Department of Nursing Grading Criteria for Complete Health Assessment Case Study Paper Team #_____________________________Names:______________________________________________________________________________________Date: __________ Content Possible Points Student’s Score 1. Biographical Data, Source and Reliability of Information, Reason for Seeking Care are complete. 5 2. History of Present Illness is written in paragraph form. 15 3. Review of Systems (Subjective data)– discuss history of each system and use abbreviated format, not complete sentences: general, psychiatric, skin, hair, nails, lymph nodes, HEENT (head, eyes, ears, nose, mouth, throat), neck, blood, breasts, cardiovascular, respiratory, GI, GU, musculoskeletal, neurologic, endocrine 20 4. Physical Assessment: General Survey, Vital Signs, Height and Weight, Pain Assessment, BMI 10 5. Physical Examination (Objective Data)– Vital signs, general appearance, psychiatric, HEENT, neck, breasts, lymph nodes, pulmonary, cardiovascular, skin, nails, abdomen, genitourinary, pelvic, rectal, extremities, musculoskeletal, neurological (DTR’s, reflex grading, cranial nerve evaluation) 25 6. Medications - For each medication the client is taking fill out a Patient Education Sheet that includes  Why/How patient takes the medication  The 3 most common side effects & symptom(s) to report  Address patient medication related concerns 15 7. Health Promotion: State 3 areas where health promotion is needed for this patient. Provide specific examples of how you would educate this patient. Describe how these health promotion teachings fall in line with the Healthy People 2020 Objectives. 10 TOTAL 100 Note - Students may use the Complete Health Assessment form on pg.784 in the Jarvis textbook as a guide as a guide for write-up but using own words as it relates to the case study. References should be cited using proper APA format. Use the Patient Education Sheet provided for each medication. Comments: Determined and goal-oriented with 8 years of work experience in retail coupled with excellent communication skills and a strong customer focus. Looking to obtain a position in a fast-paced organization where exceptional leadership skill and ability will be useful to meet set organizational goals. Skills Communication Attentive and conscientious Hard worker; learns easily and quickly Time Management Organizational Problem-solving Adaptability Interpersonal Experience 2019/June-Currently Sales Associate Aldi · Assists management in achieving store appearance and maintenance standards. · Identifies and rectifies h ...

1. Department of Nursing
Grading Criteria for Complete Health Assessment Case Study
Paper
Team
#_____________________________Names:________________
_____________________________________________________
_________________Date: __________
Content Possible Points Student’s Score
1. Biographical Data, Source and Reliability of Information,
Reason for Seeking Care are complete.
5
2. History of Present Illness is written in paragraph form.
15
3. Review of Systems (Subjective data)– discuss history of
each system and use abbreviated format, not complete
sentences: general, psychiatric, skin, hair, nails, lymph
nodes, HEENT (head, eyes, ears, nose, mouth, throat),
neck, blood, breasts, cardiovascular, respiratory, GI, GU,
musculoskeletal, neurologic, endocrine

2. 20
4. Physical Assessment: General Survey, Vital Signs, Height
and Weight, Pain Assessment, BMI
10
5. Physical Examination (Objective Data)– Vital signs,
general appearance, psychiatric, HEENT, neck, breasts,
lymph nodes, pulmonary, cardiovascular, skin, nails,
abdomen, genitourinary, pelvic, rectal, extremities,
musculoskeletal, neurological (DTR’s, reflex grading,
cranial nerve evaluation)
25
6. Medications - For each medication the client is taking fill
out a Patient Education Sheet that includes
to report
15
7. Health Promotion: State 3 areas where health promotion
is needed for this patient. Provide specific examples of
how you would educate this patient. Describe how these
health promotion teachings fall in line with the Healthy
People 2020 Objectives.

