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Posted: February 26th, 2022
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Documentation of problem based assessment of the respiratory system. Imaging a patient you are Demonstrate physical examination skills of the RESPIRATORY SYSTEM. Make sure to include detail information on this assessment in a narrative form. You will document your findings, and identify two actual or potential risks factor of your patient. Include all steps below.
Write from nursing prospective
3 References , APA format
No consideration for plagiarism
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Due 2/26/22 @ 11am. Please use paper II as format
Purpose of Assignment:
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Learning the required components of documenting a problem based subjective and objective assessment of respiratory system. Identify abnormal findings.
Course Competency:
Apply assessment techniques for the neurological and respiratory systems.
Instructions:
Content: Use of three sections:
· Subjective
· Objective
· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Format:
· Standard American English (correct grammar, punctuation, etc.)
Documentation Grading Rubric - 10 possible points
Levels of Achievement
Criteria
Emerging
Competence
Proficiency
Mastery
Subjective
Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.
Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.
Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.
Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
Objective
Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”.
Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings.
Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information
Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information
Actual or Potential Risk Factors
Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion.
Brief description of one or two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selectio
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