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1st Semester Summative Assessment2024-2025

Saint Francis University

S.K. Yee School of Health Sciences
余紹基健康科學學院

Programme/Course:
課程/科目:

Bachelor of Nursing (Honours) Programme
護理學(榮譽)學士課程

Course Title:
課程名稱:

Health Assessment
健康評估

Examiner:
考官:

Ms. Jodie Szeto
Ms.司徒淑嫻

Course Code:
課程編號:

NUR203

Individual Case Project Guidelines (Draft)
個別案例專案指南(草案)

(Result review by External Examiner is pending)
(外部審查員審查結果待定)

(50% of the total course marks)
占課程總成績的 50%)

Due date: 09 December 2024 (1200 noon)
截止日期2024 年 12 月 9 日中午 1200 點)

Purpose: In this individual case project, students are with a clinical scenario. They are asked to use clinical reasoning to conduct an in-depth analysis of the physical assessment data.
目的: 在這個單獨的案例專案中,學生與臨床場景在一起。他們被要求使用臨床推理對身體評估數據進行深入分析。

Word Count: 1600 ± 10%
字數: 1600 ±10%

Submission guideline:
提交指南:

- Each submitted essay must have a cover page
- 每篇提交的文章必須有一個封面
.

- The essay should be formatted appropriately as stated in this document.
- 文章的格式應與本文檔中所述的適當格式相同。

- Each student must sign on the cover page and fill in all the fields as requested.
- 每個學生都必須在封面上簽名並按要求填寫所有欄位。

- The actual word count must be clearly stated on the cover page.
- 實際字數必須在封面上清楚地說明。

- The SOFTCOPY of the submission should be submitted as a single pdf file to Moodle.
- 提交的電子版應作為單個 pdf 檔提交給 Moodle。

-Late submission will result in a mark deduction of 5% of the total mark for each calendar day late. The deduction is up to a maximum of 100% of the total marks of the student in this assignment.
- 逾期提交將導致每延遲一個日曆日扣分總分的 5%。扣除額最高為學生在此作業中總分的 100%。

- Each student has only one chance of submission. No repeated submission is allowed. The initial (or first) submission is considered final. All subsequent submission(s) will not be marked.
- 每位學生只有一次提交的機會。不允許重複提交。初始(或第一次)提交被視為最終提交。所有後續提交將不被評分。

Suggested content
推薦內容

Cover page
封面

Table of content
目錄

Introduction

Assessment
評估

Planning and implementation
規劃和實施

Evaluation
評估

Conclusion
結論

Reference
參考

Criteria for marking the assignment
標記作業的標準

Introduction
介紹

- Description of the background of the client
- 用戶端背景描述

Assessment
評估

- History taking by using the patient assessment form for the client
- 使用患者評估為客戶記錄病史

- Justify the physical examination that you will perform in focused assessment (no need to elaborate on how to perform the assessment)
- 證明您將在 重點評估中進行的體格檢查的合理性(無需詳細說明如何進行評估)

Planning and analyzing data
規劃和分析數據

Analyzes and describe the assessment results from the TWO problematic body systems of the client
分析和描述客戶兩個有問題的身體系統的評估結果

-Clearly describes and interprets the Subjective data of the client from the scenario
- 清楚地描述和解釋 場景中客戶的數據

- Clearly describes and interprets the Objective data of the client from the scenario (differentiate normal and abnormal findings by health assessment )
- 從場景中清楚地描述和解釋 客戶的 Objective 數據(通過健康評估區分正常和異常發現)

Implementation
實現

- Sets up FIVE specific and realistic nursing cares of each body system for the client
- 為客戶設定 每個身體系統的五個具體而現實的護理

with relevant rationales and evidence
有相關理由和證據

Evaluation
評估

- Describe the appropriate and relevant methods used to evaluate the effectiveness of
- 描述用於評估

the progress
進展

Conclusion
結論

- Provides a clear, precise and concise summary of the care
- 提供清晰、準確和簡潔的護理總結

Writing skills
寫作技巧

-Logical flow and ability to organize
- 邏輯流程和組織能力

Format and Style
格式和樣式

-Correct spelling, punctuation and grammar
- 正確的拼寫、標點符號和語法

-Correct use of the APA (7th ed.) referencing format
- 正確使用 APA(第 7 版)參考格式

Qualities of a good assignment should include:
一份好的作業的品質應該包括:

