NR302 Health Assessment I Assignment: Focused SOAP Note and Clinical Reasoning Analysis

Course Context

NR302 Health Assessment I emphasizes accurate data collection, clinical reasoning, and clear documentation. Written assessment tasks in this course reflect common expectations in undergraduate nursing programs and prepare students for later clinical and practicum courses where structured documentation is required.

Assignment Overview

Students will complete a focused SOAP note based on an adult client scenario provided in the course module or approved by the instructor. The assignment requires accurate subjective and objective data, logical assessment statements, and appropriate planning aligned with foundational nursing standards. A short clinical reasoning section explains how assessment findings informed decision making.

Learning Outcomes Assessed

• Apply focused health assessment skills to an adult client situation.
• Document findings using the SOAP note format used in clinical settings.
• Link assessment data to nursing judgment and care planning.
• Use scholarly sources to support assessment and documentation choices.

Assignment Instructions

Part I: Focused SOAP Note

Prepare a focused SOAP note using an adult health scenario involving a single primary concern such as pain, respiratory symptoms, gastrointestinal complaints, or fatigue. Maintain confidentiality and avoid all identifying information.

1. Subjective
   • Chief concern stated in the client’s words.
   • History of present concern using relevant symptom analysis.
   • Relevant medical, medication, and social history.
2. Objective
   • Vital signs and focused physical assessment findings.
   • Observable and measurable data related to the concern.
3. Assessment
   • Clear summary of key findings.
   • Priority nursing problem or concern stated accurately.
4. Plan
   • Immediate nursing actions and education needs.
   • Recommendations for follow up or referral when appropriate.

Part II: Clinical Reasoning Narrative

Write a short narrative that explains how the collected data guided the assessment and plan. Address patterns noted during the assessment and justify priorities using course concepts and scholarly sources.

• Explain why selected findings were considered significant.
• Describe how subjective and objective data supported the assessment statement.
• Discuss how the plan aligns with safe and ethical nursing practice.

Length and Format Requirements

• 1,050 to 1,400 words total, excluding references.
• APA seventh edition formatting.
• Minimum of three scholarly sources published between 2018 and 2026.
• Microsoft Word document submitted through the learning management system.

Grading Rubric

Focused SOAP Note Quality (55%)

• Accurate and relevant subjective and objective data.
• Logical assessment statement supported by findings.
• Appropriate and realistic nursing plan.

Clinical Reasoning Narrative (25%)

• Clear explanation of decision making.
• Connection between assessment data and nursing priorities.
• Use of evidence to support reasoning.

Scholarly Support and APA Style (10%)

• Appropriate integration of current literature.
• Correct APA citations and reference list.

Writing Clarity and Organization (10%)

• Logical structure and clear sentence flow.
• Professional academic tone with minimal errors.

The subjective report of shortness of breath during exertion, combined with diminished breath sounds in the lower lobes, suggested impaired airway clearance. Vital sign trends supported the assessment and guided prioritization of respiratory interventions. Patient education focused on symptom monitoring and timely follow up to reduce risk of progression.

References

• Jarvis, C. (2020) Physical examination and health assessment. 8th edn. St. Louis: Elsevier. Available at: https://www.elsevier.com/books/physical-examination-and-health-assessment/jarvis/9780323552286
• Bickley, L.S. (2021) Bates’ guide to physical examination and history taking. 13th edn. Philadelphia: Wolters Kluwer. Available at: https://shop.lww.com/Bates–Guide-to-Physical-Examination-and-History-Taking/p/9781975171032
• Weber, J. and Kelley, J. (2018) Health assessment in nursing. 6th edn. Philadelphia: Wolters Kluwer. Available at: https://shop.lww.com/Health-Assessment-in-Nursing/p/9781496348178
• Levett-Jones, T. et al. (2020) ‘Clinical reasoning and nursing judgement’, Nurse Education in Practice, 47, 102837. https://doi.org/10.1016/j.nepr.2020.102837