For this 4-5 pages assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health

For this 4-5 pages assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health

For this 4-5 pages assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Esther, an elderly patient who is complaining of abdominal discomfort. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment.

Submission Parameters:

For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s).

1. Introduction (including purpose statement)
2. Focus of the assessment
   1. Describe the focus of this particular assessment on the patient complaining of abdominal discomfort.
3. Subjective Component
   1. Describe the ROS, PMH, and other relevant data in this section.
4. Objective Component
   1. Describe the physical examination findings including techniques of examination
5. Documented evidence to support clinical reasoning
   1. Describe the list of differential diagnoses
6. Plan of care
   1. Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment.
7. Conclusion
8. References (use primary and/or reliable electronic sources)

 

In regards to APA format, please use the following as a guide:

• Include a cover page and running head (this is not part of the 4-5 pages limit)
• Include transitions in your paper (i.e. headings or subheadings)
• Use in-text references throughout the paper
• Use double space, 12 point Times New Roman fonta
• Apply appropriate spelling, grammar, and organization
• Include a reference list (this is not part of the 4-5 pages limit)
• Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)

 

Competency	20	18	16	0	Points Earned
Focus of the Assessment is identified with Special Considerations including Documented Focused Health History	Documentation clearly shows student has completed a focused assessment with identified special considerations including a well-documented focused health history.	Documentation supports the student has completed the focused assessment with minimal identification of special concerns. The focused health history is documented.	Documentation supports the student has completed the focused assessment without identification of special concerns. The focused health history is documented and lacks depth and specificity of weekly topic.	Documentation supports the student attempted to complete the focused assessment without identification of special concerns. The focused health history is briefly documented and lacks depth and specificity of weekly topic.	/20
	20	18	16	0
Documented Physical Examination Findings including Techniques of Examination	Documentation clearly shows student has completed the physical examination and accurately describes the techniques of examination for the week.	Documentation supports the student has completed the physical examination and describes the techniques of examination for the week.	Documentation supports student completed some of the physical examination for the focused assessment of the week. Documentation is accurate but lacks depth.	No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability of tasks completed in this week.	/20
	20	18	16	0
Documented Evidence to Support Clinical Reasoning with External Course Resources	Discourse clearly shows the student has studied the topic and has given thought to the focused assessed topic and documentation for the week.	Discourse supports the student has studied the topic and has given thought to the focused assessment topic and documentation for the week.	Discourse supports student studied some of the topic for the focused assessment topic this week. Discourse is accurate but lacks depth.	No evidence that that student has read or studied the topic. Discourse lacks depth. May be presented in a rambling manner. Content is inaccurate &/or is unclear.	/20
	20	18	16	0
Individualized Plan of Care Based Upon Clinical Findings	Accurately presents an individualized plan of care based upon clinical findings.	Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted.	Presents a plan of care that is not individualized based upon the clinical findings.	A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings.	/20
	5	4	3	0
Developmentally and Culturally Specific	Accurately documents a developmentally and culturally specific assessment and plan of care for the selected patient.	Documents a developmentally and culturally specific assessment and plan of care.	Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient.	A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings.	/5
	5	4	3	0
Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice	Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the focused physical assessment.	Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation.	Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the focused physical assessment or inaccuracies are evidenced in the written assessment.	Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the focused physical assessment.	/5
	10	9	8	0
Grammar, Spelling, and Punctuation APA Format	APA Format, grammar, punctuation and spelling is accurate with errors.	APA Format, grammar, punctuation and spelling is accurate with less than two types of errors.	APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors.	APA Format, grammar, punctuation and spelling is accurate with more than five types of errors.	/10
COMMENTS:				TOTAL:	/100