Assignment 1: Application – 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 Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting.
By Day 7 of Week 9
This Assignment is due. It is highly recommended that you begin planning and working on this Assignment as soon as it is viable.
To prepare
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.
To complete
Write an 8- to 10-page comprehensive 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
Expert Solution Preview
Assignment 1: Application – Comprehensive Patient Assessment
Introduction:
In this assignment, students are required to demonstrate their understanding and application of a comprehensive patient assessment. The assignment focuses on a female patient from the student’s current practicum setting. The objective is to analyze and document the patient’s background, medical history, physical examination, lab results, diagnosis, treatment plan, education strategies, and follow-up care.
Answer:
To begin with, the age, race and ethnicity, as well as partner status of the patient, are essential components to include in the comprehensive assessment paper. These details provide important contextual information that may influence the patient’s health status and decision-making process.
The current health status of the patient should be thoroughly described, including the chief concern or complaint that led to the examination. This information forms the basis of the assessment and directs further investigation and analysis.
In addition to the patient’s health status, it is crucial to include information about the contraception method, if any, utilized by the patient. This allows for a comprehensive understanding of the patient’s reproductive health and potential factors that may contribute to their overall well-being.
A comprehensive patient assessment requires a thorough understanding of the patient’s history. This includes the patient’s medical history, family medical history, gynecologic history, obstetric history, and personal social history. Relevant details from each of these areas should be incorporated into the assessment, as appropriate to the current problem or concern being addressed.
A review of systems is another crucial component of a comprehensive patient assessment. This involves a systematic examination of each body system and the documentation of any related symptoms or abnormalities. It provides a comprehensive overview of the patient’s overall health and potential areas of concern.
Furthermore, a detailed physical examination should be conducted and documented. This includes a comprehensive examination of the head, neck, chest, abdomen, pelvis, extremities, and other relevant areas depending on the patient’s condition. Key findings and abnormalities should be noted.
The assessment should also include the results of any relevant labs, tests, and other diagnostic procedures. These findings contribute to the overall evaluation and understanding of the patient’s health status.
Based on the collected information, the assessment should propose a list of differential diagnoses. This involves considering various possible conditions or diseases that may explain the patient’s symptoms and findings. Each potential diagnosis should be thoroughly discussed and supported by appropriate evidence.
Finally, the management plan should be outlined. This includes the diagnosis, treatment strategies, patient education, and follow-up care. The plan should be comprehensive, evidence-based, and tailored to the patient’s individual needs and preferences.
In conclusion, a comprehensive patient assessment paper requires the integration of multiple components, including patient demographics, current health status, contraception method, patient history, review of systems, physical exam findings, lab results, differential diagnoses, and a management plan. By critically analyzing and documenting this information, healthcare professionals ensure a comprehensive evaluation of the patient’s health and provide appropriate care.
