Danny Riviera Shadow Health: Focused Exam: Cough Results
Danny Riviera Shadow Health Focused Exam Cough Results
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Status
Student Response Model Answer Explanation Points Earned
is at risk for is at risk for The correct status for the nursing diagnosis is “is at risk for,” because Danny’s most pressing vulnerability is to an infection that he has not yet, but could, develop. 0.5 out of 0.5
Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 100 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 90 points; and students successfully scoring at the Proficiency level on the third attempt will earn a grade of 80 points. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points).
Diagnosis
Student Response Model Answer Explanation Points Earned
infection infection While a cough can be unpleasant, the most alarming thing it indicates about Danny’s health is that he is at risk for an infection. 0.5 out of 0.5
Etiologies
Student Response Model Answer Explanation Points Earned
played w/ sick peer played w/ sick peer Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
touches face often touches face often Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
rare hand washing rare hand washing Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
secondhand smoke secondhand smoke Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
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Signs & Symptoms
Student Response Model Answer Explanation Points Earned
N/A N/A Because the infection that Danny may develop hasn’t happened yet, he is not currently presenting with any signs or symptoms, so the correct answer here is “N/A.” 0.5 out of 0.5
Self Assessment
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
Why would a nursing diagnosis of a cough be incorrect, compared to a risk for infection? Consider the difference between nursing and medical diagnoses. Whereas the cough can be unpleasant and a bother, it is a symptom of something more severe in the sense that it shows that the immune system could be at risk of getting an infection. The most effective nursing care you should prioritize is to educate the patient on avoiding the more serious outcome. While a cough can be unpleasant and frequent, it is actually a symptom of something more alarming: the immune system being at risk for an infection. The most effective nursing care you should prioritize is to educate your patient on avoiding this more serious outcome. Your nursing diagnosis should always take into account what condition is most serious, receiving the greatest benefit from your help. This diagnosis may not be the most obvious physical symptom to you or your patient, so always consider what is jeopardizing a patient’s health the most.
Planning
3.5 out of 4
Short-Term Goal
Student Response Model Answer Explanation Points Earned
To have patient report decreased discomfort and coughing by end of clinic visit. To have the patient and his guardian verbalize and agree to their instructions on how to avoid infection & practice respiratory hygiene, by end of the healthcare visit. A risk-based diagnosis does not require medical interventions as the problem is hypothetical; the goal that does suit the diagnosis involves teaching the patient and his guardian about risk-reduction methods. 0 out of 0.5
Interventions
Student Response Model Answer Explanation Points Earned
Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroom Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroom Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct family and patient that patient should increase fluid intake Instruct family and patient that patient should increase fluid intake Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct family to keep their house smoke-free (reducing exposure to environmental pathogens) Instruct family to keep their house smoke-free (reducing exposure to environmental pathogens) Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct patient on washing hands or using hand sanitizer after coughing or being near someone sick Instruct patient on washing hands or using hand sanitizer after coughing or being near someone sick Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct patient to avoid touching fingers to eyes, nose, or mouth Instruct patient to avoid touching fingers to eyes, nose, or mouth Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct patient to cough into tissue, or sleeve if tissue is unavailable Instruct patient to cough into tissue, or sleeve if tissue is unavailable Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Intervention Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal. Ask patients and family memebers to verbalize and agree to their instructions on infection prevention and respiratory hygiene. These interventions will teach Danny and his guardian how to keep their hands and lungs clean in a variety of ways, so that Danny’s risk for infection is reduced as pathogens are eliminated. Infection can be caused by multiple culprits, so it’s important that your patient teaching covers a thorough and specific array of anti-infection habits.
