NURS 6512 Congestive Heart Failure
NURS 6512 Congestive Heart Failure
Initials: M.H Age: 60 years Old Sex: Male Race: Caucasian
S.
CC: “I am having shortness of breath; it’s been getting worse. I just feel tired all the time.”
HPI: M.H is a 60 years old Caucasian male patient who came to the hospital complaining of shortness of breath which has been worsening over time.
Location:
Onset:
Character:
Associated signs and symptoms:
Timing:
Exacerbating/ relieving factors:
Severity:
Current Medications:
Allergies:
PMHx:
Soc Hx: The patient has been smoking in the past with no success in quitting. Currently, he confirms smoking three cigarettes a day.
Fam Hx:
ROS:
GENERAL: proper posture. No weight loss or weight gain, chills, fever, nausea or vomiting.
HEENT: Eyes: denies visual loss, double vision, blurred vision, or using a visual aid. Ears, Nose, Throat: denies hearing difficulties, sneezing, sore throat or running nose.
SKIN: No rash, mole or itching.
CARDIOVASCULAR: confirms chest pressure and chest discomfort. Irregular heart rate with S1 and S2 sounds and no S3 or S4 sounds. No murmurs.
RESPIRATORY: confirms shortness of breath. Denies congestion or wheezing. Denies being exposed to an infected individual with a contagious respiratory infection in the past.
GASTROINTESTINAL: Denies anorexia, diarrhea, nausea or vomiting. Confirms a slight protuberant of the abdomen.
GENITOURINARY: denies burning on urination, foul urine odor or strange urine color. Confirms normal urine frequency.
NEUROLOGICAL: Denies headache, syncope, dizziness, paralysis, numbness, ataxia, or tingling in the extremities.
MUSCULOSKELETAL: Denies muscle pain. Confirms pain associated with joint movement of the lower extremities.
LYMPHATICS: Confirms edema on the right calf.
PSYCHIATRIC: Denies any history of anxiety or depression.
O.
Physical exam: Physical exam: Vital signs: B/P 148/88, HR 112bpm (Fast and irregular); T 97.9F orally; RR 32; labored; SpO2: 90% room air; Wt.: 210lbs; Hit: 5’7
General: Well oriented and cooperative. Slightly anxious but able to respond appropriately to the questions asked. Seems to have slight respiratory distress.
HEENT: head: atraumatic and normocephalic. Eyes: bilateral with no visual aid. The pupils are round, equal and bilaterally reactive to light. Ears: normal bilateral hearing.
Skin: Cool and diaphoretic. No cervical lymphadenopathy. No rashes
Chest/Lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds on the left lung.
Heart/Peripheral Vascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur. Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally
Abdomen: Bulgy with normoactive bowel sounds auscultated x4 quadrants
Genital/Rectal: The bladder is continent. No rashes around the genitalia.
Musculoskeletal: moderate pain of 5/10 on the RLE calf. Right calf with 2+ edema. Motion is of the normal range. There are no deformities of the joints.
Neuro: Alert and well oriented. Normal body posture. Slightly lethargic but with intact sensation.
Diagnostic results: Evaluation of the patient’s health complication require incorporation of the patient history, physical examination and lab test results. Based on the provided information, further diagnosis can be made with regard to the results of several lab tests. A complete blood count is necessary for ruling out infections or anemia as the root cause of the patient’s symptoms. Urinalysis is required in evaluating proteinuria in association with cardiovascular disease. CMP to check for renal dysfunction or fluid retention. An elevated level of fasting glucose also indicates high risks of heart failure (Papadakis, McPhee, & Bernstein, 2019). Natriuretic peptides should also be tested as they increase significantly in cases associated with heart failure. Lipid profile tests and TSH are relevant in assessing thyroid diseases in relation to heart failure. EKG will reveal arrhythmias, coronary artery disease, myocardial infarction and ischemia as possible causes of cardiac failure. Chest X-ray may reveal pulmonary congestion, hypertrophied cardiac silhouette among other causes of the patient’s symptoms.
A.
Differential Diagnoses
- Congestive Heart Failure: This condition is characterized by the buildup of fluids in the feet, legs, ankle, liver, abdomen and veins on the neck region, in addition to fatigue and shortness of breath (Shahbazi, & Asl, 2015). The patient displays symptoms of shortness of breath, and fatigue. Upon physical examination, it was revealed that the patient’s lower extremities were swollen, abdomen distended, irregular heart rate slightly elevated blood pressure, oxygen concentration and respiratory rate. All these symptoms point towards CHF as the primary diagnosis of the patient presenting illness.
