NR305 Week 2 iHuman Nurse Notes Template
Name: Date: 16/9/2023
Complete each item below:
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Luciana Gonzalez, a 32-year old female who presented for a comprehensive health assessment. She reports concerns with pain (4/10) and discomfort on urination. Urinalysis (UA) shows cloudy urine and bacteriuria (8+).
Luciana Gonzalez is a Hispanic female, today she visits the clinic for a comprehensive health assessment. Luciana changed her jobs recently. She needs life insurance and lacks a regular HCP (healthcare provider).
Height/Weight: 64” 185lb
HEENT: Head: normocephalic, without bruising or lesions. Eyes: vision 30/30 (RE & LE), PERRLA,no enophthalmos, or exophthalmos, nevus flammeus on the right eye. Ears: hearing is intact, tympanic membrane is intact. Nose & Throat: mucus membranes are pink and moist without bruises or bleeds. Tongue is soft and without exudates. No pain with neck movement. No masses or lumps on neck palpation.
Respiratory: chest has no scars, lumps, or swellings, its movement is symmetrical with breathing, lungs are bilaterally clear (without crackles, rhonchi, wheezing, or rales). No nipple discharge or skin dimpling with raising of arms.
Cardiovascular: S1 and S2 heard, no rubs, murmurs, or gallop. No facial, upper, or lower extremity edema. 2+ pulses in brachial, pedal, radial, and femoral pulse.
Gastrointestinal: no abdominal scars, abdomen is soft with normoactive bowel sounds, no guarding, tenderness or rebound tenderness
Genitourinary: external genitalia is withoutsores, edema, or erythema. The urethra is moist and pink. Bladder is non-distended. There are no tears, odor, or abnormal discharge from the vagina.
Musculoskeletal: lower and upper symmetrical muscle development, all joints have a FROM, Muscle strength is 5/5 in all groups, no deficits in coordination, gait, and balance.
CNS: the patient is AOX4, deep tendon reflexes are intact, cranial nerves II-XII are grossly intact,long-term and short-term memories are intact.
Integumentary: normal skin turgor, no lesions, sores, or wounds. Skin is warm and dry without evidence of bleeding or bruising.
Laboratory findings are significant for bacteriuria (8+) and cloudy urine suggestive of a UTI. Luciana will be referred to a PCP (primary care physician) for pharmacological management. She will also be educated on measures such as taking cranberry juice, proper wiping technique, and hygiene to prevent recurrent UTIs in future. Considering her BMI (31.8-obese), Luciana will be referred to a registered dietician for dietary recommendations to lower her BMI and subsequent obesity-related healthcare risks.
- State at least three additional assessment questions you would like to ask Ms. Gonzalez.
- Have you experienced other associated symptoms of nausea, vomiting, fevers, or rigors?
- Has any of your 1st degree relatives been diagnosed with bladder, kidney, or prostate problems?
- What does your diet look like on a average day including the fluid intake?
- In a one paragraph response, what made you select these questions?
- Patients with urological pathology can present with a wide range of symptoms and potential symptoms of worsening pathology (pyelonephritis) include rigors, fevers, nausea & vomiting (Storme et al., 2019). The family history will help to identify an underlying urological diseases while the patient’s diet history will inform on her dietary patterns since persistently dehydrated patients are at a higher risk of renal impairment and UTIs.
- Two priority opportunities for health promotion and/or disease prevention for Ms. Gonzalez.
- Educating Luciana Gonzalez on hydration and good personal hygiene to prevent UTIs in the future.
- Patient education on behavior change modification (physical activity and diet) to decrease her BMI and lower the risk of type 2 diabetes mellitus.
- What assessment findings led to selecting the two opportunities identified?
- In ihuman, the patient Luciana Gonzalez’s BMI is 31.8. This BMI falls under the obese range. Obesity is a known risk factor for cardovascular disease development, hypertension, dyslipidemia, and type 2 Diabetes Mellitus (Cercato & Fonseca, 2019). Other than the impact on health, obesity has social, economic, and psychological consequences that can negatively the patiet and close family members, hence the need to be addressed. Another assessmemnt finding was bacteriuria 8+ on urinalysis and cloudy urine. These are characteristic findings of a urinary tract infection (UTIs). The known UTI risk factors include; poor hygiene, pregnancy, sexual activity, history of recurrent UTIs, and age (Storme et al., 2019). Considering the patient’s history, from the listed risk factors, the most likely risk factor for this patient is poor wiping technique and hygiene. With a gap in knowledge, this finding presents the opportunity to educate the patient on measures to implement to prevent UTIsv in future.