Data Collections
Student Response Model Answer Explanation Points Earned
Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene It is important that your patient and his guardian agree to their instructions, as changing lifestyle habits can be intimidating but necessary for the patient’s health. Having Danny and his father verbalize back their instructions also assures they remember and understand the details. 0.5 out of 0.5
Discussion Of Care
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
Explain the rationale behind your nursing diagnosis. Hello Danny, since you have been feeling unwell for the last three days, it is my responsibility to ensure that you get in the habit of practicing hand hygiene. Because you are at risk for developing an upper respiratory infection. My goal to you is to you and your family to avoid unnecessary infections by following these instructions. Some of the things that make you sicker are being near sick friend, being exposed to second hand smoke, washing your hands more, and touching your face with hands. I know it sounds like a lot of things but working together, we can reduce the infections in an effective manner. Danny, given that you aren’t feeling well, we want to make sure you don’t develop an infection, which for you just means getting even sicker. We’re going to talk about the ways we can work to prevent that, especially focusing on your risk factors, which are just things that give you a bigger chance of being sick. Some of your risk factors are that you were near a sick friend, have been exposed to cigar smoke, could stand to wash your hands more, and have touched your face with your fingers. I know that sounds like a lot, but if we work together, reducing your risk factors for infection can be easy and effective. A patient should understand their nursing diagnosis and the rationale behind it to increase their sense of involvement and to identify areas for future improvement.
Explain your goal for Danny and the interventions and data collections through which you will achieve it. All right. In order to talk to you about how you are not going to get sicker, I will have a conversation with you and your father. Him, you and myself are going to work together to discuss and then have to agree to your goals. And then I am going to have you and your father repeat what you have learned so we can make sure that you have got it down pat. Let’s talk about how we’re going to help you not get sicker! So, I’m going to have a conversation with you and your father about things to do to ensure your health. You, he, and I will work together to discuss, and then have you agree to your goals. Then I’m going to have you and your father repeat what you’ve learned, so we can make extra sure you’ve got it down pat! You should communicate the Care Plan to the patient, allowing them to exercise involvement and agency in their own healthcare.
Explicitly ask for Danny’s consent to the Care Plan. Does this sound like a plan? Does this plan I just talked about sound good to you? A patient must consent to all interventions in their Care Plan. Disagreements are opportunities to provide further patient education and to consider alternative options.
Inform Danny you will now begin educating him and will then call to educate his guardian. Now, Danny, if you lack other questions, we can start now! Danny, if you don’t have any other questions, we can start our discussion now! It’s time to begin your education interventions, so let your patient know!
Intervention & Evaluation
2.5 out of 2.5
Student Response Model Answer Explanation Points Earned
Partially Partially While Danny correctly verbalizes and agrees to his instructions for reducing infection risks, his father only agrees to some of his instructions, expressing apprehension toward not smoking inside the house. Your goal has been partially achieved. 2.5 out of 2.5
Intervention & Evaluation Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
Did you achieve your goal for your patient and his guardian by the end of the visit, getting each of them to agree to and verbalize your instructions for avoiding infection and practicing respiratory hygiene? Whereas Danny agrees to his instructions and has verbalized a complete and correct understanding of what to do, his father expresses reluctance about reducing his smoking inside of his house. One of his instructions was to keep the house smoke free so as to reduce Danny’s risk of infection so this aspect of the goal has not been achieved. However, the paties verbally agree to most of the other interventions, which implies that the overall goal has been achieved partially. While Danny agrees to his instructions and has verbalized a complete and correct understanding of what to do, his father expresses reluctance about reducing his smoking inside of the house. One of his instructions was to keep the house smoke-free in order to reduce Danny’s risk of infection, so this aspect of your goal has not been achieved. However, both parties verbally agree to most of their other instructions, so your overall goal has been partially achieved. Even with progress being made in almost all aspects of your patient teaching, you must adhere to your goal and consider your work incomplete if certain agreements have not been reached.
Assessment Description
Within the Shadow Health platform, complete the Focused Exam: Cough Results. The estimated average time to complete this assignment each time is 1 hour and 15 minutes. Please note, this is an average time. Some students may need longer.
This clinical experience is a focused exam. Students must score at the level of “Proficiency” in the Shadow Health Digital Clinical Experience. Students have three opportunities to complete this assignment and score at the Proficiency level. Upon completion, submit the lab pass through the assignment dropbox.
Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 100 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 90 points; and students successfully scoring at the Proficiency level on the third attempt will earn a grade of 80 points. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points).