Demonstrate knowledge of the topic
展示主題知識

Logical flow of discussion
討論的邏輯流程

Concise organization with appropriate subheadings
簡潔的組織,帶有適當的小標題

Elaborate on the discussion with the support of relevant references
在相關參考資料的支援下詳細闡述討論

Evidence of reading various sources of literature
閱讀各種文獻來源的證據

Note on Plagiarism
關於抄襲的說明

**Plagiarism is copying all or part of others’ work or using materials from websites or books without acknowledging the sources. All students must attach a declaration form and declare their work is their own with no plagiarism. Attached please find the sample of the form.
**剽竊是指複製他人的全部或部分作品,或使用網站或書籍中的材料而不註明來源。所有學生必須附上一份聲明表,並聲明他們的作品是自己的,沒有抄襲。請找到表格樣本。

Template of Cover Page
封面範本

Saint Francis University

S. K. Yee School of Health Sciences
S. K. Yee 健康科學學院

Bachelor of Nursing (Honours) Programme
護理學(榮譽學士課程

2024-2025

Assignment Cover Page
作業封面

All details must be completed.
必須填寫所有詳細資訊。

Student Name
學生姓名

Student ID
學生證

Year/ Semester
年/學期

2024/Semester 1
2024/第 1 學期

Course Code
課程編號

NUR203

Course Title
課程名稱

Health Assessment
健康評估

Assignment Topic
作業主題

Summative Assessment
總結性評估

Course Coordinator
課程統籌

Ms Jodie Szeto
司徒淑嫻女士

Due Date
期限

9th December 2024
9th 十二月 2024

Word Count
字數

Academic Honesty and Plagiarism
學術誠信與抄襲

Plagiarism at the Institute is defined as the act of copying, paraphrasing and/or adopting the work of others in the preparation and presentation of assessment materials in any form, including using generative AI tools, without giving proper acknowledgment(s) of the source(s) of the work copied, paraphrased and/or adopted, thus giving the impression that the assessment materials are the sole work of the student.”
學院的剽竊被定義為在以任何形式準備和展示評估材料時複製、改寫和/或採用他人的作品的行為,包括使用生成式人工智慧工具,而沒有適當承認所複製、改寫和/或採用的作品的來源,從而給人一種評估材料是學生唯一作品的印象。”

Plagiarism is an unacceptable and undesirable practice. Serious attention is drawn to the policies for honesty in academic work. Detailed information on plagiarism policy and disciplinary procedures can be found in the Student Handbook (General Information) for SFU Undergraduate Programme 2024-2025. Students are strongly reminded that the assignment must be your work
剽竊是一種不可接受且不可取的做法。學術工作中的誠實政策引起了人們的嚴肅關注。有關剽竊政策和紀律處分程序的詳細資訊,請參閱 SFU 本科課程 2024-2025 年學生手冊(一般資訊)。強烈提醒學生,作業必須是您的作業
.

Declaration by the student(s)
學生聲明

I/We* declare that the assignment here submitted is original except for source material explicitly acknowledged and that the same or related material has not been previously submitted for another course. I/We* also acknowledge that I/We* are aware of University academic regulations, and of the disciplinary guidelines and procedures applicable to violations of such policy and regulations, as contained in the Student Handbook.
我/我們*聲明,此處提交的作業是原創的,但明確註明的原始材料除外,並且之前未為其他課程提交過相同或相關的材料。本人/我們*亦承認,本人/我們*知悉大學學術規定,以及適用於違反學生手冊中所載政策和規定的紀律準則和程式。

* Delete as appropriate
* 根據需要刪除

Student Signature(s)
學生簽名

SFU HOSPITAL
SFU 醫院

Progress Note
進度說明

HN No: HN705834615 (5)
HN 編號: HN705834615 (5)

Name: Chan Emily HKID: A123456 (7)
姓名:Chan Emily香港身份證號碼:A123456 (7)

