Assessment Summary for 3b ePortfolio – Semester 2, 2023
Include an assignment cover page
Word count: 2500 words +/- 10%. Word count includes in-cite references and the table (actual and potential problems). Headings, subheadings, the reference list, and appendices are not included in the word count.
Weighting: 30%
Title: Professional Experience Patient Assessment and Analysis Assignment
Introduction (approximately 50 words):
A succinct introduction to the assignment
Introduction of your chosen patient (approximately 350 words):
Choose a patient during your clinical placement/professional experience practice (PEP) and complete an in person (face-to-face) health and social history. You may additionally include family members if available.
Compliment collected subjective data from your client with data from electronic medical records (EMR) or hard copy medical records and medication charts. Name all medications, dose, and frequency (e.g., PRN, daily, Bd) and include within the paragraph (do not list or put in table format).
Present the required data of your chosen patient, making sure all data is de-identified to maintain the confidentiality and privacy of the patient and the hospital. Please refer to the statement within the subject guide regarding what is and what is not permitted within this context and clearly state when a pseudonym is used.
Completion and documentation of a systematic head-to-toe assessment (approximately 900 words):
Please complete and document a systematic head-to-toe assessment, providing all details of the patient assessment findings for all systems. Document subjective and objective data for each body system. Do not omit data because it is within the normal range, and don’t simply state that it is within the normal range, provide the values.
Under the Cardiovascular System (CVS) please include an electrocardiogram (ECG) (a copy of a deidentified ECG needs to be included in the Appendix). Using the twelve questions below as a guide only, determine the rate, rhythm, and any ST changes. Please collate the answers to the questions below in paragraph format for this assignment (do not just state the questions and answers below in your assignment).
1. Why did you perform an ECG on this patient?
2. Note the P wave. Is it upright or inverted? Is there one for every QRS?
3. Evaluate the atrial rhythm. Is it regular or irregular?
4. Calculate the atrial rate
5. Measure the duration of the PR interval. Is it of normal duration or prolonged?
6. Evaluate the ventricular rhythm. Is it regular or irregular?
7. Calculate the ventricular rate
8. Measure the duration of the QRS complex. Is it of normal duration or prolonged?
9. Assess the ST segment. Is it isoelectric, elevated, or depressed?
10. Note the T wave. Is it upright or inverted?
11. What is the rhythm diagnosis?
12. Are there any ST changes in any of the 12 leads?
If you cannot get an ECG on your patient, or it is not suitable (e.g., pediatric patients), please e-mail Philippa and she will send you an ECG to analysis. If the ECG is not from your patient, please write up the ECG analysis and put this in the Appendix with a copy of the ECG. Do not include it in the assignment.
Identification and prioritisation of nursing problems (approximately 100 words):
Complete the table of nursing problems (provided in the template), and in list format, identify all actual and potential problems
Identification of Nursing interventions (600 words):
Choose two nursing problems (can be either actual or potential problems) from the table above and provide rationale for your choice. Then explore one independent nursing and one collaborative intervention for each nursing problem. Provide a justification for each intervention, discuss the rationale behind your choice, and support your decision with evidence-based research.
Include how you would evaluate the outcome of your independent and collaborative nursing interventions for both identified problems (how would you know your chosen intervention had been successful).
This must all be written in paragraph form.
Evidence-based discussion on the similarities and differences between independent and collaborative nursing interventions, using peer reviewed evidence to support your discussion (approximately 450 words):
Using contemporary, evidence-based literature, discuss the similarities and differences between independent and collaborative nursing interventions. Please ensure that you use literature to support your discussion.
Conclusion (approximately 50 words):
A succinct conclusion to the assignment
Reference list in APA 7th style (not included in word count)
Appendix (not included in the word count)
Clinical assessment table 2023 Semester 2 (optional)
De-identified Electrocardiogram (compulsory)