Description

Purpose

The purpose of this assignment is for learners to demonstrate completing a comprehensive wellness assessment on a virtual patient.

Course Outcomes

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)

Points Possible

150 Points Total

• 100 points – Case Completion
• 50 points – Nurse Notes Responses

Directions

1. Access the Luciana Gonzalez Case Assignment in iHuman by clicking on the “Load Assignment in a New Window” button at the bottom of this assignment page. 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 your web browser, so please be patient.
2. Complete the prework questions associated with the case.
3. Begin the case and complete these sections: (100 points total, immediate feedback/grade will be provided to you by iHuman when complete)
   1. EHR Review
   2. Health History
   3. Physical Assessment
4. Type your responses to the questions in the Nurse Notes section in the box provided (50 points, graded by instructor after submission).
5. Review the 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 highest score will be recorded in the grade book.
6. The Nurse Notes will be graded by your instructor and will be a separate grade in the grade book.

Solution/Answer

This is part of the solution to the iHuman case study on Luciana Gonzalez.

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Luciana Gonzalez – iHuman case study

Name: Luciana Gonzalez

Age: 32 years

Sex: Female

Height: 5”4’ (163cm)

Weight: 185.0 lb (84.1 kg)

Chief issue: She attended the clinic to get a comprehensive health assessment that would enable her to apply for insurance cover.

Health Assessment (Including physical assessment)

Note – Look for current and previous treatment history and any illness.

1. Macrolide Check – Check for antibiotics such as erythromycin, clarithromycin, azithromycin, fidaxomicin, and telithromycin that are used to treat a wide variety of bacterial infections. Such infections include pneumonia, pharyngitis, sinusitis, and bronchitis. additional infections that the patient could treat include gastrointestinal tract, ear, and skin infections, as well as sexually transmitted diseases (STDs).
2. Urinary Tract Infection (UTI) – The symptoms in adults (the elderly) could be confusion, withdrawal, and/or agitation while in young patients it could be bed wetting. Other overall symptoms include;
   • A strong urge to urinate
   • A burning micturition – discharge of the urine from the bladder
   • Oliguria – urinating less frequently or pee amounts of less than 400ml per day
   • Pyuria – presence of at least 10 white blood cells in urine
   • Hematuria – The presence of blood or red blood cells in urine
   • Odynuria – Pain during urination especially from using a catheter
   • Pelvic pain
3. Costovertebral angle (CVA) tenderness – Could indicate cystitis, when paired with symptoms like ever, chills, nausea, and vomiting it could be a case of pyelonephritis. it is also a kidney-related condition and may indicate STIs in young people.
4. Assess;
   • Eye, ear, walking, oral health, proper hygiene, and physical activity
   • Regular checkups and follow ups
   • Calorie intake via the 24hrs recall method
5. Body Mass Index (BMI) – weight in Kgs divided by height in M²
6. Immunization history
7. Gynecological examination
   1. Cervical cancer
   1. Breast cancer
8. History of acute respiratory infection and diarrhea
9. Universal Health Coverage (UHC) index
10. If high BMI check;
    1. Diabetes

Also, considering that Luciana Gonzalez is Hispanic:

The primary concerns for her as a patient will be monitoring of blood sugar and liver function or cirrhosis. These conditions could be associated with a history of alcoholism and smoking and so it would be wise to ask questions in this line as well. Weight and diet assessments are particularly important in such a patient. Tests on this part include checks for footsore as well as limited vascular and neurological examination. Liver function tests can be done to rule out any abnormalities in the liver while blood sugar tests would be suitable for determining the sugar levels in the patient’s blood. Mainly, the assessment is based on testing for risk of diabetes or liver disease as the chances for these conditions are 50% higher in Hispanics than non-Hispanics.

Interpretation or Diagnosis

Check all the above conditions as part of the health and wellness assessment and then offer a diagnosis for any abnormal conditions.

Treatment

Recommend a choice of treatment based on the diagnosis provided

Get the full solution HERE.

See also:

Neurovascular assessment – Athena Washington – iHuman Case Study Solution