If Proficiency is not achieved on the first attempt, it is recommended that you review your answers with the correct answers on the Experience Overview page. Review the report by clicking on each tab to the left titled Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Reviewing this overview and the course resources may help you improve your score.
Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion.
You are not required to submit this assignment to LopesWrite.
Attachments
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Hello!
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Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
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What is the situation?
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Your patient is Danny Rivera, an 8-year-old Puerto Rican boy presenting with a cough in the Shadowville Elementary nurse’s office. Your role in this simulation is that of a healthcare provider who will perform a focused history and physical examination in order to collect data, assess Danny’s condition, and transfer care. In this simulation, you will be able to perform procedures not always typical to a school setting so you can gather as much data as possible.
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What are my objectives in this assessment?
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Danny is very health literate and a good historian of his own health history; he can answer questions that not every child may be able to. In your interview with Danny, you will ask about the history of his presenting illness and the functioning of relevant systems in order to obtain subjective data related to his cough. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Danny’s family so you can determine his genetic predisposition to any diseases. In addition to collecting subjective data, you will perform a physical exam on Danny to gather objective data about his health and physiology. Throughout the conversation, you should educate and empathize with Danny when appropriate to increase his health literacy and sense of well-being. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
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What else will this exam involve?
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Because Danny is a pediatric patient, you will also be required to make a phone call to his guardian’s home to gather additional information. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. After the exam, you will transfer care of the patient to me, Preceptor Diana, communicating key information about the Situation, Background, Assessment, and Recommendation, or SBAR. Activities other than Subjective and Objective Data Collection, and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
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How will I be evaluated?
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In this assignment, you will be evaluated on your Subjective and Objective Data Collection, as well as Education and Empathy. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. This assignment takes on average between 40 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
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How does this assignment prepare me for the real world?
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In this assessment, you will become familiarized with the structure and content of a cough focused exam so that with real-life patients, you can: º ask effective and comprehensive questions º educate and empathize with the patient º evaluate the patient’s risk of disease, infection, injury, and complications º obtain and assess objective data. º and transfer patient care using SBAR.
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In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What strategies can you use to develop rapport with a pediatric patient?
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The most important strategy would be deploy effective communication that would make the patient to feel comfortable
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Time to begin.
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Hello, my name is Constantine and I will be conducting this session.
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Hi.
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Do you have cough?
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I guess I’m kind of sick. . . I’ve been coughing a lot.
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I am so sorry to hear that. It must be tough on you.
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Empathize |
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Thanks.
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How long have you had a cough?
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I think the cough started two . . . No, it started three days ago.
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Is your cough a wet cough?
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Yeah . . . my cough seems kind of gurgly and watery.
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Do you have any phlegm or sputum with your cough? (Clarified to Do you produce any phlegm or sputum with your cough?.)
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Sometimes I cough up this slimy, clear stuff. (Clarified to if I produce phlegm or sputum when I cough.)
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how frequently are you coughing?
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I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
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Your nights must be really long
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Thanks for saying that.
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How long do your coughs last?
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A couple seconds, I guess. [AUDIO COMING SOON]
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Is the cough worse at night
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Yeah, my cough’s worse at night. It makes it hard to sleep.
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Do you smoke?
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No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.
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Are you ever around cigarette smoke?
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Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it’s not all the time or anything. I don’t like how it smells, and I don’t like that he is hurting himself. He could get sick.
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What makes your cough worse?
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I don’t think anything makes my cough be worse.
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Have you done anything to treat your cough?
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My mom gave me some medicine this morning. . . that helped my cough a little. I don’t remember what it was called though, sorry.
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What colour was the cough medicine?
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Um, it was purple-ish. It tasted gross.
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How much medicine did you take?
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It was just a spoonful.
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Who gave you the medicine for your cough?
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My mom gave it to me.
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How many times have you taken the cough medicine
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I only had it this morning.
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Have you tried any home remedies for you cough? (Clarified to Did you try any home remedies for your throat?.)
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No, I didn’t get anything like that. (Clarified to if I tried any home remedies for my throat.)
