HEENT Needs Subjective Case Study Discussion
HEENT Needs Subjective Case Study Discussion
This is the assignment You will perform a history of a head, ear, or eye problem that your instructor has provided you or one that you have experienced and perform an assessment including head, ears, and eyes. You will document your findings, identify actual or potential risks, and submit. Title: Documentation of problem based assessment of the head, ears, and eyes. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of a head, ears, and eyes. Identify abnormal findings. Course Competency: Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics. Instructions: Content: Use of three sections: o o o Subjective Objective Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Format: • Standard American English (correct grammar, punctuation, etc.) Resources: Chapter 3: SOAP Notes (subjective and objective only) Sullivan, D. (2018). Guide to clinical documentation. https://ebookcentral.proquest.com/lib/ras/detail.action?docID=5553403 Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=rzh&AN=107055742&site=eds-live Documentation Grading Rubric- 10 possible points Levels of Achievement Criteria Subjective (4 Pts) Emerging Missing components such as biographic data, medications, or allergies. Symptoms analysis is Competence Basic biographic data provided. Medications and allergies included. Symptoms analysis Proficiency Mastery Basic biographic data provided. Included list of medications and allergies. Symptoms Basic biographic data provided. Included list of medications and allergies. Symptoms Objective (4 Pts) incomplete. May contain objective data. incomplete. Lacking detail. No objective data. Points: 1 Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”. Points: 1 Actual or Potential Risk Factors (2 pts) Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Points: 0.5 Points: 2 analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. Points: 3 analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided. Points: 4 Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings. Points: 2 Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information Points: 3 Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information Points: 4 Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Points: 1 Points: 1.5 Points: 2 HEENT Case Study Physical Assessment Elizabeth Rodgers, DNP, RN Simulation SLS Simulation. (2017). Evolve SLS Simulation. (2017). Evolve Implement NURSING CARE Review: What additional chart information is helpful? Discuss: Patient and husband handing you note sheet Priorities Suctioning technique Oxygenation Assessment
