Health Assessment

Purpose: This assessment is allowed students to provide an overview of health problems through the analysing and synthesizing the subjective and objective data in physical assessment. It helps to make the possible clinical conditions related to nursing diagnosis for implement appropriate nursing interventions to address the health needs of client.
Submission guideline:
 Each submitted essay must have a cover page
 The essay should be formatted appropriately as stated in this document.
 Each student must sign on the cover page and fill in all the fields as requested.
 The actual word count is 1600 words (+/- 10%), which must be clearly stated on the cover page. Words beyond the word count will not be marked
 A soft copy should be submitted as a single PDF file to Moodle by 22/04/2024 on or before 17:00, and an identical hardcopy file also need to submit to the Assignment Box located at 8/F, SFU
 Any late submission is subject to a 5%-mark deduction penalty for each calendar day
 Each student has only one chance of submission. No repeated submission is allowed. The first submission is considered final. All subsequent submission(s) will not be marked.
 No Turnitin is required

Submission Format:
 Font style: Times New Roman.
 Font size: 12.
 Margins: 2.5cm margin in each side of pages.
 Spacing: double-spaced.
 All pages must be numbered (at the center of the bottom of each page).
 Write your student ID ONLY at the right top corner of each page.
 The softcopy of the project should have a white background with the text in black. It is submitted to the collection box (with named of your assigned Workshop Teacher) in Moodle. Upload ONLY pdf format file
 No email submission is allowed.

Suggested content:

1. Cover page
2. Table of content
3. Introduction
4. Assessment
5. Planning and implementation
6. Evaluation
7. Conclusion
8. Reference

Marking criteria:

Introduction
Describe the background information of the given scenario

Assessment:

• History taking by using the Patient Assessment Form (PAF) to elaborate client’s current physio-psychosocial status according to the related questions
• Analysis and describe the assessment findings from TWO problematic body systems

Planning and implementation

• Describe and interpret clearly the Subjective Data of the client
• Describe and interpret clearly the Objective Data of the client
• Differentiate normal and abnormal findings
• Establish FIVE specific and realistic nursing care / intervention of each problematic body system for the client

Evaluation

• Describe the appropriate and relevant methods used to evaluate the effectiveness of the progress

Conclusion

• Provides a clear, precise, and concise summary of the care

Writing skills

• Logical flow and showing ability to organize

Format and style

• Correct spelling, punctuation and grammar
• Correct use of the APA (7th ed.) (2020-21) referencing guide

Academic Honesty and Plagiarism
Plagiarism is an unacceptable and undesirable practice. Serious attention is drawn to the policies for honesty in academic work. Details can be found in the Student Handbook for CIHE Sub-degree Programmers 2023-2024. Students are strongly reminded that the assignment must be your own work. Copying from other people’s work and quoting of others’ ideas without proper citation and the use the APA referencing style, see CIHE Library (2020) APA Referencing Guide. A ZERO mark will be given if the student(s) is/are found to have plagiarized.

Scenario

Progress Note Hosp No.: HN 24000133
Name: Lee Loi HKID: A123321(A)
李來 DOB: 01/01/1942
Sex: F Age:80
Ward: S4 SPEC: MED
Progress Date: 21/3/2024 Entry Date: 21/3/2024
Last updated by: Peter Sin on 21/3/2024 07:30
Progress: 80/F
NKDA
Married, lives with daughter
ADL-partial dependence, walk with frame at day time Chronic smoker: over 30 years

PHx
Hypertension, congestive heart failure, atrial fibrillation on warfarin

Emergency admission xxxxxx P/E:
Conscious but tired looking, able to answer simple questions
Slurring-speak, verbal report of slip and fell at home twice in recent two weeks GCS 14/15 (E3V5M6)
BP 168/92 mmHg Pulse: 148bpm RR:16/min Temp: 36.2C SpO2: 95% in room air
TOCC: -ve

Complaint of right-side weakness x 2/7 with no trauma Limb power left 5/5, right side 4/5
Paralysis of face and right eye drop Generalizes oedema x 1/52 Increase headache in recent month
On self-medication (claimed use pain killer_ Panadol), pain cannot be subsided

Chest: clear
Air entry: normal HSD with murmur
Bilateral lower limbs swelling caused by CHF Engorged neck vein observed
BW: 60Kg BH: 1.77M

Progress Note Hosp No.: HN24000133
Name: Lee Loi HKID: A123321(A)
DOB: 01/01/1942
Sex F Age 80
Ward: S4 SPEC: MED
Progress Date: 21/3/2024 Entry Date: 21/3/2024
Last updated by: Peter Sin
Progress: ECG: fast AF 168 beats/min CXR: cardiomegaly
CT brain: left hypodense lesion, ischemic changes
IMP: xxxxxxx

Current medications
Number Medication Route/Dosage/Frequency

1. Lasix PO/20mg/BD
2. Warfarin PO/3mg/QD
3. Losartan PO/12mg/QD
4. Betaloc PO/25mg/OM
   Mx:
   BP/P, GCS Q4H
   Cardiac monitor
   Fluid restriction 1L/day Strict I/O
   Checking blood x CBP/RFT/LFT/TnT, clotting profile to titration of warfarin BW daily
   Inform MO if decrease GC
   Add Amiodarone loading dose 150mg in D5 100ml over 30 minutes Repeat ECG after loading dose
   Signed: Peter Sin
   Dr. Peter Sin MO 2343