Cercato, C., & Fonseca, F. A. (2019). Cardiovascular risk and obesity. Diabetol Metab Syndr, 11, 74-88. doi: 10.1186/s13098-019-0468-0.
Storme, O., Tirán Saucedo, J., Garcia-Mora, A., Dehesa-Dávila, M., & Naber, K. G. (2019). Risk factors and predisposing conditions for urinary tract infection. Therapeutic advances in urology, 11, 1756287218814382. doi: 10.1177/1756287218814382.
In last week’s assessment of Luciana Gonzalez, I felt like moving through the whole simulation was fairly easy and the system is set up to kind of help you out along the way. I felt most confident going through the labs and looking for abnormalities there and then later applying those findings to the physical assessment and past medical history findings. I feel that the scenario was as realistic as it could be. It is hard to really interact with a computer patient – the rapport building between caregiver and patient kind of goes out the window – but overall, it was not that bad. I still felt as if I was talking to and helping a real patient.
One of the things that I struggled with the first time I tried the assessment was that I asked way too many assessment questions, and then got lost in the assignment in terms of trying to hit all the key areas. I should have just focused more on the patient and why she was there or what needed to be treated. When I have a patient like this, I will make sure to take the time to concentrate on the patient and their needs. It is easy for nurses to get bogged down in all the things we must do daily for our patients and then we miss the opportunity to connect with the people we are caring for. iHuman is a great program teaching us valuable assessment skills, but there were a couple of things that did not really surprise me in the feedback – they were just things that I did not think about, I guess is a good way to put it. For example, I was dinged a few times for not asking questions that I did not think applied to this assessment and for asking questions that I did think were relevant. I was also given feedback on how to properly take blood pressure and check for pulses, which made me giggle because these are things that I do daily. However, it is hard to translate some physical things into a simulation.
I learned that I do not have to ask so many questions in order to figure out the information I need to treat a patient. When I hear that we must do a comprehensive assessment in my brain I think along the lines of okay I need to know everything that has ever transpired for them health-wise. When this is not the case at all. I need to learn to just step back and ask relevant questions that will focus on the health issues at hand. This will also help me in building rapport with my patients as well because I will not be taking up so much of their time and will be handling the issues they want to be treated in a timely manner.
I do not have any questions about last week’s scenario. It was pretty straightforward.
Wellness Assessment: Luciana Gonzalez (iHuman) (Graded)
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The purpose of this assignment is for learners to demonstrate completing a comprehensive wellness assessment on a virtual patient.
This assignment enables the student to meet the following course outcomes:
- CO 1: Demonstrate a head to toe physical assessment. (PO 1)
- CO 2: Differentiate between normal and abnormal health assessment findings. (PO 4)
- CO 4: Demonstrate effective communication skills during health assessment and documentation. (PO 3)
- CO 5: Identify collaborative opportunities for health promotion, risk reduction, and disease prevention. (POs 1, 2)
- CO 6: Demonstrate caring and professional behavior during patient interactions. (POs 6, 7)
Sunday 11:59 p.m. MT at the end of Week 2
Total Points Possible
This assignment is worth 150 points.
- 100 points – Case Completion
- 50 points – Nurse Notes Responses
Late Assignment Policy
If the assignment is not submitted by due date, a late deduction will be applied. See rubric below.
- Access the Luciana Gonzalez case assignment by locating the case in the Week 2 Module menu under Application to Practice. If prompted, select to load the case in a new browser window. Note: it may take a few moments for iHuman cases to load in our web browser.
- Select Proceed and begin by answering the Prework questions. Your prework answers are not graded. The questions are intended to get you thinking about the case. You will continue to select the Proceed button to move you through the entire case.
- Begin the case and complete these sections: (100 points total, immediate feedback/grade will be provided to you by iHuman when complete)
- EHR Review
- Health History
- Physical Assessment
- Note: there is no time limit on completing cases
- As you move through your first attempt and once you complete the case, you will receive feedback from the “Expert” on the important findings that you included (or should have included), and information that should have been collected on the health history and physical assessment. The system will also tell you if you asked questions or performed assessments that are considered extraneous or inappropriate for that particular case. Review this information carefully and take notes to be used on your second attempt, if you would like to work toward a higher score.
