Health Assessment: Written Assignment - Nursing 773

Assessment 1 NURSING 773 Health Assessment: Written Assignment PURPOSE: The purpose of this written assignment is to enable the student to develop skills to systematically appraise a patient case study by employing an evidence-based diagnostic reasoning process to support the clinical decision making process. The diagnostic reasoning process is outlined in the first three chapters of the paper’s core text book Bates Guide to Physical examination and history taking (13th ed.). You are required to integrate literature to support your content throughout the assignment. Client Selection: You are required to select a patient/client with an actual diagnosis from your clinical practice and base the assignment on their case. The following are suggestions of presenting complaints that you might consider, however you may choose any patient/client relevant to your practice. Shortness of breath or Chest pain or Abdominal pain or Headache or Ear pain, sore throat or other common presentation in primary care There is benefit from choosing a patient or client with a fairly straight forward complaint for purposes of being able to clearly articulate the diagnostic reasoning process. METHOD: You are required to present and discuss the patient/client using this format: General appearance / presenting complaint/ history of presenting complaint / past history / family history / personal and social history. The clinical skills checklist in this folder will guide you on the history that needs to be included. • Discuss the data you have gathered for your client and link where relevant to the evidence. (this section will probably be lighter with literature/evidence than other areas of the assignment) Three early diagnostic considerations • Discuss three of the most likely early diagnostic considerations for your patient’s presenting complaint and discuss aspects of the history that would help support these considerations Physical examination • Discuss the general appearance and physical examination that has been performed on your client with rationale and links to the literature. The clinical skills checklist will guide you in the systematic approach to follow for the clinical exam but the required depth will be obtained from a clinical exam text book e.g. Bates. Differential diagnoses • Discuss your three early diagnostic considerations. Demonstrate the linkage using the patient’s data and physical exam findings to help support or refute these considerations Diagnostic tests • Select three diagnostic tests that would help rule in or out your earlier diagnostic considerations. Include evidence/literature to support rationale for selecting these tests. • There does not have to be one diagnostic test for one diagnostic consideration. One test may help rule out two diagnostic considerations, alternatively a diagnostic consideration may get excluded because a diagnostic test result makes another consideration more likely. • It is advisable to discuss the actual diagnostic test results in the diagnostic reasoning section of the assignment. Diagnostic reasoning and formulation of a diagnostic decision Select two of your diagnostic considerations and using the literature explain how the general appearance, history, physical examination and diagnostic tests would support or refute these two possible diagnoses. Include pathophysiology discussion for both diagnoses. Please included a final diagnosis for the patient. Assignment Notes: - Please use the N773 written assignment marking rubric as a guide when writing the assignment. - ALWAYS proof read your assignment prior to submitting it. - Ensure the assignment is formatted per presentation guidelines ( see post graduate study insert) and 7th edition APA referencing has been used (see guide to 7th edition APA references). - Assignment one will be marked via Turnitin. Prior to submitting your assignment, (including reference list) you must put it through Turnitin, via Canvas. - Confidentiality of patients, families and staff: It is essential that the confidentiality of patients, families and staff are protected at all times in your assignment. Any content with the potential for personal identification must be deleted or changed prior to submission. Any work submitted which fails to protect the identity of patients, families and staff will not be eligible for a pass grade. - Assignment word limit: If your assignment exceeds the word limit and is a one grade penalty will apply i.e. 5%. Any assignment overwill not be marked. Words in the reference list are not counted in the assignment’s word count. Format: Written Assignment . Weighting: 40% of the final grade for this paper. Grading: Refer to marking rubric available in the Course Outline and from Canvas I have started an assignment but it is not good, needs to be a lot better, better literature it is to fluffy want to make it very easy to understand a follow there is also things missing that is required such as spiritual and cultural beliefs better family history literature to support. However I will attach as this will give you some idea about my patient. He presents to ED with SOB end diagnosis is pneumonia family HX his father died from this as left untreated not sure if this is important. He was diagnosed with COPD 2 years ago not sure if this is a good thing and can link it or if we start again please see all info attached for assignment more info that needs to be included under each heading as in assignment help i have attached these fit into each category. Nursing 773 Advanced Assessment & Diagnostic Reasoning Clinical skills checklist - IE lifestyle alcohol illicit drugs smoker