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Do you take any medications from a doctor
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No, the only medicine I’ve taken recently was the syrup for my cough.
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Do you take vitamins?
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Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don’t think I’m supposed to, but sometimes I sneak extra ones to be super healthy!
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Are you usually active?
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I have gym class every day. I do all my exercises there. Abuela always has to remind me to play outside for a little bit on the weekends. . . I guess I like to play inside more.
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Have you been less active since getting sick?
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I haven’t been playing as much since getting sick, because I’m tired. But I can still do gym class.
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Are you able to keep up when you play with your classmates
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We have to go to gym class every day. I can do all my exercises, but I’ve been slower since getting sick. I’ve been a little tired.
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Are you able to focus in class?
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I can focus normally, but I couldn’t sleep very well last night because of my coughing, so it was harder than normal. Plus, it’s harder to pay attention when you keep having to cough.
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Do you currently have a runny nose?
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My nose is always a little bit runny. . .but ever since I started coughing it’s been worse, I think.
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Have you been sneezing?
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I don’t sneeze a lot, just if my nose gets itchy . . . but that doesn’t usually happen. My nose sometimes gets a little bit runny though.
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What colour is you snot? (Clarified to What color is your nasal discharge?.)
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You mean like when I blow my nose? It’s clear. (Clarified to what color my nasal discharge is.)
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What is the consistency of your nasal discharge?
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The stuff coming from my nose? It’s really drippy, like water, if that’s what you mean.
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Do you have any ear pain?
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My ears are okay. They don’t hurt or anything.
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Have you ever had ear infections?
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Mom said I had ear infections a lot. . . when I was baby, but not now. Now they’re fine.
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Do you have any ear discharge?
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No, nothing comes out of my ears.
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Do you have any hearing problem?
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A lady came here to school to give all the kids a hearing test. It was kind of cool! I was hoping I would have super hearing, but I think it was just normal . . .
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Is your throat sore?
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It feels a little bit sore, yeah.
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Does it hurt when you swallow?
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I can swallow OK, but it hurts a little bit.
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Do you have runny noses often?
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My nose is always a little bit runny. . .but ever since I started coughing it’s been worse, I think.
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Do you have coughs very often?
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I sometimes get coughs like this, but it’s not all the time. I don’t think it’s a lot.
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Have you had pneumonia?
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I think I had that last year, when I was seven. My mom was really worried.
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Do you have asthma?
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No. But my mom says Papi had asthma when he was a little kid. He shouldn’t be smoking cigars because of it, but he does, and it makes me upset.
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Do you have current immunizations?
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Like getting shots? It seems like I get shots whenever I go to the doctor. Mom says I need them for school, but I hate it.
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Do you have seasonal allergies?
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I’m not allergic to anything like that.
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Do you have food allergies?
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I’m pretty sure I’m not allergic to any foods. I think I would know about that!
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Are you allergic to any medications?
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I don’t think I’m allergic to any medicines.
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Do you have a family history of asthma?
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Mom says Papi had asthma when he was a little kid. It’s not good to smoke cigars now, but he still does. I’m scared he’ll get sick. . .
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Do you have family history of allergies?
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No, I don’t think anybody in my family is allergic to anything.
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Do you have chills?
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No, I haven’t felt that.
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Do you have a fever?
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My mom said I didn’t have a fever before I came to school. . . she took my temperature.
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Do you have fatigue?
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Yeah, I feel kind of tired. I think it’s because I couldn’t sleep much at night. My cough kept me from falling asleep.
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Do you have night sweats?
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I don’t sweat at night unless it gets really hot or something.
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Have you been sleeping okay?
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Most times I sleep OK, but I haven’t been able to sleep much because of my cough.
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Have you noticed any swelling?
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I don’t think anything is swollen.
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Do you have unusually frequent colds?
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I get colds a lot. My nose is always runny.
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Do you get headaches?
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I don’t usually get headaches.
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Do you have nosebleeds?
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Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.
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Do you have any problem with your vision?
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No, I see really good. Oh, I mean, I see well. I think glasses are kind of cool though. My friend Tony has them.
