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iHuman Virtual Patient Encounter – Cardiovascular Assessment

NR509 Advanced Physical Assessment

Week 4 Assessment   

iHuman Virtual Patient Encounter – Cardiovascular Assessment

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

 

This assignment enables the student to meet the following course outcomes:

 

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 HPI is a concise, clear, and chronologic description of the problems prompting the patient’s visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date. The HPI in its most basic form is the story of the patient’s problem. It should reveal the patient’s responses to his or her symptoms and what effect the illness has had on the patient’s life. Always remember, the information flows spontaneously from the patient, but the task of oral and written organization is yours. Reflect on how well you constructed the HPI for this patient encounter and rate your performance using the following rating scale (0=unacceptable, 1=needs improvement, 2=average, 3=effective, 4=exceptional performer). Explain your rationale for the rating and identify at least ONE evidence-based strategy to improve your performance in the next virtual patient encounter.

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