a diagnosis for your chosen character, and identify and describe what body systems need to be explored further.

Referencing:

It is essential that you use appropriate APA style for citing and referencing research. Please see more information on referencing here

https://library.torrens.edu.au/academicskills/apa/tool

Submission Instructions

Please submit your Case Evaluation word document into Assessment 2 submission link in the Assessment section found in the main navigation menu of the subject Blackboard site. A rubric will be attached to the assessment. The Learning Facilitator will provide feedback via the Grade Centre in the LMS portal. Feedback can be viewed in My Grades.

Appendix 1:

Additional observation data for the 2 video characters:

David

Work involves physical activity. Mentally stressful job position.

Diagnosed: Ischemic heart disease (IHD). Hypertension (HTN).

PULSE: 55 bpm (beats per min). BLOOD PRESSURE: 140/90 mmHg BODY TEMPERATURE: 36.5˚C

RESPIRATIONS: Resting 18, exertion 24

SaO2: 95% on room air

WEIGHT: Body Mass Index (BMI) 20

CENTRAL NERVOUS SYSTEM (CNS):  GCS 15.

MOBILITY: Ambulant (no regular exercise, puffing on exertion).

URINALYSIS: Ketone ++; Glucose +++; Specific Gravity (SG) 1.010; PH 7; Colour straw; Smell none;

BLOOD RESULTS (last G.P. visit) Cholesterol >5.5mmol/L; Blood Glucose Level (BGL) 6.9mmol/L

Theo 

PULSE: 70 bpm (resting), 100 bpm (on exertion).

TEMPERATURE: 37.5˚C

RESPIRATION: 18 (Theo reports thick secretions, ‘worse when getting up in the morning’, primary auscultation- audible moist cough that Theo states ‘is hard to get rid of’).

SaO2: 95% room air (RA)

WEIGHT: Body Mass Index (BMI) 16.

BP: 100/70 mmHg

CNS: GCS 15

GENERAL APPEARANCE: Dishevelled, tooth decay, nicotine stained fingers, initial visual inspection Theo observed to have to have minimal body fat.

Mobility: ambulant does not appear to have any deficits.

Urinalysis: Leukocytes ++. Slight Specific Gravity increase of 1.010.