Title: End of Module 2 / Beginning of Module 3
Course: HEALTH ASSESSMENT 80FA20

Very good postings last week for your documentation on Skin, Hair and Nails. I hope you are finding the Sherpath system user friendly and getting into a rhythm with working on readings and assignments with this course.

All grading is complete from Week # 1 now that everyone has been able to get into and complete the Sherpath assignments. I will have grading completed for the Discussion Board from Week # 2 in the next couple of days. Overall, your contributions to the weekly discussions were strong, but there is always room for improvement with documentation. A couple of things that were consistent was an incomplete subjective data assessment. Your subjective documentation should read "denies" or "no". For example, No hair loss or denies hair loss. You can also document all items together instead of writing multiple sentences For example, “patient denies previous skin problems or diseases, changes in existing moles or new moles, changes in skin color .....”

Be specific and purposeful with your documentation. I want you to move from using within normal limits to writing out the aspects of the assessment. This only helps to make a stronger assessment and stronger documentation if you were ever to be called to testify in court. Could you defend your documentation when only documenting within normal limits if something were truly missed? Your documentation should paint a clear picture of what is going on with your patient. What kind of picture are you painting?

You are completing these assignments for a grade in this course, but I challenge you to also reflect on your current practice and how you can improve documentation of patient assessments. Is your documentation in practice where it should be? How could you improve not only with your actual assessment, but documentation of those assessments as well?

Week 3:

This week, we will move on to the chest & lungs and heart. Nurses in all clinical practice settings need to develop the skills needed to conduct a comprehensive physical assessment of the respiratory and cardiovascular systems. These assessment skills are critical because respiratory and cardiac health problems can be life threatening. You will use Sherpath to review these systems and you will have the opportunity to document your findings from the simulated experience in a discussion posting for this week.

This week, you will also work on your first of three case studies in this course. For your weekly case studies, you will be choosing from a list of possible cases from the Clinical Reasoning Cases in Nursing text. Complete the case study as presented in the text, answering all of the questions included with the case study.

After completing that portion of the case study, you will re-evaluate the case using the health assessment information learned in this week’s lessons and answer the following questions:

1. As the BSN nurse caring for this patient, what would I include in my initial focused assessment for this patient & why?
2. What findings would I expect to be abnormal & why?
3. What would I include in my follow-up assessments & why?

These additional 3 questions account for a large percentage of the grade for this assignment. Be sure to include them in your response. (There are usually 1-2 students who forget to add these questions.) Please see the tab in Module 3 for your case study options and instructions for this assignment. It is due by Sunday at midnight this week.

As always, please contact me with any issues or questions.  Have a great week!

Dr. Ventura