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Trinity Valley Community CollegeAssociate Degree Nursing ProgramLevel I – Well-Elderly Case Study Rubric Your Name:Date:Resident’s Initials:Name of Clinical Instructor:Name of Facility:Total Points (earned/possible): /16 AreaComplete2 ptsPartial1 ptInsufficient0 ptsWeightPointsSection 1. Assessment (Clinical Judgment)1a. AssessmentSubjective DataFills in blanks with appropriate data [≤ 4 inappropriate or missing]Total 4 ptsFills in blanks with appropriate data [5-8 inappropriate or missing]Total 2 ptsFills in blanks with appropriate data [>8 inappropriate or missing]Total 0 pts[X2]Total Possible: 4Earned: 1b. AssessmentAbnormal DataHighlights abnormal data except ≤ 4 instances of highlighting normal data or not highlighting abnormal dataTotal 4 ptsHighlights abnormal data except 5-8 instances of highlighting normal data or not highlighting abnormal data Total 2 pts1 Highlights abnormal data except >8 instances of highlighting normal data or not highlighting abnormal data Total 0 pts[X2]Total Possible: 4Earned:Section 2. Nutritional ScreeningNutrition(Critical Thinking Exercise)Lists two or more nutrition recommendations.Total 2 ptsLists one nutrition recommendation Total 1 ptMissing nutrition recommendationsTotal 0 pts[X1]Total Possible: 2Earned:Section 3. Environmental (Safety)Environment (Critical Thinking Exercise)List of identified hazards AND corresponding recommendations. If environment is hazard-free, then writes one paragraph describing the environmentTotal 2 ptsList of identified hazards AND corresponding recommendations, except missing 1 hazard/recommendation OR 1 inappropriate recommendation. OR If environment is hazard free and environmental descriptive paragraph is two to four sentences.Total 1 ptList of identified hazards AND corresponding recommendationsMissing ≥2 hazard AND/OR incorrect recommendation OR if environment is hazard-free and descriptive paragraph is less than two sentences.Total 0 pts[X1]Total Possible: 2Earned:Section 4. Team work & Collaboration (Critical Thinking)Team work & Collaboration (Critical Thinking Exercise)Identifies 5 or more resources already available that is used or not used by the client.Total 2 ptsIdentifies 3 or 4 resources already available that is used or not used by the client.Total 1 ptIdentifies 2 or fewer resources already available that is used or not used by the client or omits paragraph.Total 0 pts[X1]Total Possible: 2Earned:Section 5. APA References APA References All references alphabetized with APA format: Author, year, title, and journal.Total 2 ptsAll references alphabetized with APA format except one or two kinds of errors made of author, year, title, journal.Total 1 ptReferences not alphabetized and/or with APA format except three or more kinds of errors made of author, year, title, journal. Total 0 pts[X1]Total Possible: 2Earned:Trinity Valley Community CollegeAssociate Degree Nursing ProgramLevel I – Well-Elderly Case Study Section 1 a. Assessment (Clinical Judgment)Demographics: (Diversity concept) Age: _____ Gender: _____ Race: _____________ Ethnicity: _______________ Religion: ______________Do your spiritual beliefs apply to your health? Affects treatment decisions End-of-life care Special dietary needs Use of Faith/Folk healer Other: _____________________________________________________________________________________ Education completed: __________________________________________________________________________Present Health History __________________________________________________________________________________________________________________________________________________________________________________________Past Health HistoryMedical History: _____________________________________________________________________Surgical History: _____________________________________________________________________Accidents or Injuries: _________________________________________________________________How do you define health? _____________________________________________________________View of own health now: _______________________________________________________________What are your concerns? _______________________________________________________________What are your health goals? _____________________________________________________________Allergies: (Immunity concept) ? Food ? Drugs Comments: ____________________________________________________________Communicable Diseases: _______________________________________________________________Childhood Illnesses: ___________________________________________________________________Immunizations: Shingles vaccine Pneumococcal vaccine Influenza (flu) vaccine Tetanus, diphtheria, pertussis (Tdap) vaccine Date of