- Myocardial Infarction: This condition is characterised by fatigue, malaise, chest discomfort, shortness of breath, rapid and irregular heartbeat and cough. Upon physical examination, patients with MI, usually exhibit an increased and irregular heart rate, elevated blood pressure, increased respiratory rate, fever, rales or wheezes may be auscultated, and edematous extremities (Reddy, Khaliq, & Henning, 2015). The patient was positive for most of these sign and symptoms.
- Pulmonary Embolism: The main indication for pulmonary embolism is a sudden onset of pleuritic chest pain, hypoxia and shortness of breath. Some patients may, however, lack the apparent symptoms, and instead present with an abrupt, catastrophic hemodynamic collapse or gradually progressive dyspnea (Kan et al., 2015). Due to the variation of the symptoms, pulmonary embolism is usually suspected in individuals with respiratory symptoms which are unexplainable by an alternative diagnosis, just like in the above case scenario.
- Pneumonia: Patients with pneumonia usually display symptoms such as fever, dyspnea, pleuritic chest pain, fatigue and cough. Upon physical examination, some of the findings will include tachypnea, bronchial breath sounds, rales noted over the affected lobe, decreased tactile fremitus and dullness on percussion of the chest (Papadakis, McPhee, & Bernstein, 2019). Some of these sign and symptoms were exhibited by M.H making pneumonia a potential differential diagnosis.
- Pericardial effusion: This condition usually presents as a result of inflammation of the pericardium following an injury or illness. It is characterized by chest congestion, dyspnea, fatigue, orthopnea, cough and lightheadedness. The patient was positive for most of these symptoms (Papadakis, McPhee, & Bernstein, 2019). Consequently, the physical examination findings of an individual with pericardial effusion include decreased breathing sounds, Ewart sign, tachypnea, tachycardia, pericardial friction rub, pulses paradoxus and hepatojugular reflux.
References
Shahbazi, F., & Asl, B. M. (November 01, 2015). Generalised discriminant analysis for congestive heart failure risk assessment based on long-term heart rate variability. Computer Methods and Programs in Biomedicine, 122, 2, 191-198.
Reddy, K., Khaliq, A., & Henning, R. J. (January 01, 2015). Recent advances in the diagnosis and treatment of acute myocardial infarction. World Journal of Cardiology, 7, 5, 243-276.
Kan, Y., Yuan, L., Meeks, J. K., Li, C., Liu, W., & Yang, J. (May 01, 2015). The accuracy of V/Q SPECT in the diagnosis of pulmonary embolism: a meta-analysis. Acta Radiologica, 56, 5, 565-572.
In Papadakis, M. A., In McPhee, S. J., & In Bernstein, J. (2019). Quick medical diagnosis & treatment 2019. New York, N.Y.: McGraw-Hill Education LLC.
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
To Prepare
- Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
- Consider what history would be necessary to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
DCE Focused Exam: Chest Pain Assignment:
Complete the following in Shadow Health:
- Cardiovascular Concept Lab (Required)
- Respiratory(Recommended but not required)
- Cardiovascular (Recommended but not required)
- Episodic/Focused Note for Focused Exam (Required): Chest Pain
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 7 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 7
- Complete your Focused Exam: Chest Pain DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
- Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
- (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
- Review the Week 7 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
- Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
- Complete the Code of Conduct Acknowledgement.
Grading Criteria
To access your rubric:
Week 7 Assignment 1 DCE Rubric
Submit Your Assignment by Day 7 of Week 7
To submit your Lab Pass:
Week 7 Lab Pass
To participate in this Assignment:
Week 7 Documentation Notes for Assignment 1
To Submit your Student Acknowledgement:
Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Cardiovascular disease (CVD) is the largest cause of death worldwide. Accounting for 610,000 deaths annually (CDC, 2017), CVD
frequently goes unnoticed until it is too late. Early detection and prevention measures can save the lives of many patients who have CVD. Conducting an assessment of the heart, lungs, and peripheral vascular system is one of the first steps that can be taken to detect CVD and many more conditions that may occur in the thorax or chest area.
This week, you will evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.
Learning Objectives
Students will:
- Evaluate abnormal cardiac and respiratory findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system
- Evaluate chest X-Ray and ECG imaging
Learning Resources
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 14, “Chest and Lungs”This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.
- Chapter 15, “Heart”The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.
- Chapter 16, “Blood Vessels”This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
- Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (specifically focus on pp. 480–481)
Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Note: Download the Student Checklists and Key Points to use during your practice cardiac and respiratory examination.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.
The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word document)
Use this template to complete your Assignment 1 for this week.
