Instruction to students: This is an individual assignment.
Length: 2000 Words
Submission Method: Online – To be submitted via Turnitin
Task: NURS6620 Health Assessment Report Assignment
Assessment Type: Written Assessment – What steps would be taken in a problem solving approach.
Description Choose a typical patient/women/consumer from your current clinical practice that you have been clinically involved with, including the assessment, intervention and management. You may choose to continue with the patient/women/consumer that was presented at residential.
This assessment requires the following:
A.Full history:
- Reason for patient/women/consumer presenting;
- Present the previous medical history, social history, medications, allergies, relevant lifestyle factors and psychosocial issues (including domestic violence, smoking, illicit drug and alcohol history);
- For those aspects of the history of the presenting illness not given spontaneously, please explain what questions you asked and reasoning/rationale behind these questions (provide references).
- Conclude with a list of initial differential diagnoses based on the cues from this part of the assessment.
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B.Physical examination:
- Describe the physical examination, including basic observations and the reasons for undertaking the physical examination you performed, i.e. neurological/cervical / abdominal
- Relate the examination cues to the differential diagnoses identified.
- In order of likeliness provide critical thinking to accept or reject your differential diagnoses, based on the cues obtained from the history, physical examination, evidence, i.e. use a table.
C.Investigations required / ordered:
- Considering your findings; list the investigations ordered and reason you have chosen/ordered each test and rejected other tests i.e. you may also discuss the reasoning to order investigations sequentially over time.
D.Conclusion:
Provide the final diagnosis or diagnoses with a discussion on your rationale for the final diagnoses. Include how your assessment and critical thinking supported a diagnosis.
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