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Do you have any dizziness?
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I only get dizzy if I’m spinning around a lot at recess.
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Do you have watery eyes?
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No, my eyes don’t tear up. Well, I guess if I get sad or Papi is chopping onions for dinner they might.
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Do you have eye redness?
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I don’t think my eyes are ever red.
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Do you have any eye pain?
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No, my eyes don’t hurt, but they kind of feel like they do when I’m tired.
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Do you have any sinus pain?
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It doesn’t hurt there.
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Do you have chest tightness?
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No, my chest doesn’t feel tight. That would be scary.
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Do you have any chest pain?
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No, I don’t have pain in my chest. I would hate that!
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Do you have difficulty breathing?
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I breathe OK, but my nose is always kinda runny.
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Are you exposed to germs? (Clarified to Are you exposed to an environmental hazards?.)
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Our house is pretty safe if you ask me . . . sometimes Papi smokes in the house though and I know that’s bad, even for adults. It makes me unhappy when he smokes. (Clarified to if I am around environmental hazards.)
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Are you exposed to second hand smoke?
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Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it’s not all the time or anything. I don’t like how it smells, and I don’t like that he is hurting himself. He could get sick.
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How often do you wash your hands?
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Not a lot. I only wash them if they’re really dirty, or Abuela says we’re about to eat.
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Do you close your mouth when you cough?
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When I cough, I like to let it all out.
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Are you exposed to germs? (Clarified to Have you been exposed to chemicals?.)
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I don’t think so. (Clarified to if I am around chemicals at home.)
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Washed hands.
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Measured blood pressure
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Exam Action |
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Measured heart rate
|
Exam Action |
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Measured pulse oximetry
|
Exam Action |
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Measured respiratory rate
|
Exam Action |
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Measured temperature
|
Exam Action |
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Tested lung capacity with spirometer: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%)
|
Exam Action |
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Inspected upper conjunctiva
|
Exam Action |
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Inspected right orbital area and sclera
|
Exam Action |
|
Inspected lower conjunctiva
|
Exam Action |
|
Inspected left orbital area and sclera
|
Exam Action |
|
Inspected upper conjunctiva
|
Exam Action |
|
Inspected lower conjunctiva
|
Exam Action |
|
Performed otoscopic examination of right ear
|
Exam Action |
|
Performed otoscopic examination of left ear
|
Exam Action |
|
Performed otoscopic examination of right naris
|
Exam Action |
|
Performed otoscopic examination of left naris
|
Exam Action |
|
Inspected mouth
|
Exam Action |
|
Inspected front of neck
|
Exam Action |
|
Inspected right side of neck
|
Exam Action |
|
Inspected back of neck
|
Exam Action |
|
Inspected left side of neck
|
Exam Action |
|
Inspected front of neck
|
Exam Action |
|
Inspected right side of neck
|
Exam Action |
|
Inspected anterior chest wall
|
Exam Action |
|
Inspected posterior chest wall
|
Exam Action |
|
Inspected anterior chest wall
|
Exam Action |
|
Palpated frontal sinuses: No tenderness reported
|
Exam Action |
|
Palpated maxillary sinuses: No tenderness reported
|
Exam Action |
|
Palpated lymph nodes of head and neck: Enlarged and reported tenderness on the right side
|
Exam Action |
|
Palpated supraclavicular lymph nodes: Not palpable
|
Exam Action |
|
Palpated axillary lymph nodes: Not palpable
|
Exam Action |
|
Palpated axillary lymph nodes: Not palpable
|
Exam Action |
|
Palpated fremitus in anterior upper chest wall: Present and equal bilaterally
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated fremitus in anterior lower chest wall: Present and equal bilaterally