3. 10
TOTAL
100
Note - Students may use the Complete Health Assessment form
on pg.784 in the Jarvis textbook as a guide as a guide for write-
up but using own
words as it relates to the case study. References should be cited
using proper APA format. Use the Patient Education Sheet
provided for each
medication.
Comments:
Determined and goal-oriented with 8 years of work experience
in retail coupled with excellent communication skills and a
strong customer focus. Looking to obtain a position in a fast-
paced organization where exceptional leadership skill and
ability will be useful to meet set organizational goals.
Skills
Communication
Attentive and conscientious
Hard worker; learns easily and quickly
Time Management
Organizational
Problem-solving

4. Adaptability
Interpersonal
Experience
2019/June-Currently Sales Associate
Aldi
· Assists management in achieving store appearance and
maintenance standards.
· Identifies and rectifies hazards and/or equipment in need of
maintenance to provide a safe environment.
· Assists management in achieving payroll and total loss goals.
· Assists customers with problems or concerns, and contacts
management as appropriate regarding customers with problems
or concerns.
· Provides feedback to management on all products, inventory
losses, scanning errors, and general issues that could impact
productivity.
· Processes customer purchases, performs general cleaning
duties, and stocks shelves and displays neatly to maximize
visibility and sales.
· Participates in taking store inventory counts according to
guidelines.
· Complies with all established company policies and
procedures.
· Collaborates with team members and communicates relevant
information to direct leader.
· Upholds the security and confidentiality of documents and
data within area of responsibility.
2011/June– March/2019 Store ManagerDollar Tree
· Managing the profitable operation of a retail store with
emphasis on recruiting, hiring, training and developing store
associates in both operations and merchandising
· Performing all opening and closing procedures
· Implementing all operational and merchandising direction that
is communicated from the Store Support Center

5. · Maintaining a high standard of merchandising, placement,
store signage, and proper display techniques to create an
inviting atmosphere for customers
· Assisting in the realization of your store's maximum profit
contribution
· Protecting all company assets
· Maintaining a high level of good customer service
· Creative problem solving in the areas of Associate
Development, Merchandise Display, Store Signage Placement,
Maximizing Sales Potential, Controlling Expense and Shrink.
2013/Feb. – 2014/Nov. SupervisorSodexo (Aventura Hospital
and Medical Center)
· Maintained clean and well-organized production areas to avoid
violations or unnecessary work delays due to hazards or
inefficient layouts.
· Applied strong leadership talents and problem-solving skills to
maintain team efficiency and organize workflows to meet any
daily demand.
· Prepared, calibrated and monitored production machinery to
maintain optimal production levels and consistently achieve
daily targets.
· Conducted routine inspections of incoming materials to check
quality and compliance with established product specifications.
· Adjusted job assignments and schedules to keep pace with
dynamic business needs, factoring in processes, employee
knowledge and customer demands.
· Enhanced training programs to strengthen employee
knowledge and promote new managers from within.
· Collaborated with the ER and OR departments to establish
project guidelines and create unique products to drive
profitability.
· Partnered with various departments to ensure OSHA
regulations are upheld.

6. 2012/May. – 2013/Feb. Front Desk CoordinatorSupercuts
· Answered inquiries and resolved or escalated issues to
management personnel to ensure client satisfaction.
· Greeted incoming visitors and customers professionally and
provided friendly, knowledgeable assistance.
· Collected, sorted, distributed and sent mail and packages.
Assisted over 50 customers via phone daily.
· Resolved customer problems and complaints by reviewing
service and determined if a discount is necessary.
· Managed office inventory by restocking supplies and placing
purchase orders to maintain adequate stock levels.
· Collected and distributed messages to team members and
managers to support open communication and high customer
service.
· Collected payments from clients and updated account
balances.
· Kept reception area clean and neat to give visitors positive
first impression.
· Assisted internal staff with clerical and administrative needs
to maximize efficiency and team productivity.
· Oversaw inventory activities, including materials monitoring,
ordering or requisition and supply stocking or re-stocking.
Education
2012/April – 2015/May South University
Associate Degree in Criminal Justice
2000/Aug. -2004/June North Miami Beach Senior High
Diploma
CASE IX
Presentation
J.T. is a 72-year-old man with chronic hepatitis C and Child-