immunizations: _______________________________________________________________Current Medications: Prescription and Over the Counter (OTC) Medication NameMedication ReasonDosageFrequency*Is the client able to verbalize all home medications: Accurately Inaccurately *Does the client manage medication administration: Independently Effectively with assistanceFamily Health HistorySelfMotherFatherGrandparentsSiblingsHeart DiseaseHigh Blood PressureStrokeDiabetesBlood DisordersCancerSickle Cell AnemiaArthritisObesityKidney DiseaseTuberculosisMental IllnessSeizuresAlcohol/Drug AbuseSocial/Emotional Support Assessment: (Coping concept)? Yes ? No Support System (Especially when there are problems) ? Case worker ? Children ? Family ? Friend ? Guardian ? Pet ? Religious leader ? Sibling ?Spouse ? Support group ? Therapist ? Other: ___________________________ Sleep Assessment: (Sleep concept) Average hours of sleep: ______ Usual bedtime: _______ Usual awake time: _______ Do you feel rested after you sleep? ? Yes ? No Quality of sleep: ? Poor ? Fair ? Good Sleep problems: ? Difficulty falling asleep ? Difficulty remaining asleep ? Night awakenings ? NightmaresPain Assessment: (Comfort concept)Pain History:Location: Where is your pain? ____________________________________________________________________Quality: Tell me what your discomfort feels like. _____________________________________________________Intensity: On a scale of 0-10 with “0” representing no pain and “10” representing the worst possible pain, how would you rate your pain? ________________________________________________________________________Pattern: When did or does the pain start? ____________________________________________________________How long have you had the pain, or how long does it last? ______________________________________________Do you have pain free periods? “yes” ask client to describe when do they have pain free periods_____________________________________________________________________________________________________________Precipitating factors: What triggers the pain or makes it worse? __________________________________________Alleviating factors: What measures or methods have you found helpful in lessening or relieving the pain? ____________________________________________________________________________________________Developmental Assessment: (Human Development concept)Which stage of Erikson’s Psychosocial Development does the client exhibit? ___________________________________________________________________________________________Is the client demonstrating successful or unsuccessful resolution of Erickson’s psychosocial stage? ____________If client successful, describe how the client is meeting the task. ____________________________________________________________________________________________________________________________________If client unsuccessful, list one intervention to assist the client in achieving Erickson’s stage of development.___________________________________________________________________________________________ Functional Assessment: (Functional Ability concept)Functional AssessmentIndependent (2)Requires assistance (1)Dependent (0)CommentBathingDressingToiletingTransferringContinenceFeedingADL Index Score12 = Total independence 6 = Moderate independence 0 = Maximum dependenceTotalTotalLawton Instrumental Activities of Daily Living (IADL):(The first answer in each case indicates independence, the second capability with assistance, the third; dependence The maximum score is 21. Declining scores over time reveal deterioration) Ability to use telephone: (3) Operates telephone on own initiative; looks up and dials numbers, etc. () Dials a few well known numbers (1) Answers telephone but does not dial (0) Does not use telephone at allShopping: (3) Takes care of all shopping needs independently (2) Shops independently for small purchases (1) Needs to be accompanied on any shopping trip (0) Completely unable to shop Food preparation: (3) Plans, prepares and serves adequate meals independently (2) Prepares adequate meals if supplied with ingredients (1) Heats and serves prepared meals or prepares meals but does not maintain adequate diet (0) Needs to have meals prepared and servedHousekeeping: (3) Maintains house alone or with occasional assistance (2) Performs light daily tasks but cannot maintain acceptable levels of cleanliness (1) Needs help with all home maintenance tasks (0) Does not participate in any housekeeping tasksLaundry: (2) Does personal laundry completely (1) Launders small items; rinses socks; stockings; etc. (0) All laundry must be done by othersMode of Transportation: (3) Travels independently or drives on vehicle (2) Arranges own travel via taxi, but does not