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Assignment Instructions:
For this 5-6 page 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 Danny Rivera, a child who is complaining of a cough. 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 5-6pages, which does not include the cover page and reference page(s). Please synthesize your assessment data rather than sharing all of the data in your written work. Your final written paper should be an APA formatted analysis of your assessment no more than 6 pages in length, excluding title page & reference list.
Introduction (including purpose statement)
Focus of the assessment
Describe the focus of this particular assessment on the patient complaining of a cough
Subjective Component
Analyze the health history data accumulated, including, but not limited to the Review of Systems & Past Medical History.
Objective Component
Analyze the physical examination findings including techniques of examination
Documented evidence to support clinical reasoning (connecting the assessment data to the diagnoses)
Choose & list the differential diagnoses based upon the clinical evidence
Plan of care
Briefly describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for the focused area of assessment.
Conclusion
References
In regard 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 font
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
Focus of the Assessment is identified with Special Considerations including Documented Focused Health History Focus of the assessment is provided with analysis of the subjective data
20
Physical Examination Findings including Techniques of Examination Analysis of the physical examination findings
20
Clinical Reasoning Demonstration Analysis of the data shown in the differential diagnoses
20
Individualized Plan of Care An individualized plan of care specific to the focus of the assessment including life stage considerations, culture, & clinical findings is provided
10
Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice Analysis of compliance with the legal & ethical standards of professional nursing practice required during a patient assessment
10
Grammar, Spelling, and Punctuation APA Format APA Format, grammar, punctuation and spellibcing is accurate with no errors.
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