7. Pugh grade A (clinically well-compensated) cirrhosis. He takes
propranolol (propranolol 20 mg PO BID) for esophageal
variceal bleeding prophylaxis. He had a blood transfusion 25
years ago. Hepatitis C was diagnosed 10 years ago, and
cirrhosis was diagnosed by liver biopsy 2 years ago. He does
not drink alcohol. He has never been overweight. He has no
personal or family history of diabetes. Over the past year,
random plasma glucose levels have ranged from 110 to 180
mg/dl. The most recent random glucose was 210 mg/dl. The
patient denies polydipsia, polyuria, nocturia, or any other
symptoms of hyperglycemia. He weighs 150 lb. (BMI 22
kg/m2).
Physical examination findings are normal except for mild
palmar erythema, spider angiomata on the upper chest, and a
palpable spleen tip. Fasting blood glucose was 136 mg/dl, and
hemoglobin A1c (A1C) was 6.3%. Another fasting glucose
several weeks later was 128 mg/dl.
At first glance, many clinicians might assume this patient has
type 2 diabetes. The history is compatible with this diagnosis.
However, the absence of classic risk factors for type 2 diabetes
and the appearance of new hyperglycemia in the setting of
known cirrhosis makes it more likely he has “liver diabetes,”
also known as hepatogenous diabetes.1,2 Patients with cirrhosis
have insulin resistance. Impaired glucose tolerance (IGT) is
common, and about 20–40% have diabetes.1,3 While there is no
definitive test to distinguish type 2 diabetes from diabetes
caused by liver disease, liver diabetes appears to be caused by
hepatic dysfunction. It should be noted that the American
Diabetes Association and the World Health Organization do not
recognize liver diabetes as a specific type of diabetes.
Regardless of whether the diagnosis is that of liver diabetes or
type 2 diabetes, decisions about when and how to treat
hyperglycemia should take into account comorbid conditions
such as hepatic dysfunction.
This patient has only a minimal elevation in A1C, and the value
is within standard treatment goals for diabetes. However, it

8. should be noted that A1C reference ranges assume a normal
erythrocyte life span. Older erythrocytes have higher A1C
levels than younger cells. Any condition that reduces
erythrocyte survival, such as cirrhosis4 or hemolysis resulting
from hypersplenism can cause spuriously low A1C levels.
Therefore, in this patient, it would be desirable to institute
home blood glucose monitoring in order to better assess the
severity of his hyperglycemia. The decision about whether to
start treatment for any condition is based on a comparison of the
risks and benefits of that treatment. First, a review is in order of
the risks of each therapeutic option that should be considered
for patients with hepatic dysfunction.
Diet and exercise are usually considered a very safe first-line of
therapy for patients with mild hyperglycemia. However, many
patients with cirrhosis are malnourished, and dietary restriction
with a goal of weight loss may exacerbate hypoalbuminuria and
worsen overall prognosis. If dietary restriction results in lower
vitamin K intake, then a coagulopathy may result. Every class
of oral hypoglycemic medication currently available in the
United States has been associated with at least a small risk of
hepatotoxicity. For patients with marginal hepatic function at
baseline, even mild hepatotoxicity can be fatal. Hepatic
dysfunction can also cause an exaggerated response to a
standard dose of medication and a higher risk of side effects if
the drug is metabolized by the liver. Sulfonylureas, repaglinide,
metformin, and thiazolidinediones are all extensively
metabolized by the liver. It is generally advised that metformin
and thiazolidinediones should not be used in patients with
significant hepatic dysfunction. For these reasons, many
clinicians use insulin as a first-line agent to treat diabetes in
cirrhotic patients. The main risk of insulin is severe
hypoglycemia. Patients with cirrhosis have reduced hepatic
glycogen stores. Glucagon may stimulate less hepatic
glycogenolysis in cirrhotic patients than in patients without
liver disease.1 Also, many patients with severe hepatic
dysfunction have hepatic encephalopathy, which may impair

