Conduct A Focused Health History and Physical Assessment
Order ID:89JHGSJE83839 Style:APA/MLA/Harvard/Chicago Pages:5-10 Instructions:
Conduct A Focused Health History and Physical Assessment
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, 8 years old, 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)
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 Focus of the assessment is provided with discussion of the subjective data No assessment focus is provided and/or provides only list of subjective data without discussion or analysis No identified focus or subjective data provided /20 20 18 16 0 Physical Examination Findings including Techniques of Examination Analysis of the physical examination findings Discussion of the physical examination findings Lists the physical examination findings only
Does not include physical examination findings /20 20 18 16 0 Clinical Reasoning Demonstration Analysis of the data shown in the differential diagnoses Discussion of the data shown in the differential diagnoses Lists the differential diagnoses without connection to the assessment data No differential diagnoses provided to show clinical reasoning /20 20 18 16 0 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 An individualized plan of care specific to the focus of the assessment including life stage considerations, culture, or clinical findings is provided. A plan of care is provided but is not individualized or considers the focus of the assessment, life stage considerations, culture or clinical findings. No plan of care is developed & shared /20 10 8 6 0 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 Discussion of compliance with the legal & ethical standards of professional nursing practice required during patient assessment. Lists the legal & ethical standards of professional nursing practice required during a patie
RUBRIC
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.
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.
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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