- If you must leave the case for any reason before you have totally completed it, the program will save your spot and will return you to the same point when you re-enter the case. (Look for the green “Resume” arrow at the bottom of the screen.) If you had fully completed a section, you will be able to review the section, but you will not be able to change your answers. You will only be able to move forward in the case.
- Nurse Notes (50 points) are completed outside of iHuman and are graded by your instructor. To complete the Nurse Notes, download and save the required template below under Template. Rename the template as Your Last Name Week 2 Nurse Notes. This must be saved as a Microsoft Word document (.docx). Save it to your computer or flash drive in a location where you will be able to retrieve it later. Type your answers directly on the saved document. When your Nurse Notes answers are completed, save and close the template. Follow the submission directions at the top of this page to upload your assignment.
- When you have completed a case review the final score and feedback provided by iHuman. You have the option to complete this case a second time before the submission deadline (total of 2 attempts) to improve your score. Your instructor will convert your highest score in iHuman to points earned in the grading rubric. Scores are adjusted based on your performance level. (See grading rubric.)
Click the blue question mark icon at the bottom right of your iHuman screen at any time to access iHuman Resources. A menu will appear to assist with trouble shooting. Click “Help” from the menu to contact iHuman Support.
Chamberlain College of Nursing values honesty and integrity. All students should be aware of the Academic Integrity policy and follow it in all discussions and assignments.
By submitting this assignment, I pledge on my honor that all content contained is my own original work except as quoted and cited appropriately. I have not received any unauthorized assistance on this assignment.
iHuman Case Assignments – Rubric (1)
|This criterion is linked to a Learning Outcome iHuman ScoreInstructor to enter student’s highest score achieved for the iHuman Case here.||100 pts i-Human score of 90-100 90 pts i-Human score of 80-89 80 pts i-Human score of 70-79 70 pts i-Human score of 60-69 60 pts i-Human score of 50-59 50 pts i-Human score of 40-49 40 pts i-Human score of 30-39 30 pts i-Human score of 20-29 20 pts i-Human score of 10-19 0 pts No Score||100 pts|
|This criterion is linked to a Learning Outcome SBAR Note1.All components of SBAR (Situation, Background, Assessment, Recommendations) addressed; 2. Appropriate information in each section; 3. All key findings mentioned; 4. Data is well organized and concise.||20 pts All four criteria met. 1. All components of SBAR (Situation, Background, Assessment, Recommendations) addressed; 2. Appropriate information in each section; 3. All key findings mentioned; 4. Data is well organized and concise. 18 pts One criterion is missing. 16 pts Two criteria are missing. 8 pts Three criteria are missing. 0 pts All criteria are missing.||20 pts|
|This criterion is linked to a Learning Outcome Paragraphs1.Thoroughly answers the questions in a detailed manner.|
2. Fully demonstrates an understanding of ongoing patient needs.
3. Response includes specific resources or references as requested in the questions.
|20 pts All criteria met 1.Thoroughly answers the questions in a detailed manner. 2. Fully demonstrates an understanding of ongoing patient needs. 3. Response includes specific resources or references as requested in the questions. 18 pts Answers the questions and demonstrates understanding of ongoing patient needs. Response includes specific resources or references as requested in the questions. Answer is not detailed. 16 pts Partially answers the questions and partially demonstrates understanding of ongoing needs. Resources or references included but are not specific to this case. 8 pts Minimally answers the questions and minimally demonstrates knowledge and understanding of course concepts. No resources or references included. 0 pts Did not answer the questions.||20 pts|
|This criterion is linked to a Learning Outcome Clarity of Writing1.Excellent mechanics; 2. Well organized, clear, and logical; 3. Professional writing style; 4. Proper grammar, punctuation, and spelling.||10 pts All criteria met 1.Excellent mechanics; 2. Well organized, clear, and logical; 3. Professional writing style; 4. Proper grammar, punctuation, and spelling. 8 pts One criterion is missing. 6 pts Two criteria are missing. 4 pts Three criteria are missing. 0 pts All criteria not met.||10 pts|
|This criterion is linked to a Learning Outcome Late Deduction||0 pts 0 points deducted Submitted on time. 0 pts Not Submitted on Time – Points deducted 1 day late= 7.5 deduction; 2 days late= 15 deduction; 3 days late= 22.5 deduction; 4 days late= 30 deduction; 5 days late= 37.5 deduction; 6 days late= 45 deduction; 7 days late= 52.5 deduction||0 pts|
|Total Points: 150|
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