9. their ability to comply with instructions about therapy. Patients
with cirrhosis and diabetes have a shorter life expectancy than
do nondiabetic patients with cirrhosis, but they typically die of
complications of liver disease, such as gastrointestinal
hemorrhage, rather than from complications of diabetes, such as
cardiovascular disease.2,3,5 This suggests that in cirrhotic
patients, the development of diabetes reflects a greater degree
of liver failure. No studies have been conducted to determine
whether patients with cirrhosis benefit from diabetes treatment.
However, there are several situations in which cirrhotic patients
would be expected to benefit from glucose control. Treatment
for symptomatic hyperglycemia should be used to reduce
symptoms. Treatment of persistent hyperglycemia would be
expected to lessen the risk of infection. Patients with A1C
results ≥ 7% who are awaiting liver transplantation or whose
life expectancy is expected to be several years might benefit
from a lower risk of diabetes complications if their diabetes is
treated.
In J.T.’s case, he was observed off therapy for about 6 months.
He eventually started low-dose insulin (lispro 3 units SQ before
meals and glargine 5 units SQ Q HS) for persistent
hyperglycemia > 200 mg/dl, A1C > 7.5%, and patient
preference. He did not have any episodes of severe
hypoglycemia.
INSTRUCTIONS
You are the nurse during his initial visit to the hospital. After
completing a comprehensive health history and physical
examination, you move on to provide client education on his
medications and three health promotion topics appropriate to his
case.
Clinical Pearls
• Severe hepatic dysfunction can cause IGT and diabetes. The
clinical distinction between type 2 diabetes and liver diabetes is
based on the onset of diabetes relative to the onset of cirrhosis
and on whether the patient has typical risk factors for type 2
diabetes.

10. • A1C results may be spuriously low in patients with severe
liver dysfunction.
• All currently available oral hypoglycemic agents pose some
risk of hepatotoxicity. Metformin and thiazolidinediones should
be avoided in patients with significant hepatic dysfunction.
Many clinicians consider insulin to be the first-line agent for
treating diabetes in patients with significant liver disease,
although some clinicians advocate the cautious use of
sulfonylureas in this situation.1
• Patients with cirrhosis are especially susceptible to
hypoglycemia and may respond poorly to glucagon.
• Among patients with cirrhosis and diabetes, the main cause of
death is hepatic failure rather than cardiovascular disease or
other complications of diabetes.
• An individualized assessment of risks of benefits of diabetes
treatment should be considered for each patient.
Marguerite McNeely, MD, MPH, is an assistant professor in the
Division of General Internal Medicine at the University Of
Washington School Of Medicine in Seattle.
REFERENCES
1 Petrides AS: Liver disease and diabetes mellitus. Diabetes
Revs 2:2–18, 1994 2
2Holstein A, Hinze S, Thieben E, Plaschke A, Egberts E-H:
Clinical implications of hepatogenous diabetes in liver
cirrhosis. J Gastroenterol Hepatol 17:677–681, 2002
3 Marchesini G, Ronchi M, Forlani G, Bugianesi E, Bianchi G,
Fabbri A, Zoli M, Melchionda N: Cardiovascular disease in
cirrhosis. Am J Gastroenterol 94:655–662, 1999
4 Owens D, Jones EA, Carson ER: Studies on the kinetics of
unconjugated [14C] bilirubin metabolism in normal subjects and
patients with compensated cirrhosis. Clin Sci Mol Med 52:555–
570, 1977
5 Bianchi G, Marchesini G, Zoli M, Bugianesi E, Fabbri A, Pisi
E: Prognostic significance of diabetes in patients with cirrhosis.
Hepatology 20:119–125, 1994