DOB: 14/10/1989
出生日期: 14/10/1989

Sex: F Age: 35 y
性別: F年齡: 35

Ward: A8 SPEC: SURG
病房: A8規格: 外科

Progress Date: 01-11-2024 06:30
進度日期: 01-11-2024 06:30

PMH:
PMH:

RTA 5 years ago with head trauma
5年前因頭部外傷而患有 RTA

Epilepsy default follow up
癲癇默認隨訪

Liver cirrhosis default medical follow up
肝硬化預設醫療隨訪

NKDA, live with partner, ADL-I, pub singer, smoker, drinker (2 glasses of whisky per day)
NKDA,與伴侶同住,ADL-I,酒吧歌手,吸煙者,飲酒者(每天 2 杯威士忌)

======================================================================

Patient was brought to the emergency department by her partner with complaints of severe headache, neck stiffness and high fever for two days.
患者被她的伴侶帶到急診科,抱怨劇烈頭痛、頸部僵硬和高燒兩天。

P/E:
市盈率:

Fatigue, tired looking, disorientated, barely speak in sentence
疲憊、看起來疲憊、迷失方向、幾乎不說話

Her partner reported that patient have severe headache, neck stiffness, high fever for two days ; loss of appetite, weakness and diarrhea for a week. They were back from Thailand one week ago and went to some local market for food.
她的伴侶報告說,患者連續兩天出現嚴重頭痛、頸部僵硬、高燒;食慾不振、虛弱和腹瀉一周。他們一周前從泰國回來,去了當地的某個市場買食物。

BP 85/45 mmHg HR: 120bpm RR: 20/min Temp: 39.2°C (T)
血壓 85/45 mmHg 心率:120次/分鐘 RR:20/min 溫度:392°C (T)

SpO2: 98% RA
SpO2:98% RA

GCS: E4V4M6
GCS:E4V4M6

Chest: clear no wheezing or crackles
胸部:清晰,無喘息或濕囉音

Heart sound: dual with no murmur, regular heartbeat with notable tachycardia
心音雙重心音,無雜音,心跳規則,伴有明顯心動過速

Abdomen: abdominal tenderness in all four quadrants, hyperactive on auscultation
腹部:腹部 4 個象限壓痛,聽診亢進

Skin: dry mucous membranes, decreased skin turgor
皮膚:粘膜乾燥,皮膚彈性下降

Extremity: cold and dry, capillary refill greater than 10 seconds, four limbs weakness
四肢:寒冷乾燥,毛細血管再充盈大於 10 秒,四肢無力

Eye: Sunken eyeballs
眼睛:眼球凹陷

Pain and resistance with knee extension when lying with hip flexed
髖關節屈曲躺下時膝關節伸展的疼痛和阻力

Involuntary bending of both hips and knees when passive flexion of chin on chest
下巴在胸部被動彎曲時臀部和膝蓋不自主彎曲

CXR: clear
胸部 X 線檢查:清晰

WBC: 13 x10^9/L
白細胞:13 x10^9/L

CRP:12 mg/dL
CRP:12 毫克/分升

Potassium: 3.0 mmol/L
鉀:3.0 mmol/L

ECG: Sinus Tachycardia
心電圖:竇性心動過速

Imp: XXX, XXX
小鬼: XXX, XXX

MX:
MX:

NPO except med
除 med 外的 NPO

BP/P, SpO2, NO Q4H
血壓/磷、SpO2、NOQ4H

Cardiac Monitoring
心臟監測

Lumbar puncture after CT brain
顱腦 CT 後腰椎穿刺

Save stool for culture
保存糞便進行培養

Blood culture
血培養

Med:
地中海:

IVF: NS X1 Q1H, 2D1S+10mmole K Q6H
試管嬰兒:NS X1 Q1H、2D1S + 10mmole K Q6H

Ceftxiaxone IV 2 g Q12H
頭孢夏酮靜脈注射 2 克 Q12H

Vancomycin IV 500mg Q12H
萬古黴素IV 500mg Q12H

Tegretol PO 200mg Q12H

Panadol PO Q4H PRN