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Clinical II - SIM 4 - Case Studies

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Clinical II - SIM 4 - Case Studies *to be done early in the semester Case Study 1 Scenario P.M., 24-year-old house painter, too ill to work the past 3 days. Arrived at your outpatient clinic with his girlfriend, he seems alert but acutely ill, with an average build & a deep tan over the exposed areas of skin. He reports headaches, joint pain, a low-grade fever, cough, anorexia, & nausea and vomiting (N/V), especially after eating any fatty food. P.M. describes vague abdominal pain that started about the same time as the other problems. He states that he has been using “a lot of Tylenol” for his pain. His past medical history reveals he has no health problems, is a nonsmoker, & drinks “a few” beers each evening to relax. Vital signs are 128/84, 88, 26, 100.6 ° F (38.1 ° C); awake, alert, & oriented × 3; moves all extremities well with complaints of aching pain in his muscles; very slight scleral jaundice present; heart & lung sound clear & without adventitious sounds; bowel sounds clear throughout abdomen & pelvis; & abdomen soft & palpable without distinct masses. You note moderate hepatomegaly measured at the midclavicular line; liver edge is easily palpated & tender to palpation. P.M. mentions that his urine has been getting darker over the past 2 days. 1. Your institution uses electronic charting. Based on the health history and assessment described in the scenario, which of the following systems would you mark as “abnormal” as you document your findings? Mark abnormal findings with an X and provide a brief narrative.

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Level 2: Clinical Performance Evaluation- ADNG 2100 Clinical II

 Student will complete a self-evaluation of each student learning outcome below using the criteria on the left found
under each outcome. Briefly summarize, either in bullet point or paragraph form, your own evaluation of performance
in each. Be specific, give examples. In areas you identify as needing growth, provide specific strategies for
improvement in your next clinical course.
 Submit to the Clinical Performance Evaluation assignment folder in your clinical course by the assigned due date.

HUMAN FLOURISHING
Apply knowledge and skills learned in the program to uphold patients’ right of self-determination and promote holistic well-being of client
and family.
QSEN#1- Provide patient-centered care
Expected Satisfactory Behaviors Student Self-Evaluation

Apply therapeutic communication skills in
interactions with client and family
Identify behaviors that threaten or protect client
autonomy, dignity, and rights
●Respect client autonomy and recognize
opportunities for client advocacy
Illustrate how individual differences and values
affect client outcomes
Objective Data: Holistic Assessment &
Application of Nursing Process, Reflective
Journal

NURSING JUDGMENT
Make judgments in practice, supported by evidence, that integrate nursing science in the provision of safe, quality care.
QSEN#2- Safety, Patient and Healthcare Provider
QSEN#3-Informatics
Expected Satisfactory Behaviors Student Self-Evaluation


●Utilize the nursing process to develop an
individualized plan of care
●Provide valid rationales for nursing
interventions
●Communicate assessment findings to instructor

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Geüpload op
27 augustus 2025
Aantal pagina's
3
Geschreven in
2025/2026
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Case uitwerking
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Gideon
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