Assignment: Patient Health Comprehensive Assessment Paper
When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Patient Health Comprehensive Assessment Paper Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting.
This Assignment is due. It is highly recommended that you begin planning and working on this Assignment as soon as it is viable.
- Reflect on your Practicum Experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
- Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care.
Write an 8- to 10-page Comprehensive Patient Assessment paper that addresses the following:
- Age, race and ethnicity, and partner status of the patient
- Current health status, including chief concern or complaint of the patient
- Contraception method (if any)
- Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
- Review of systems
- Physical exam
- Labs, tests, and other diagnostics
- Differential diagnoses
- Management plan, including diagnosis, treatment, patient education, and follow-up care
Note: Refer to the Comprehensive Write-up Guide in this week’s Learning Resources for a detailed outline with additional guidance.
Note: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available athttp://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.
FOLLOW THIS GUIDE. HEADINGS SHOULD BE LIKE ITS ON THE GUIDE. SETTING IS A OB/GYN OFFICE. SO SCENARIO HAS TO BE OB/GYN RELATED
Comprehensive Write-up Guide
Week 2 Patient Health Comprehensive Assessment Paper Assignment:
Comprehensive Patient Assessment When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Patient Health Comprehensive Assessment Paper Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting. To complete: Write an 8- to 10-page comprehensive paper that addresses the following:
1. General patient information a. Age b. Race/ethnicity c. Partner status
2. Current health status a. Chief concern/complaint and history of present illness (include a complete symptom analysis of chief complaint(s) utilizing OLDCART for a sick/problem focused visit) b. Last menstrual period or year of menopause c. DES exposure (if born between 1948 and 1971) d. Sexual activity status e. Barrier prevention f. Sexual preference g. Satisfaction with sexual relations
3. Contraception method (if any)
4. Patient history a. Past medical history • Major medical events (including pediatric events) • Psychological and mental health • Surgeries and/or hospitalizations if pertinent • Medications, including prescriptions, over-the-counter medications, home and herbal remedies, calcium, and vitamin supplements • Allergies, including drug, food, and environment © 2013 Laureate Education, Inc. 2 • Health maintenance/screenings, including results of patient’s last Pap and mammogram as appropriate, as well as previous vaccinations (HPV, MMR, hepatitis B, last dT, and pneumovax/influenza as appropriate) b. Family medical history c. Gynecologic history • Nullipara vs. multipara • History of sexually transmitted infections and sexually transmitted diseases • Menarche and menstrual patterns • Menopause or peri-menopausal symptoms (if applicable) d. Obstetric history • Gravida and parity status (TPAL) • Pregnancy history, including history of preterm or low birth weight, other pregnancy complications, history of sexually transmitted diseases, and any pertinent negatives e. Personal social history (as appropriate to the current problem) • Cultural background • Education and economic condition • Abuse history including assault and forced sex (past and current) • Occupational health patterns • Environment • Current health habits and/or risk factors • Substance use (must include for every patient) • Tobacco including frequency and longevity • Alcohol including results of CAGE unless patient has never used • Recreational drug use (past and current) • Exercise and physical activity • Diet and nutrition • Sleep • Caffeine
5. Review of systems (ROS) a. Must include reproductive system as well as other pertinent systems (systems relevant to HPI should be included under HPI)
6. Physical exam a. General exam, including vital signs, height, weight, and BMI on every patient b. Physical exam focused on episodic complaint (include numbers of weeks gestation, fundal height, and fetal heart tones for OB patients)
7. Labs, tests, and other diagnostics © 2013 Laureate Education, Inc. 3 a. Pertinent labs, test, and other diagnostics (include routine tests such as triple screen and urine dip for OB patients) in your
8. Differential diagnoses a. Explain why this set of differential diagnoses should be considered and why each diagnosis should be ruled in or ruled out.
9. Management plan a. Diagnosis b. Treatment c. Patient education d. Follow-up care .
Reminder: The School of Nursing requires that any Comprehensive Patient Assessment Paper submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting. Please contact the course Instructor with any questions regarding this Patient Health Comprehensive Assessment Paper.
Important information for writing discussion questions and participation
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource
Welcome to class
Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to.
I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.
Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.
If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.
Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.
Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!