PART ONE: Health assessment Background Case studies have long been used as tools

PART ONE: Health assessment
Background
Case studies have long been used as tools for learning law, medicine, and management. Case analysis allows for the translation of theory and principles into practice and allows for the application of critical thinking and decision-making skills in simulated situations.
In your case study group assignment, you will have the opportunity to analyze and create a “template” for the Nursing Process by creating one (1), well done, nursing care plan/map using the theories and principles discussed in this lesson. Part 1 is the beginning of your template, which you will build upon with your group throughout this course and use in the future as you move forward in the program. Discussions of the case within your group will provide for team-building and critical thinking skills development.
A complete assessment considers all of the following:
HIPAA-compliant Biographical Data
HPI (History of Present Illness)
Past Medical History – Only the medical and/or surgical history. Include a concise definition of each medical or surgical diagnosis.
Medications – Name and dose
Diagnostic Studies – Pertinent results of labs, procedures, and other tests (radiology, etc.)Cultural and Spiritual Health Assessment
Culture/ethnicity, language
Health Beliefs
Economic/Educational
Spiritual Beliefs
Significant Others
Physical Assessment Findings (All systems required)All subjective and objective findings for each system must be documented as assessed in the case study or documented as missing.
Example Case Study
Example of subjective finding – Review of systemsSkin: Patient does not endorse any skin abnormalities.
Example of objective finding – Physical assessmentSkin: Reports rash from poison ivy exposure. Denies skin disease, pigment changes, mottling, change in mole, acne, easy bruising, easy bleeding, and changes in hair or nails. OR: assessment data unavailable at this time.
Instructions
You will automatically be assigned to a group during the first class. Meet with your group and determine each group member’s role and responsibilities (e.g., editor or checking for accuracy) and who will be the group’s leader. The leader is responsible for submitting the assignment in the online course for the group and forwarding the graded assignment with instructor feedback to all group members. The leader is not limited to this task. The leader is expected to make substantive contributions to the group.Use the following naming convention for the group’s file: Group-Case Study Number_ Name of Group Leader_Assignment Part Number
Example: Group-#_JamesDaniels_Part1
Your group will be assigned a number with a corresponding case study. Review your group’s case study. Your case study will guide you as your group categorizes and records the assessment data.Group 1 Case Study
Use the case study to classify subjective and objective assessment findings in the appropriate format. Do not add any information that is not found in the case study. Apply the concepts in Lesson 1.
If some of the data is missing, it is intentional and mirrors future assessments that you will perform on real patients. Apply the concepts that you have learned in this lesson.
Subjective data is captured in the review of systems and must mirror the object of data that is captured in the physical assessment. This is why all body systems must be listed.If the case study does not provide data for a body system please indicate that the data was missing.
For subjective data that is missing, you may state, “patient does not endorse.”
For objective data that is missing you may state, “not observed,” or “assessment data unavailable at this time.”
Write and format your paper according to APA style. Include the following:APA title page (list all members of your group)
In-text citation of sources
References page
It is expected that Part 1 will be at least two to three pages in length, excluding the title page and the references page. However, your case study may call for more extensive writing to include all required components.
For Part 1, it is not expected that you will refer to resources other than the required textbook. You are expected to cite the textbook as well as any other resources that you use.

Do not rely on citation or formatting generators to format your paper or provide citations. If you need guidance on APA, review the resources available at Citation Resources Guide: APA.
Additional Resources
Chapter 4: Review of Systems in Physical Examination and Health Assessment (8th ed.)
Citation Resources Guide: APA
PART TWO: Nursing Diagnosis
Background
A nursing diagnosis is based on the nurse’s assessment of a patient’s actual or potential health status. The nursing diagnosis is informed by NANDA-International, which is committed to increasing the visibility of nursing’s contribution to patient care by continuing to develop, refine and classify phenomena of concern to nurses. (NANDA-I, 2018-2020) To meet this end, standardization of nursing actions and common terminology is important in the provision of consistent care over time, among nurses, across shifts, and even between different health-care agencies. How to Write a Nursing Diagnosis” NANDA Taxonomy incorporates the nomenclature of Taxonomy II that has been adopted by NANDA-I.
There are three essential components in a nursing diagnosis, which comprise the PES format.
P identifies the health problem. The health problem is the NANDA-I diagnosis.
E represents the etiology (i.e., cause) of the problem.
S describes a cluster of signs and symptoms, or what has come to be known as “defining characteristics.”
These three parts are combined into one statement by the use of “connecting words.”
The diagnosis would then be written in this manner:
Problem “related to”: The problem, or NANDA-I Diagnosis, is identified as the human response to actual or potential (risk for) health problems as assessed by the nurse.
Etiology “evidenced by” (meaning, caused by): The etiology may be represented by past experiences of the individual, genetic influences, current environmental factors, or pathophysiological changes.
Signs (subjective) and symptoms (objective) data: Signs and symptoms are the defining characteristics that describe what the patient says (i.e., signs: subjective data) and what the nurse observes (i.e., symptoms: objective data) that indicate the existence of a particular problem.
The Nursing diagnoses, complete with all three components (i.e., PES), become the basis for the care plan.
Instructions
Continue working with your assigned group. The leader is responsible for submitting the assignment in the online course for the group and forwarding the graded assignment with instructor feedback to all group members. The leader is not limited to this task and is expected to make substantive contributions to the group as are all group members.Use the following naming convention for the group’s file: Group-Case Study Number_ Name of Group Leader_Assignment Part Number
Example: Group-#_JamesDaniels_Part2
Review your instructor’s feedback on your group’s submission of Part 1 and update Part 1 as necessary. Any and all revisions will be submitted with Part 2.
Review How to Write a Nursing Diagnosis Statement.
Review your group’s case study and identify the highest priority issue.
Develop one nursing diagnosis that correlates with that issue. Write the Nursing Diagnosis to model the PES format Be sure to include the following information in your nursing diagnosis:Definition: Identify the problem using the approved NANDA definition.
Possible Etiologies (“related to”): This section suggests possible causes for the problem identified. Related/Risk Factors are given for diagnoses for which the patient is at risk. Note: Defining characteristics are replaced by “related/risk factors” for the “Risk for” diagnoses.
Defining Characteristics (“evidenced by”): This section includes signs and symptoms that may be evident to indicate that the problem exists.
Your submission must include Part 1. Write and format your paper according to APA style. Include the following:APA title page (list all members of your group)
In-text citation of sources
References page
Part 2 should be a single, concise sentence that meets the PES format. However, the sentence must not mirror a diagnosis from a nursing diagnosis manual. It should be an original sentence drafted by your group. As such, you should not have referred to a resource to complete Part 2.