Instructions
- 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.
Answer
- Write an SBAR note (Situation, Background, Assessment, Recommendations) to summarize this assessment. Hint: Since this is a wellness assessment your summary should include a comprehensive, but brief, review of all of your findings, not only abnormal results. To develop your note, type the appropriate information after each letter below.
S – Gonzalez is a 32-year-old female, who came to the clinic for a comprehensive assessment as she applied for insurance, considering ….
B – Gonzalez is alert and oriented, she described her health as being good. However, she does not have an…. To access full answer, use the purchase button below.