NURS5012 Assessment 3: Instructions for preparation Students are to identify a patient in their clinical specialty area as suitable for undertake a comprehensive patient assessment. It is essential that informed patient consent is obtained prior to the comprehensive patient assessment and all subsequent documentation pertaining to the assessment is de-identified. Students need to complete a comprehensive and focused patient assessment and produce a report of the assessment findings. The assessment consists of 2 parts: Part A: comprehensive clinical assessment, and Part B: the case study report. Note The Comprehensive Clinical Assessment does not form part of the word count. Part A: Comprehensive Clinical Assessment Assessment Tools Students will be provided with clinical assessment reporting guidelines for the purposes of this assessment. Students should use an assessment approach that is appropriate for their clinical setting and the patient’s clinical presentation. The clinical assessment reporting guidelines are available on the NURS 5012 eLearning site under the icon Assessment Tools. In addition, students need to incorporate the clinical assessment tool that was used in Assessment one. This should form part of the comprehensive clinical assessment (but does not need to be the focus of your assessment findings. (If it is not appropriate for this particular patient, and you are unable to find a suitable patient case for the use of this tool, describe the circumstances under which it might be used in a similar clinical presentation). Part B: Case study report Using the data obtained from the comprehensive clinical assessment of the patient, students need to construct a case study report. The case study should address all following questions: 1a. WHAT IS GOING ON HERE? (750 words max) • Patient’s presentation – what did the person present with? (one paragraph) • Evident clinical manifestations – signs and symptoms. Please include both observed mental and physical health signs and symptoms. 1b. PATHOPHYSIOLOGY OF CLINICAL MANIFESTATION (750 words max) • Pick one (1) aspect of the patient’s pathophysiological presentation. For example, the patient may have the following clinical manifestation: • purulent sputum, • elevated blood glucose levels, • changes in heart rate or rhythm, • anxiety, • increased white cell count • How did the selected problem arise in pathophysiological terms? PLEASE NOTE: Students need to describe the pathophysiological process leading to the clinical manifestation, not a general explanation of disease processes (that is, for example, asthma or diabetes). 2. WHAT ELSE DO I NEED TO KNOW? (1000 words max) • What further information is required at this point? • What other assessments/investigations need to be performed or recommended in order to complete the clinical picture? • What aspects of the patient’s health history need further information to inform the comprehensive clinical assessment? 3. WHAT DOES THIS ALL MEAN? (500 words max) • Overall clinical impression – based on above, students need to describe what they consider is going on with the patient? • Provide details about the understanding of what is happening to the patient based on the clinical impression (consider and include both mental and physical considerations). • How did the clinical assessment tool (explored in Assessment one) inform clinical judgment for this patient? Students should present the report as outlined above with headings for each section to clearly distinguish the different aspects. Dot points are acceptable and references need to be included to support the students work…..
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