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 1, “Chest Wall, Pulmonary, and Cardiovascular Systems,” pp. 302–433)Note: Section 2 of this chapter will be addressed in Week 10.This section of Chapter 8 describes the anatomy of the chest wall, pulmonary, and cardiovascular systems. Section 1 also explains how to properly conduct examinations of these areas.
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Advanced Health Assessment and Diagnostic Reasoning
Thoughtful, reasoned questioning leads from initial complaint to diagnosis in these three scenarios.
Note: Close the viewing window after the intro segment and after each diagnosis segment to view the menu. (12m)
Photo Credit:Provided courtesy of the Laureate International Network of Universities.
Assessment of the Heart, Lungs, and Peripheral Vascular System – Week 7 (28m)
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s media, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 13 and 14 that relate to the assessment of the chest, heart, and lungs. Refer to Week 4 for access instructions on https://evolve.elsevier.com/
SUBJECTIVE DATA:
Chief Complaint (CC): “I have sporadic chest pain”
History of Present Illness (HPI): Mr. J.M. is a 38-year-old African American male who presented to the emergency department with complaints of sporadic chest pain for the last one month. The pain is usually centrally located and radiates to the left arm. He has experienced 3 episodes since the last month with each episode lasting several minutes. Currently, the pain is at 0 on a scale of zero to 10 although it is generally at 5 at its worst. The pain is characteristically uncomfortable and tight. It is aggravated by activities such as climbing stairs and yardwork while brief episodes of rest relieve the pain. He has not taken any medications for the pain.
Medications: Reports taking Lopressor 100mg PO once daily for hypertension and Lipitor 20mg PO once daily for hyperlipidemia as well as fish oil 1000mg PO twice daily.
Allergies: None
Past Medical History (PMH): Reports hypertension and hypercholesterolemia. No previous hospitalizations or blood transfusions. Denies prior chest pain treatment. Poor blood pressure monitoring both at home. Denies regular blood pressure checks at the pharmacy and drug store. Reports a recent EKG test that was normal. His last visit to a healthcare provider was three months ago.
Past Surgical History (PSH): No previous surgeries.
Sexual/Reproductive History: Heterosexual.
Personal/Social History: Has lived a relatively stress-free lifestyle. Regular water intake of about a liter per day. Drinks 2 cups of coffee daily. Denies routine regular physical activity and his last regular exercise was 2 years ago. Reports moderate alcohol consumption of about 2 to 3 drinks per week mostly on weekends but no tobacco or illicit drug use. His typical breakfast is a granola bar and instant breakfast shake, lunch turkey sub, and his dinner is typically grilled meat alongside vegetables.
Immunization History: All immunization up to date. The last COVID-19 vaccine was February this year, the last Tdap was May 2022 and the last influenza was January 2022.
Significant Family History: His mother is 65 years old and hypertensive while the father is 70 years old and obese. The grandmother died at 77 years due to a heart attack while the grandfather is 85 but suffered a stroke at 80 years. He has two daughters all alive and well.
Review of Systems:
General: Denies fever, changes in weight, chills, fatigue, night sweats, and palpitations.
Cardiovascular/Peripheral Vascular: No edema, easy bruising, angina, or easy bleeding.
Respiratory: No difficulty in bleeding, sputum, cough, or shortness of breath.
Gastrointestinal: Denies alteration in bowel habits, abdominal pain and nausea, and vomiting
Musculoskeletal: No back pains, joint pains, and muscle weakness.
Psychiatric: No anxiety, depression, delusions, or hallucinations
OBJECTIVE DATA:
Physical Exam:
Vital signs: Temperature- 98.5 F, pulse 80 beats per min, respiratory rate- 19 breaths per minute, blood pressure- 132/86 mmHg, saturation- 92% on room air, height 70. 86 inches, weight 251 lbs. BMI- 29.
General: A young African American male, well kempt and groomed, and appropriate for his stated age. Not in any obvious distress, good body built and well hydrated. No pallor, finger clubbing, splinter hemorrhages, jaundice, cyanosis, lymphadenopathy, or peripheral edema.
Cardiovascular/Peripheral Vascular: Nondistended neck veins (JVP less than 4cm above sternal angle), right carotid pulse 3+ with a thrill and bruit, left carotid pulse 2+ with no thrill or bruit, right and left brachial and radial arteries pulses 2+ with no thrills, right and left femoral arteries pulses 2+ with no thrills and bruits, right and left popliteal arteries pulses 1+ with no thrills, right and left tibial and dorsalis pedis pulses 1+ with no thrills, no renal, iliac and abdominal aorta bruits, and capillary refill is less than 3 seconds in all the digits. Precordium is brisk and tapping. The point of maximal impulse is displaced laterally and less than 3 cm, with a heave but no thrill. S1, S2, and S3 were heard with gallops, no murmurs.
