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NURS 6512 Drooping of Face Case Study Clinical Experience Notes
NURS 6512 Drooping of Face Case Study Clinical Experience Notes
I’m giving you the attachment with the SOAP Template filled out for the case scenario “drooping face” for the first assignment. You will read the transcript of the conversation between the patient and the APRN for a thorough physical examination before filling out the WALDEN SOAP TEMPLATE I supplied you. You must cite sources in APA format and offer justification for both tasks. references no more than four years old. NURS 6512 Drooping of Face Case Study Clinical Experience Notes
Week 9: Assessment of Cognition and the Neurologic System
A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.
An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life. NURS 6512 Drooping of Face Case Study Clinical Experience Notes
This week, you will explore methods for assessing the cognition and the neurologic system.
NURS 6512 Drooping of Face Case Study Clinical Experience Notes Learning Objectives
Students will:
- Evaluate abnormal neurological symptoms
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
- Assess health conditions based on a head-to-toe physical examination NURS 6512 Drooping of Face Case Study & Clinical Experience Notes
Learning Resources
NURS 6512 Drooping of Face Case Study Clinical Experience Notes Required Readings
Ball, J. W., Dais, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 7, “Mental Status”
This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms. - Chapter 23, “Neurologic System”
The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. NURS 6512 Drooping of Face Case Study Clinical Experience Notes
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources: NURS 6512 Drooping of Face Case Study Clinical Experience Notes
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Student Acknowledgement Form (Word document)
Use this template to complete your Assignment 3 for this week.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 14, “The Neurologic Examination” (pp. 683–765)
This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams. - Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)
In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.
NURS 6512 Drooping of Face Case Study Clinical Experience Notes Required Media
Neurologic System – Week 9 (16m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
Photo Credit: Getty Images/iStockphoto
Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors. NURS 6512 Drooping of Face Case Study Clinical Experience Notes
In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To Prepare
- By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
- Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
- Review this week’s Learning Resources, and consider the insights they provide about the case study.
- Consider what history would be necessary to collect from the patient in the case study you were assigned.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. NURS 6512 Drooping of Face Case Study Clinical Experience Notes
The Case Study Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
By Day 6 of Week 9
Submit your Assignment.
NURS 6512 Drooping of Face Case Study Clinical Experience Notes Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.
- Click the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
- Click the Week 9 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn1+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 9 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 9 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 6 of Week 9
To participate in this Assignment:
Week 9 Assignment 1
Rubric Detail ASSIGNMRNT#1
NURS 6512 Drooping of Face Case Study Clinical Experience Notes Rubric
| Excellent | Fair | Poor | ||||
| Using the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. · Provide evidence from the literature to support diagnostic tests that would be appropriate for your case. |
45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. |
NURS 6512 Drooping of Face Case Study Clinical Experience Notes | 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. |
0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. |
||
| · List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. | 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study and provides a thorough, accurate, and detailed justification for each of the five conditions selected. |
NURS 6512 Drooping of Face Case Study Clinical Experience Notes | 18 (18%) – 23 (23%)
The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each. |
0 (0%) – 17 (17%)
The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. |
||
| Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. |
NURS 6512 Drooping of Face Case Study Clinical Experience Notes | 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. |
0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. |
||
| Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. |
NURS 6512 Drooping of Face Case Study Clinical Experience Notes | 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. |
0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
||
| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. | 5 (5%) – 5 (5%)
Uses correct APA format with no errors. |
NURS 6512 Drooping of Face Case Study Clinical Experience Notes | 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. |
0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors. |
||
| Total Points: 100 | ||||||
Name: NURS 6512 Drooping of Face Case Study Clinical Experience Notes Rubric
Rubric Detail ASSIGNMENT# 3
Select Grid View or List View to change the rubric’s layout. NURS 6512 Drooping of Face Case Study Clinical Experience Notes
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments.
Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course. NURS 6512 Drooping of Face Case Study Clinical Experience Notes
| Excellent | Fair | Poor | ||||
| Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score. |
56 (56%) – 60 (60%)
DCE score>93 |
NURS 6512 Drooping of Face Case Study Clinical Experience Notes | 46 (46%) – 50 (50%)
DCE Score 80-85 |
0 (0%) – 45 (45%)
DCE Score <79 No DCE completed. NURS 6512 Drooping of Face Case Study Clinical Experience Notes |
||
| Documentation in Provider Notes Area
Subjective documentation of the comprehensive exam in Provider Notes is detailed, organized, and includes documentation of identifying data, general survey, reason for visit/chief complaint, history of present illness, medications, allergies, medical history, health maintenance, family history, social history, mental health history, and review of systems. The review of systems is clearly defined by each body system (skin, eyes, cardiac, etc.) and all conditions or illnesses asked of the patient are documented along with the patient response. |
16 (16%) – 20 (20%)
Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
NURS 6512 Drooping of Face Case Study Clinical Experience Notes | 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
0 (0%) – 5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. NURS 6512 Drooping of Face Case Study Clinical Experience Notes |
||
| Objective Documentation in Provider Notes – this is to be completed in Shadow Health
Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. Diagnostic result- Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). |
16 (16%) – 20 (20%)
Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam.
Use as many as necessary resources to support your information. References not older than 4 years. |
NURS 6512 Drooping of Face Case Study Clinical Experience Notes | 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. NURS 6512 Drooping of Face Case Study Clinical Experience Notes |
0 (0%) – 5 (5%)
Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. NURS 6512 Drooping of Face Case Study Clinical Experience Notes |
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| Total Points: 100 | ||||||
Name:NURS 6512 Drooping of Face Case Study Clinical Experience Notes Rubric