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Document a focused history, physical exam, nursing diagnoses, and nursing process of the case study
Focused Assessment
Details:
Document a focused history, physical exam, nursing diagnoses, and nursing process of the case study below and compare the differences with components a complete assessment.
Case Study
A 22-year-old woman reports being “sick with the flu” for the past 8 days. She is vomiting several times every day, having difficulty keeping liquids or food down, and has been using more than the recommended dose of antacids in an attempt to calm the nausea. She has become severely dehydrated. After fainting at home, she was taken to a local hospital. An arterial blood gas sample was drawn and then an IV was placed to help rehydrate her. The arterial blood gas revealed the following:
Test Result Normal levels
pH 7.5 7.35 – 7.45
PaCO2 40 mm Hg 35-45 mm Hg
PaO2 95 mm Hg 80-100 mm Hg
SaO2 97% 95-100%
HCO3– 32 meq/liter 22-26 meq/liter
What pharmacologic intervention is commonly used to correct this acid-base disturbance?
Describe the educational needs for this patient and what your approach will be.
Focused Assessment
| 1 No Submission 0.00% |
2 Unsatisfactory 75.00% |
3 Less than Satisfactory 80.00% |
4 Satisfactory 88.00% |
5 Good 92.00% |
6 Excellent 100.00% |
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| 70.0 %Content | |||||||
| 20.0 %Documents a Case History (Includes historical data, chief complaint, history of present illness, review of systems, and pertinent medications or allergies.) | None. | Case history is either not present or incomplete. Assignment criteria has not been met. | Minimally describes case history. Data lacks details and/or is incomplete. Discussion significantly lacks depth. | Outlines case history. Briefly addresses all criteria components. Statements may lack depth of understanding or detail. | Provides a basic clear case history with minimal evidence of all criteria components. | Thoroughly presents complete case history. Addresses all components: historical data, chief complaint, history of present illness, review of systems, and pertinent medications or allergies. Describes in-depth and with supporting evidence. | |
| 20.0 %Documents a Focused Assessment | None. | Does not describe focused assessment. Assignment criteria has not been met. | Minimally describes focused assessment. Data lacks details and/or is incomplete. Discussion significantly lacks depth. | Outlines the focused assessment. Statements may lack depth of understanding or detail. | Provides a basic description of focused assessment. Some details are presented. | Clearly and comprehensively describes the focused assessment. Descriptions are in-depth and supported by evidence. | |
| 10.0 %Includes Appropriate Nursing Diagnoses | None. | The nursing diagnosis is inappropriate to the scenario presented. | The nursing diagnosis loosely fits the scenario presented. | The nursing diagnosis is appropriate to the scenario presented. | The nursing diagnosis fits the scenario presented. | The nursing diagnosis fits the scenario presented and is a priority for patient care. | |
| 20.0 %Compares the Similarities and Differences in a Focused Assessment Versus a Complete Assessment | None. | Analysis of the assessments is not outlined or is outlined poorly. Does not distinguish similarities and differences. | Ignores or superficially evaluates the assessments. Draws unwarranted or fallacious conclusions. Recognizes simple relationship examples without providing rationale. | Surface level of evaluation of the assessments is offered. Describes basic similarities and differences. | Analysis is direct, competent, and appropriate of the assessments. Illuminates relationships. | Thoughtfully analyzes and evaluates major points of the assessments. Draws warranted, judicious, non-fallacious conclusions. Identifies the salient arguments (reasons and claims) pro and con providing explicit examples and details. | |
| 20.0 %Organization and Effectiveness | |||||||
| 7.0 %Thesis Development and Purpose | None. | Paper lacks any discernible overall purpose or organizing claim. | Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear. | Thesis and/or main claim are apparent and appropriate to purpose. | Thesis and/or main claim are clear and forecast the development of the paper. It is descriptive and reflective of the arguments and appropriate to the purpose. | Thesis and/or main claim are comprehensive. The essence of the paper is contained within the thesis. Thesis statement makes the purpose of the paper clear. | |
| 8.0 %Argument Logic and Construction | None. | Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses non-credible sources. | Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility. | Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis. | Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative. | Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. | |
| 5.0 %Mechanics of Writing (Includes spelling, punctuation, grammar, and language use.) | None. | Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used. | Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present. | Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. | Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. | Writer is clearly in command of standard, written, academic English. | |
| 10.0 %Format | |||||||
| 5.0 %Paper Format (Use of appropriate style for the major and assignment.) | None. | Template is not used appropriately, or documentation format is rarely followed correctly. | Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent. | Appropriate template is used. Formatting is correct, although some minor errors may be present. | Appropriate template is fully used. There are virtually no errors in formatting style. | All format elements are correct. | |
| 5.0 %Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment and style.) | None. | No reference page is included. No citations are used. | Reference page is present. Citations are inconsistently used. | Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present. | Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and citation style is usually correct. | In-text citations and a reference page are complete and correct. The documentation of cited sources is free of error. | |
| 100 %Total Weightage | |||||||
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