Analyze the health history data accumulated, including, but not limited to the Review of Systems & Past Medical History.
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.
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.
1. Introduction (including purpose statement)
2. Focus of the assessment
1. Describe the focus of this particular assessment on the patient complaining of a cough
3. Subjective Component
3. Analyze the health history data accumulated, including, but not limited to the Review of Systems & Past Medical History.
1. Objective Component
4. Analyze the physical examination findings including techniques of examination
1. Documented evidence to support clinical reasoning (connecting the assessment data to the diagnoses)
5. Choose & list the differential diagnoses based upon the clinical evidence
1. Plan of care
6. Briefly describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for the focused area of assessment.
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|
|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|
|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|
|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|
|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 patient as|