This two-part assessment item requires you to undertake a comprehensive health assessment of a patient in your specialty area of clinical practice. You need to: select a health assessment framework to use with your chosen patient; present all data; and identify four priority patient problems using evidenced-based literature to justify your assessment.
PART 1 (1000 words):
Choose any assessment tool or framework suiting the needs of your patient and/or speciality area of clinical practice (see ‘some points to consider’ for framework examples). Provide a justification of your choice of health assessment framework. This justification needs to be supported by literature.
Select a patient (either upon admission or an in-patient for whom you care over a single shift), gain consent and then perform a thorough health assessment. Identify at what stage of the patient’s admission your health assessment was undertaken in the introduction of your assessment item.
Present your patient’s assessment data. You must show all findings, including subjective and objective data. You need to present your health assessment data logically and clearly. You may present this section under key areas/headings of your framework and then in bullet point form. Your assessment data should highlight pertinent findings/observations (use italics to highlight); you should identify what are normal ranges/observations for this health area and use the literature to support this (that is, provide support/prove the data presented is abnormal/negative).
PART 2 (2000 words):
Identify all your patient’s actual or potential problems, within reason. Select the most important four priority problems based on the assessment data gathered in Part 1. Justify and explain why these are priority problems for your patient, using the case study data and evidence-based literature.
Some points to consider:
• You are not required to address interventions for your patient’s management. These aspects are addressed in your other clinical speciality units.
• I would suggest choosing a patient whose clinical presentation is relatively straightforward. The reason for this is that health assessment of patients with multiple co-morbidities and problems would be very difficult to present within the confines of the word limit for Assessment 2.
• Examples of health assessment tools are: functional health patterns; the health assessment documentation that is currently used in your workplace; a systems-orientated approach, such as the Emergency Care Cycle or head to toe/body systems assessment.
• You must include a copy of your health assessment framework in your submission (this will not be included in your word count).