Description
ntroduction – Performing a symptom analysis or expanding on the “History of Present Health Concern,” takes into account several aspects of the health problem and asks questions that can provide a detailed description of the concern. The client’s answers may provide the nurse with a beneficial information about the client’s problem(s).
Purpose and Objectives – Practice collecting, analyzing, and prioritizing data from a client with a complaint. This will help you develop clinical judgment skills and to care for client’s in the clinical setting.
The student will address:
Character or signs and symptoms of the problem.
Onset, progression, and duration of the problem.
What the client believes is the cause of the problem and client appraisal of the problem (minor, severe, etc.).
What makes the problem better or worse.
Treatments that make the problem better or worse and there effectiveness.
How the problem has effected the client’s daily life or lifestyle AND other symptoms associated with the problem.
The student will:
Document assessment findings.
Analyze assessment and lab/diagnostic findings.
Identify priority nursing diagnoses, interventions, and client teaching opportunities.
Detailed Tasks
Step 1: Select one of the case scenarios (abdominal, respiratory, cardiovascular, or neurological) to further evaluate.
Step 2: Review the patient chart and patient scenario video. You will need the subjective and objective data to reach a clinical judgment.
Must be typed to receive credit. Type into provided template.
All areas must be addressed per rubric.
Items not addressed in the video or chart should be charted as “not performed”. If you identify something as “not performed” and it was addressed, points will be deducted.
Remember to avoid client identifiers to practice HIPAA compliant documentation. Even though this is a scenario, we treat simulation and scenario based care as we would with actual client’s in the hospital setting.
Unformatted Attachment Preview
1
Symptom Analysis Template
Major Assignment: Must achieve a benchmark of 80% in two attempts, per the syllabus, to pass the
course.
1. Select one of the case scenarios: abdominal, cardiovascular, respiratory, or neurological.
2. Review the patient chart and patient scenario video. You will need the chart, subjective and
objective data to reach a clinical judgment.
3. Complete symptom analysis using this template. Items not addressed in the video or chart should
be charted as “not performed”. If you identify an item as “not performed” and it was addressed,
points will be deducted.
Name:
Instructor/Coach:
System:
Instructions
& Points
General Patient Information
4 pts total
Symptom 1 pt.
Ex. Pain-right knee
Demographic Data 1 pt.
Age, Date of Birth
Medical Diagnosis related to
symptom 1 pt.
Past Medical History 1 pt.
Serious or Chronic Illness
Past Surgeries
Allergies
Smoking and Alcohol Use
History of Present Illness
(COLDSPA): Answers only
5 pts total
C
O
L
NURS3320 – Spring 2024
Patient information
2
Instructions
& Points
Patient information
D
S
P
A
Laboratory/Diagnostic Data
6 pts total
Pertinent Laboratory or Diagnostic
Data (lab, x-ray, etc.)
Include test, client result and
normal range.
Must relate to the symptom
Assessment Findings
8 pts total
Vital signs 1 pt.
Temp including route
BP
Pulse
Respiratory Rate
Oxygen Saturation
Pain
Height
Weight
Neuro & Mental Status
Level of Consciousness
Orientation
PERRLA
Paresthesia
Behavior/affect
Speech
Other
General Survey
Distress: present/not present
Posture/gait
Skin, hair & nails
Skin:
– General skin coloration
NURS3320 – Spring 2024
1 pt. deduction per issue: max dedication 8 pts
3
Instructions
& Points
– Temperature: Upper/Lower
– Skin Intact/Not Intact (wounds,
etc.)
Nails: Capillary refill, clubbing
HEENT
Facial features: symmetric or
asymmetric
Able to see nurse
Able to hear and respond
Able to breathe/patent air flow
Respiratory
Breath sounds
Quality and effort of breathing
Accessory muscles/position used
Room Air or Oxygen: LPM & device
Heart & Vascular
Heart rhythm
Heart sounds (S1, S2)
Presence/absence:
– Extra Sounds (S3 or S4)
– Murmurs
Pulses bilaterally:
– Radial
– Dorsalis pedis
– posterior tibial
Presence/absence of edema
Appearance of skin on legs/feet
– Lesions, ulcers, coloration
Abdomen
Inspection:
– color, contour, skin (striae,
scars, etc.), pulsations
Auscultation:
– Bowel sounds
Palpation
Presence of tubes or drains
Musculoskeletal
ROM: Full/Limited & Passive/Active
– Upper
– Lower
Muscle strength
NURS3320 – Spring 2024
Patient information
4
Instructions
& Points
– Upper
– Lower
Gait: Steady/Unsteady
Mobility: Ambulatory/Bedrest
Analysis
62 pts total
7 pts
What is happening with the client?
Are they recovering or declining?
What makes you think this?
Provide specific evidence.
Explain in 3 or more sentences.
5 pts
What are anticipated or common
findings for this for ANYONE with
this diagnosis?
List 5 or more findings.
15 pts
How does the client’s assessment
data fit with their lab or diagnostic
findings? Include all lab and
diagnostic data.
(For example: does the client’s pain
rating seem to correlate with the
nature of the fracture as shown in
the x-ray?)
Explain in 3 or more sentences.
10 pts
What are some key assessment
findings for this client?
Did you expect these findings?
Did you expect different findings?
Why?
Explain in 3 or more sentences.
10 pts
Summarize the pathophysiology
for your client’s medical diagnosis.
Do not copy and paste.
Provide an in-text citation here and
reference page at the end of the
document in APA format.
NURS3320 – Spring 2024
Patient information
5
Instructions
& Points
Use reputable source such as STAT
Pearls or Lippincott from within
last 5 years.
Explain in 3 or more sentences.
15 pts
Summarize your analysis of these
findings including client
assessment data, lab/diagnostic
data, medical diagnosis. Must be
substantive with patient details.
Explain in 3 or more sentences.
Nursing Diagnosis & Interventions
15 pts total
3 pts
Priority Nursing Diagnosis with
client specific evidence.
6 pts
List two NURSING independent
interventions specific to your client
and the priority nursing diagnosis.
Include your rationale.
6 pts
List two educational interventions
specific to your client and the
priority nursing diagnosis. What
should you teach your client?
NURS3320 – Spring 2024
Patient information
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