otherwise use public transportation (1) Travel limited to Taxi or car, with assistance of another (0) Does not travel at allResponsibility for own medication: (2) Is responsible for taking medication in correct dosages at correct time (1) Takes responsibility if medication is prepared in advance in separate dosages (0) Is not capable of dispensing own medication Ability to handle finances: (2) Manages financial matters independently; collects and keeps track of income (1) Manages day-to-day purchases, but needs help with banking, major purchases, etc. (0) Incapable of handling money IADL Total: __________Morse Fall Risk Assessment (Safety concept)YesNoPointsHistory of Falling immediate or in the last three monthsYes response = 25Presence of secondary diagnosisYes response = 15Use of ambulatory aidFurniture =30 Crutches, cane, walker = 15IV/Heparin lockYes response =20Gait/TransferringImpaired = 20 Weak =10Mental StatusForgets limitations = 15Total Score:0-44 indicates need for standard environmental safety precautions.A score of 45 or > will add a problem “At Risk for Falls” to the problem list. Please initiate the Fall Prevention Plan of Care.TotalSection 1b. Abnormal Data – Review the above assessment and highlight ALL abnormal data.Section 2. Nutritional Screening: (Nutrition concept) Usual Weight: ___________ Appetite: Good Fair Poor Other: _________________ Unintentional weight change greater than 10 lbs. in the last 6 months: Yes NoWeight gain: Yes _________ No Weight loss: Yes _________ NoDiet: NPO Regular Bland Diabetic Dysphagia Ground Kosher Low cholesterol Low fat Low sodium Mechanical soft No added salt Pureed Renal VegetarianEating difficulties: Chewing Loose teeth No teeth SwallowingIf eating difficulties present, describe the problem: ______________________________________________Nutritional Risk Factors YesIf yes, ask and describe history of problemConstipationEating DisorderEnteral FeedingsImpaired Nutritional Intake Fluid intake < 50% of normal in last three days Nausea/Vomiting/DiarrheaHistory of Skin Breakdown/Decubitus Ulcers24 hour RecallTimeList food and drink consumedApproximate how much protein, fat and carbohydrate in food /drink item listed BreakfastLunchAfternoon snackDinnerHS snackSection 2b. Critical Thinking Exercise (Nutrition)Review and analyze the data collected from the nutritional screening, nutritional risk factors and the 24-hour food recall. Based on your analysis list 2 or more recommendations that would increase healthier choices for good nutrition. (For example, does the client need to include, limit or avoid other food groups? If so, then what?) Document recommendations in the space below_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Section 3a. Environmental Safety Assessment: (Safety concept)Is there good lighting available? _ Yes _ NoIs temperature of home within a comfortable range? _ Yes _ No Are there loose extension cords, small sliding rugs, and slippery linoleum tiles present? _ Yes _ NoIf yes, describe: _________________________________________________________________Are the edges of rugs tacked down? _ Yes _ No Are electrical cords in good condition? _ Yes _ No Is furniture arranged to allow for free movement in heavily traveled areas? _ Yes _ No Is furniture sturdy enough to give support? _ Yes _ No Is furniture designed to accommodate easy transfers on and off? _ Yes _ No Is there a telephone present? _ Yes _ No Are smoke detectors present? _ Yes _ No Are there grab bars in the bath, in shower, and around the toilet? _ Yes _ NoSection 3b. Critical Thinking Exercise for Environment Assessment (Safety)Provide recommendations for all identified safety, environmental and/or hazardous problems from the “Assessment of Home Environment for Safety Hazards” in this case study form. Complete one paragraph describing all hazards identified; if no hazards identified, then write one summary paragraph.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Section 4. Critical Thinking Exercise (Teamwork and Collaboration)Because of the increasing number of older adults, identify 5 resources available in your community to assist with this growing population. 1.) __________________________________________________________________________________________2.) __________________________________________________________________________________________3.) __________________________________________________________________________________________4.) __________________________________________________________________________________________5.) __________________________________________________________________________________________ Section 5. APA Style Reference Format ................
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