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated fremitus in posterior upper chest wall: Present and equal bilaterally
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated fremitus in posterior middle chest wall: Present and equal bilaterally
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated fremitus in posterior lower chest wall: Present and equal bilaterally
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated chest expansion: Both sides rise symmetrically
|
Exam Action |
|
Auscultated breath sounds in anterior right upper lobe
|
Exam Action |
|
Auscultated breath sounds in anterior left upper lobe
|
Exam Action |
|
Auscultated breath sounds in anterior right upper lobe
|
Exam Action |
|
Auscultated breath sounds in anterior left middle lobe
|
Exam Action |
|
Auscultated breath sounds in anterior right middle lobe
|
Exam Action |
|
Auscultated breath sounds in anterior left middle lobe
|
Exam Action |
|
Auscultated breath sounds in anterior right lower lobe
|
Exam Action |
|
Auscultated breath sounds in anterior left lower lobe
|
Exam Action |
|
Auscultated breath sounds in posterior left upper lobe
|
Exam Action |
|
Auscultated breath sounds in posterior right upper lobe
|
Exam Action |
|
Auscultated breath sounds in posterior left mid-back (lower lobe)
|
Exam Action |
|
Auscultated breath sounds in posterior right mid-back (lower lobe)
|
Exam Action |
|
Auscultated breath sounds in posterior left lower lobe near spine
|
Exam Action |
|
Auscultated breath sounds in posterior right lower lobe near spine
|
Exam Action |
|
Auscultated breath sounds in posterior left lower lobe on side
|
Exam Action |
|
Auscultated breath sounds in posterior left lower lobe
|
Exam Action |
|
Auscultated breath sounds in posterior right lower lobe
|
Exam Action |
|
Auscultated breath sounds in posterior right lower lobe on side
|
Exam Action |
|
Auscultated voice sounds in anterior right upper lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in anterior left upper lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in anterior right upper lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in anterior left mid-chest (upper lobe)
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in anterior right middle lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in anterior left mid-chest (upper lobe)
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in anterior right lower lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in anterior left lower lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior left upper lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior right upper lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior left mid-back (lower lobe)
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior right mid-back (lower lobe)
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior left lower lobe near spine
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior right lower lobe near spine
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior left lower lobe on side
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior left lower lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior right lower lobe
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in posterior right lower lobe on side
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated aortic area with the bell
|
Exam Action |
|
Auscultated aortic area with the diaphragm
|
Exam Action |
|
Auscultated aortic area with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated pulmonic area with the diaphragm
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated Erb’s point with the diaphragm
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated tricuspid area with the diaphragm
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated mitral area with the bell
|
Exam Action |
|
Auscultated mitral area with the diaphragm
|
Exam Action |
|
Auscultated mitral area with the bell
|
Exam Action |
|
Percussed anterior right upper lobe
|
Exam Action |
|
Percussed anterior left upper lobe
|
Exam Action |
|
Percussed anterior right middle lobe
|
Exam Action |
|
Percussed anterior left mid-chest (upper lobe)
|
Exam Action |
|
Percussed anterior right lower lobe
|
Exam Action |
|
Percussed anterior left lower lobe
|
Exam Action |
|
Percussed posterior left upper lobe
|
Exam Action |
|
Percussed posterior right upper lobe
|
Exam Action |
|
Percussed posterior left mid-back (lower lobe)
|
Exam Action |
|
Percussed posterior right mid-back (lower lobe)
|
Exam Action |
|
Percussed posterior left lower lobe
|
Exam Action |
|
Percussed posterior left lower lobe on side
|
Exam Action |
|
Percussed posterior left lower lobe near spine
|
Exam Action |
|
Percussed posterior right lower lobe
|
Exam Action |
|
Percussed posterior right lower lobe near spine
|
Exam Action |
|
Percussed posterior left right lobe on side
|
Exam Action |
|
Measured diaphragmatic excursion: 3 cm
|
Exam Action |
Advanced Heath Assessment Documentation Tutorial
In each of the Shadow Health (SH) Assignments, you will be asked to complete a narrative note as part of the grading criteria. Narrative or progress notes are often a new skill. This document is provided to assist students in understanding how to write a narrative note. Shadow Health refers to these notes as Provider Notes.
