NR509 Week 5 Assessment Latest 2022 March (soap and reflection only)

NR509 Advanced Physical Assessment

Week 5 Assessment   

iHuman Virtual Patient Encounter Activity

Purpose

The iHuman assignments provide students with an opportunity to experience clinical scenarios that are relevant to the lesson content through virtual patient encounters. iHuman is a highly interactive and dynamic way to enhance student learning.

Course Outcomes

Through this assignment, the student will demonstrate the ability to:

CO 1: Apply advanced practice nursing knowledge to collecting health history information and physical examination findings for various patient populations. (POs 1, 2)

CO 2: Differentiate normal and abnormal health history and physical examination findings. (POs 1, 2)

CO 3: Document health history and physical examination findings in a logical and organized sequence. (POs 1, 2)

CO 5: Conduct focused and comprehensive health histories and examinations for various patient populations. (POs 1, 2)

Preparing the Assignment

Follow these guidelines when completing?each component of the?assignment.?Contact your course faculty if you have questions.?

Access?iHuman?by clicking the link provided below.? Clicking the blue bar will?launch the activity in a new browser window. You do not need to complete the case in one sitting; if you leave the case and return later, the program will begin where you left off.

All graded documentation, including the Management Plan, must be completed within the iHuman platform. Follow the iHuman Documentation Guide (Links to an external site.) as you prepare your client’s EMR.

You may use the Fillable SOAP note template (Links to an external site.) to assist with documentation and organization as you complete the case.

Complete the following components in the iHuman Virtual Patient Encounter for the assessment of the abdomen.

History: Complete a focused health history. Your score will be automatically calculated after the health history is submitted.

Physical Exam: Complete a focused physical exam. Your score will be automatically calculated after the focused physical exam is submitted.

EMR Documentation: Document within the Patient Record in iHuman using professional language. include the following components:

History of present illness

Previous medical history

Current medications

Allergies

Relevant completed screenings and preventive health

Relevant family history

Relevant social history

Focused review of systems

Focused physical exam findings

Key Findings/Most Significant Active Problem: Document Key Findings from your history and physical exam in the Assessment tab of the case. Organize Key Findings, identifying the most significant active problem (MSAP) and the relation of other key findings to the MSAP.

Problem Statement: Document a problem statement using professional language. Include the following components.

name, age

chief complaint

brief description of pertinent positive and negative subjective findings

brief description of pertinent positive and negative objective findings

Management Plan: Using the expert diagnosis provided, create a comprehensive treatment plan using professional language. Include at least one appropriate, evidence-based, scholarly source to support your decisions. Include the following components:

diagnostic tests

medications

suggested consults/referrals

client education

follow-up

Reflection: In a Microsoft Word document, respond to the self-reflection questions below. Include a title page in APA format using the title iHuman Reflection Week 5. In 2-3 paragraphs, respond substantively to all required reflection questions. Analyze your personal strengths and areas for growth.

The process of clinical reasoning may seem opaque and even mysterious to beginning students. Experienced clinicians often think quickly, with little overt or conscious effort. They differ widely in personal style, communication skills, clinical training, experience, and expertise. Some clinicians may find it difficult to explain the logic behind their clinical thinking. As you gain experience, your clinical reasoning will begin at the outset of the patient encounter, not at the end. Reflect on the clinical reasoning you used during this virtual patient encounter. Describe the steps taken to identify and interpret the key findings in this case.  What are some “lessons learned” within the assessment that you can apply to your professional practice as a provider?

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