NUR 607 Final Project Part II Guidelines and Rubric
Overview
For this stage of your assessment, you will submit a report that includes an overview of the interview and review of systems that you conducted on your
practice client previously in the course, interpretation of the findings from the physical health assessment, possible collaborative diagnoses, and a discussion of
theoretical models and the use of informatics in health assessments.
This part of the final project addresses the following course outcomes:
- NUR-607-02: Interpret health assessment data for creating client-centered and culturally appropriate plans of care
- NUR-607-03: Formulate client-centered and culturally focused collaborative diagnoses using appropriate health assessment data
- NUR-607-04: Synthesize theoretical models in culture, nursing, and health promotion for assessing and providing care for diverse client populations
- NUR-607-05: Evaluate informatics systems for their impact on best practices in master’s-level nursing assessment to enhance client care
Sample Answer
Interpretation of Data
Overview
Vitals signs and symptoms, Eye, Nose, Throat, cardiovascular evaluation, digestive system assessment, and mental assessment were among the tests done. The patient’s eyes, ears, nose, and throat were evaluated using an ENT (Eyes, Nose, Throat) evaluation. The purpose of a cardiovascular evaluation is to examine the patient’s lungs and heart (Okon & Christensen, 2020). The heart was examined based on four cardiac sounds. A digestive system examination was carried out on the belly to check for any unusual intestinal noises. Lastly, the patient’s cervical, thoracic, and lumbar spines were evaluated during a neurological examination. Furthermore, as part of the overall evaluation, the gait was assessed.
Interpretation of the Finding
The results indicated a temperature of approximately thirty-six point seven degrees Celsius, the systolic blood pressure was 125mg Hg while the diastolic blood pressure was eighty-five millimeters per mercury, the respiration rate was nineteen, and the pulse was sixty-two beats per minute. The patient, a twenty-eight-year-old woman, gave her informed consent before undergoing the medical examination. The first skull was examined, and it was found to be typical cephalic with a thick texture. In a temporomandibular joint examination, the sinuses are examined in the head and found to be normal. The eyes were examined for whitish sclera and pink conjunctive eye. Both the conservative and liberal eyes were found to have identical, circular, and sensitive lighting. In addition, both eyes had an accommodation with twenty out of twenty visions. Examination of the ears indicated non-tender canals that were pink and reported no redness. However, the patient acuity was good in both her ears. Nose assessment showed that the mucosal membrane of the nose was pink. Following the nasal examination was the mouth examination. The mouth examination showed that the patient had pink oral mucosa. In addition, the patient had a lesion or an open area in her mouth.
The assessment of the neck was done from the midline part. From the evaluation, the patient had a full range of neck movements, both back and forth. The neck assessment did not show any lesion. The results of the heart assessment showed that the patient had a heartbeat of sixty-two beats per minute. The patient did not show any irregularity or hard sound from the first, second, third, and fourth sound assessments. However, the murmurs examination did not show any friction rib sound. The patient had an asymmetrical chest line. The assessment of the lung was done from the back. The lung assessment showed all the three lopes of the patient lungs are clear. The patient did not report any breathing difficulties, such as shortness of breath. Investigation of the skin started with examining the hands, which showed no rashes, clubbing, or open lesions. Generally, the patient skin condition was good. Similar to the hand, the legs did not indicate any lesion or swelling. In other words, the skin of the legs was intact without deformities. The cervical, lumbar and thoracic spines were all intact.
The evaluation of the gastrointestinal systems was conducted beginning with the belly. From the examination, the bowel sounds were normal all through. The stomach examination did not show any tenderness or pain. To assess the gait, the patient was told to walk. She had a steady gait.
