Instructions
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 2030 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, write a 7-8 page paper, using 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)
5. Application of Nursing Theory (Apply one nursing theory in planning care for this patient)
6. Healthy People 2030 (Incorporate three Healthy People 2030 Objectives into the plan of care prioritized to meet the health needs of the patient)
7. Support for Clinical Reasoning (Document evidence to support clinical reasoning for selected evidence-based plan of care)
8. Individualized Plan of Care (Plan of care is individualized to findings, life-span stage of development with culturally specific considerations, and patient-centered with patient education topics included)
9. Developmental & Cultural Care
10. Ethical & Legal Standards of Professional Nursing Practice
11. 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)
12. Conclusion
13. 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
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
Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)
Final Project Grading Rubric
Competency
20 points
18 points
16 points
0 points
Points Earned
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
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.
/20
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.
Lacks integration of either one applied nursing theory or integration of Healthy People 2030.
No evidence that that student has read or studied the topic.
Discourse lacks depth. May be presented in a rambling manner.
Content is inaccurate &/or is unclear. No use of one applied nursing theory or integration of Healthy People 2030.
/20
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.
/20
5 points
4 points
3 points
0 points
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
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.
/5
10 points
9 points
8 points
0 points
APA, Grammar, spelling, and punctuation
No errors in APA, grammar, spelling, and punctuation.
One to three errors in APA, grammar, spelling, and punctuation.
Four to six errors in APA, grammar, spelling, and punctuation.
Seven or more errors in APA, spelling, and punctuation.
The submission does not meet format guidelines.
/10
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