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.
To preparePlease ensure no plagiarism
Reflect on your Practicum Experience and select a female patient (you can choose HPV fibroids infertility ovarian cyst or chronic bacterialvaginosis as the topic)
Think about the details of the patients 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:
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
Health maintenance/screenings including results of patients 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
a. Pertinent labs test and other diagnostics (include routine tests such as triple
screen and urine dip for OB patients)
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
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.
PLEASE REVIEW SAMPLE PAPER ATTACHED BELOW. This is the guide to this assignment