Documentation of patient care is essential to quality and safety of care. Much of the clinical documentation is completed electronically using point and click tools to describe the patient condition (Lindo, et al., 2016). Often computer prompts fall short of fully describing the patient condition. Other situations such as lack of technology, electrical outages, system hacking, failure of equipment, and any number of situations which may interfere with normal electronic documentation may require a narrative nurses/progress note. Nurses must be able to clearly communicate patient information with everyone on the health care team to ensure quality and safety of care (Lindo, et al., 2016).
Documentation must be clear, paint a picture of the patient, and provide measurable concise information in a timely manner. The information communicated must be able to be understood by others and provide enough information to understand if a change has occurred in the patient condition and to clearly communicate all treatments, interventions, and therapies received by the patient and/or planned for the patient. Documentation also serves as a legal record of care (Lippincott Williams and Wilkins, 2007).
Documentation begins with subjective data/information. This is information the patient, family member, or caregiver may provide if the patient is unable to communicate which includes such data as the history of present illness (HPI), the past history- allergies, medications, medical surgical & social and the review of systems (ROS). Objective data/information includes the physical exam, observations and measurements obtained during the examination of the patient. Objective data also includes vital signs, laboratory and diagnostic results (Bates, 2017, pg.7)
Subjective vs. Objective Data-As you begin to acquire data from the patient interview and physical exam, it is important to remember the difference between subjective and objective information. Symptoms are the subjective concerns of what the patient tells you of their experience. Signs are the objective findings from your observations. (Bates, 2017, pg.6). Sequence of data is documented in the manner it is collected from the sequence of the examination. Physical examination follows a cephalocaudal sequence with the cardinal techniques of inspection, palpation percussion and auscultation (Bates, 2018)
Subjective information assists in understanding the patient condition and provides a basis upon which the nurse decides which body systems need to be assessed and which assessments need to be completed. Many of the assessments to be performed in the class are focused or problem based and focus on the assessment of a specific body system. The Comprehensive assessment is a complete health history and physical exam of most all body systems (Bates, 2017. Pg.5)
Once subjective and objective information are obtained and have been thoroughly considered an assessment/nursing diagnosis or medical diagnosis (physicians and advanced practice only) is identified. A plan of care will then be developed based on the nursing diagnoses. In the health assessment competencies, the primary focus is on gathering accurate subjective and objective data (Bates, 2017, pg.24)
Subjective data should be recorded using the patient’s own words and describing his/her feelings and experiences related to health. When interviewing the patient about a current issue or illness the seven attributes of a symptom need to be included in the documentation (Bates, 2017, pg.79)). The seven attributes of a symptom would be asked for any positive response during the health history (HH) and review of systems (ROS). Here is a list of the attirbutes and a few sample questions for a patient with complains of abdominal pain (Bates, 2017, pg.79)
- Location: “Where does it hurt?” “Please point to the area of pain.”
- Quality: “How would you describe the pain?” “Is it sharp pain?” “Dull pain?”
- Quantity or Severity: “On a scale of 0-10, 0 being no pain and 10 being the worst pain ever, what is your level of pain?” “How has the pain impacted your daily routine?”
- Timing: “When does the pain occur?” “How long does it last?” “Approximately how long after you have eaten does the pain begin?” ”Does the pain radiate?” “If yes, where does it radiate?”
- Onset or Setting in which it occurs: “What were you doing when the pain began?”
- Aggravating or Relieving Factors: “Is the pain worse after eating certain foods?” “What makes the pain better?”
- Associated Factors: “Do you have any nausea or vomiting?” “Any diarrhea?” “Any constipation?”
Another way to remember what to ask the patient is to use the mnemonic OLDCARTS or OPQRST (Bates, 2017. p.79)
O: Onset
L: Location
D: Duration of symptoms
C: Character
A: Aggravating/Alleviating Factors
R: Radiation
T: Timing
S: Severity
OR
O: Onset
P: Provocative or Palliative
Q: Quality or Quantity
R: Region or Radiation
S: Site
T: Timing
When documenting the ROS it is necessary to document each condition or item asked about because others will be reading the notes and relying on the information provided. If information is incomplete or inaccurate patient safety and quality of care may be affected. Documentation of pertinent negatives should be specifically described. Do not overgeneralize by using terms such as “WNL”, or neurologic exam negative” as this does not convey what exactly was assessed subjectively and/or objectively (Bates, 2018, p. 38)
ROS (Subjective) Documentation Example:
Review the following ROS areas and the associated documentation and note the quality of the information provided for each system.
