This assignment synthesizes the study of advanced physical assessment by conducting a comprehensive virtual assessment of Tina Jones in Shadow Health.
This synthesis is focused upon designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan. Assessment of competency is based on the Comprehensive Patient Interview, Physical Examination and
Individualized Plan of Care
incorporating Healthy People
2
0
3
0 and evidence-based interventions and patient-centered goals.
You will use one comprehensive digital clinical experience health history and physical assessment for this assignment: Comprehensive Assessment.
For this assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. Use the following headings in your paper to clarify your content—recommended headings are bolded below:
1. An introductory paragraph including a purpose statement (The title of the paper should head this section)
2. Subjective Findings Synthesis (Do not list all the assessment data—you will need to synthesize it to develop a clear plan of care)
3. Objective Findings Synthesis (Do not list all the assessment data—you will need to synthesize it to develop a clear plan of care)
4
. Plan of Care (Use the sections below for subheadings within your plan of care)
a. Application of Nursing Theory (Apply one nursing theory in planning care for this patient)
b. Healthy People
20
30 (Incorporate three Healthy People 2030 Objectives into the plan of care prioritized to meet the health needs of the patient)
c. Support for
Clinical Reasoning
(Document evidence to support clinical reasoning for selected evidence-based plan of care)
d. Individualized Plan of Care (Plan of care is individualized to findings, life-span stage of development with culturally specific considerations, and patient-centered)
e. Health Informatics Technology (Include an analysis of how health informatics technology could be used in this plan of care to improve decision making, evaluate evidence to prevent or treat illness, perform patient education, or formulate an adaptive needs list)
5
. Conclusion
6. References (use primary and/or reliable electronic sources)
Remember, this is a formal paper and should be written with APA formatting in mind.
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 6-
8
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 6-8 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 |
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|
Subjective data findings |
Documentation clearly shows student has completed a comprehensive assessment with a written synthesis of key findings. |
Documentation supports the student has completed the comprehensive assessment with discussion of key findings. |
Documentation supports the student has completed the assessment with only a list of key findings. |
Documentation supports the student attempted to complete the comprehensive assessment without identification of key findings. The comprehensive health history is briefly documented and lacks depth and specificity. |
/20 |
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Physical Examination Findings |
Documentation clearly shows student has completed the physical examination with findings prioritized. |
Documentation supports the student has completed the physical examination with findings. |
Documentation supports student completed some of the physical examination. 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. |
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| Clinical Reasoning |
Discourse clearly shows the student has studied the topic and has given thought in developing the final plan of care with one nursing theory applied and integration of Healthy People 2030. |
Discourse supports the student has studied the topic and has given thought in developing the final plan of care. Lacks integration of either one applied nursing theory or integration of Healthy People 2030. |
Discourse supports student studied some of the topic, however, lacks detail and depth in developing the final plan of care. |
No evidence that that student has read or studied the topic. |
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| Individualized Plan of Care |
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. |
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| 5 | 4 | 3 | ||||||||||||||||||
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Developmental & Cultural Care Ethical & Legal Standards of Professional Nursing Practice |
Accurately documents a developmentally and culturally specific assessment and individualized plan of care for the selected patient. Includes analysis of the ethical & legal standards of Professional Nursing practice that is individualized to the patient |
Documents a developmentally and culturally specific assessment and plan of care without individualization Includes discussion of the ethical & legal standards of Professional Nursing practice that is individualized to the patient |
Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient. Includes a list of the ethical & legal standards of Professional Nursing practice without individualizing to the patient |
A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings. . Does not discuss ethical or legal standards. |
/5 |
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Health Information Technology |
Includes an analysis of how health informatics technology could be used in this plan of care to improve decision making, evaluate evidence to prevent or treat illness, perform patient education, or formulate an adaptive needs list |
Includes a discussion of how health informatics technology could be used in this plan of care to improve decision making, evaluate evidence to prevent or treat illness, perform patient education, or formulate an adaptive needs list |
Includes a list of ways health informatics technology could be used in this plan of care to improve decision making, evaluate evidence to prevent or treat illness, perform patient education, or formulate an adaptive needs list |
No discussion of Health IT is present. |
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10 |
9 |
8 | ||||||||||||||||||
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Grammar, Spelling, and Punctuation APA Format |
APA Format, grammar, punctuation and spelling is accurate with no 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. |
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