Order ID:89JHGSJE83839 | Style:APA/MLA/Harvard/Chicago | Pages:5-10 |
Instructions:
Physical Assessment from Head to Toe
Title:
Documentation of the entire physical examination from head to toe.
The assignment’s goal is to help you improve your writing skills.
To demonstrate the ability to document and identify anomalous results through an objective head to toe assessment.
Competency in the Course:
Demonstrate skin, hair, nail, and musculoskeletal system physical examination skills.
Determine which assessment approaches are most appropriate for the gastrointestinal, breast, and genitourinary systems.
Physically examine the head, ears, and eyes, as well as the nose, mouth, neck, and regional lymphatics.
Apply neurological and respiratory system assessment procedures.
Choose the right physical exam abilities for the cardiovascular and peripheral vascular systems.
Instructions:
Content:
Objective findings, giving a brief description of each section’s findings.
Actual or possible risk factors for the client based on the assessment findings, along with a summary of why they were chosen.
Format:
Typical American English (correct grammar, punctuation, etc.)
Resources:
SOAP Notes: Only the subjective and objective portions of Chapter 5
D. D. Sullivan, D. D. Sullivan, D. D. Sullivan (2012). Clinical documentation guide. [E-Book]. http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp 91&db=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_
L. S. Smith, L. S. Smith, L. S. Smith, L (2001, September). Do’s and don’ts in documentation 30. Nursing, 31(9). http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-live retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true
A thorough examination from head to toe
General Questionnaire (mental health and appearance):
Head:
Eyes:
Ears:
Nose:
Mouth:
Neck:
Assessment of the thorax, lungs, and back:
Assessment of the Cardiac and Central Vessels:
Gastrointestinal:
Genitourinary:
Assessment of the musculoskeletal, neurologic, and PV systems:
Various: (Add any additional findings here)
Factors of Actual/Potential Risk:
Rubric for grading documents: 20 potential points
RUBRIC |
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Excellent Quality 95-100%
|
Introduction
45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Literature Support 91-84 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met. |
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Average Score 50-85% |
40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided. |
83-76 points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration. |
52-49 points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met. |
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Poor Quality 0-45% |
37-1 points The background and/or significance are missing. No search history information is provided. |
75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration. |
48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met |
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Complete physical assessment from head to toe