- Skin: Denies any rashes or changes to skin
- Head: No problems with head or headaches.
- Ears: Positive for fullness feeling in bilateral ears for past 2 days, denies changes in hearing, pain in ears or any drainage.
- Eyes: No problems, says they are normal.
Skin and ears are documented correctly. The skin description relays what items were subjectively asked of the patient. The ears ROS also includes pertinent positive with further information and pertinent negatives.
Head and eyes are not documented correctly. There is not a description of the items subjectively asked and is an incomplete picture.
(Bates, 2017, pg. 32)
Assessment (Objective) Documentation Example:
Skin: Uniform in color, tan, warm, dry, intact. Turgor good, skin returns immediately when released. Scattered flat small macules on face around nose. On back of left shoulder 4mm, symmetrical, smooth borders, dark brown, evenly colored, slightly raised nevus, without tenderness or discharge. Well healed pale scar 3 cm right forearm. Left wrist approximately 1 cm area around the circumference of the wrist pruritic papules and vesicles with an erythematous base. Silver colored striae around lower outer quadrants of abdomen and hips.
- Head: Shape okay.
- Eyes: Eye color brown. brows, lids, and lashes symmetric, right brow ridge piercing with intact silver hoop, no redness, tenderness, or discharge; lacrimal ducts pink and open without discharge. Conjunctiva clear, sclera white, moist, and clear, no lesions or redness, no ptosis, lid lag, discharge or crusting. Snellen vision assessment 20/20 in each eye with corrective lenses. EOMs intact, no nystagmus, PERRLA
- Ears: TM with good cone of light, pearly gray appearance, canal clear of wax bilaterally, no edema or drainage present. Auditory acuity present bilaterally to whispered voice.
Skin is documented very complete and concise a picture of the patient is evolving and measurable assessment data is provided. Complete description of the rash on the left wrist provides a measurable concise picture. A mole was noted and documentation included the ABCDE of the mole. It is important to describe both normal and abnormal findings in a measurable manner. The text offers examples of how to provide measurable information for many assessment findings such as tonsils, pulses, reflexes, and strength (Bates, 2017, pg. 33)
The documentation for head is less measurable. How is one to know what “shape okay” is for this patient?
The documentation for the eyes is very thorough and concise. Measurable terms are used and a description of the patient’s eyes is provided.
The documentation for the ears is also very concise and thorough. Measurable terminology is used and a description is provided.
Some of the Shadow Health (SH) exams focus on one body system such as Cardiac. In this situation focus on pertinent questions related to the ROS and physical assessment for cardiac and any associated body systems. In the case of cardiac, peripheral vascular and respiratory would be additional systems to assess.
When completing the assessments in SH use the textbook as a guide. Open to the appropriate chapter and follow along to ensure all aspects of the assessment are covered for both subjective and objective assessment areas. Document carefully for each assessment area keeping in mind the differences between subjective and objective information and ensuring measurable concise information is recorded.
Subjective and objective information is separated and each body system is used as a heading for easier retrieval of information. When information is disorganized it is difficult to know which is the information provided by the patient and which is the objective clinical assessment data. In an emergency retrieval of information must be done quickly. Well organized and written notes allow for timely retrieval (Lindo et al., 2016).
References
Bickley, L. S. (2017). Bates Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins: Philadelphia, PA.
Lindo, J., Stennett, R., Stephenson-Wilson, K., Barrett, K.A., Bunnaman, D., Anderson-Johnson, P., Waugh-Brown, V., and Wint, Y. (2016). An audit of nursing documentation at three public hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 508-516.
Lippincott Williams & Wilkins (2007). Charting: An incredibly easy pocket guide. Ambler, PA: Author.