Respiratory: Symmetric chest, moves with respiration with no obvious scars or masses on inspection. the trachea is central, with equal chest expansion, no tenderness or palpable masses, and equal tactile fremitus on palpation. Resonant on percussion. Good air entry and vesicular breath sounds in all lung zones, and no wheezes or rhonchi on auscultation.
Gastrointestinal: Nondistended, moves with respiration, symmetric, normal contour and fullness, umbilicus everted and no visible distended veins, striae, or scars. No tenderness or palpable masses on light and deep palpation. The liver is palpable 2 cm below the right costal margin. Liver span 8 cm. Spleen and both kidneys are impalpable. Tympanic on percussion, no shifting dullness or fluid thrill. No friction rubs over the liver and spleen.
Musculoskeletal: Normal muscle bulk, power of 5/5 in all muscle groups, normal reflexes, and range of movement across all joints.
Neurological: GCS 15/15, oriented to time place, and person, all cranial nerves and sensation intact, no neurological deficits noted, good bladder and bowel function.
Skin: No rashes, darkening, tenting, or nail changes.
Diagnostic Test/Labs: An EKG was done which revealed a sinus rhythm with no ST changes. Other critical tests include cardiac biomarkers particularly, troponin T/I, CK-MB, and myoglobin to exclude myocardial injury (Harskamp et al., 2019). Lipid profile and random blood sugar are required to check the level of lipid control and exclude diabetes mellitus respectively. Additionally, LDH to assess for cell necrosis, BNP to exclude concurrent heart failure, and inflammatory markers especially CRP for prognostication. Similarly, complete blood count with differential, urea creatinine, and electrolytes as well as liver function tests are required as a baseline for medication. Imaging tests include a transthoracic echocardiogram to assess left ventricular function, detect any wall motion abnormalities and identify any complications (Harskamp et al., 2019). Finally, a cardiac CT with IV contrast may be required to rule out differentials such as pulmonary embolism and aortic dissection.
ASSESSMENT:
Mr. J.M. is a 38-year-old African American male, known patient with hyperlipidemia and hypertension who presents with complaints of sporadic centrally located chest pain that radiates to the left arm. The pain is usually aggravated by exertion but relieved by rest with a history of physical inactivity. On examination, the right carotid artery pulse is increased with a bruit and thrill, the apex is displaced laterally, and S1, S2, and S3 are heard with gallops but no murmurs.
Main Diagnosis- The primary diagnosis is stable angina. Mr. J.M. presents with retrosternal chest pain that is tight and uncomfortable and that radiates to the left arm. This is characteristic of angina. However, these symptoms are worsened by exertion but relieved by rest which is a distinct feature of stable angina (Rousan & Thadani, 2019). According to Rousan and Thadani (2019), atherosclerosis is the most common etiology of this condition. Mr. J.M. has classic risk factors for atherosclerosis including arterial hypertension, hyperlipidemia, alcohol consumption, and overweight as well as a family history of cardiovascular events.
Differential diagnosis
Non-ST segmented elevated myocardial infarction- Myocardial infarction refers to an acute myocardial injury caused ischemia that results in tissue necrosis. This condition also presents with a retrosternal chest pain that dull and tight, precipitated by exertion and radiates to the left arm, shoulder, neck or jaw. Myocardial infarction may also be precipitated by an atherosclerotic event. However, lack of ST changes on EKG suggests NSTEMI (Cohen & Visveswaran, 2020).
Hypertension and hyperlipidemia- Mr. J.M. has previous history of hypertension on metoprolol and hyperlipidemia on Lipitor. Furthermore, lateral displacement of the apex beat as well as a heave suggest left ventricular hypertrophy which is usually a consequence of arterial hypertension (Oparil et al., 2018).
References
Cohen, M., & Visveswaran, G. (2020). Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types. Clinical Cardiology, 43(3), 242–250. https://doi.org/10.1002/clc.23308
Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W. A. M., & van Weert, H. C. P. M. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ Open, 9(2), e027081. https://doi.org/10.1136/bmjopen-2018-027081
Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature Reviews. Disease Primers, 4(1), 18014. https://doi.org/10.1038/nrdp.2018.14
Rousan, T. A., & Thadani, U. (2019). Stable angina medical therapy management guidelines: A critical review of guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence. European Cardiology, 14(1), 18–22. https://doi.org/10.15420/ecr.2018.26.1
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
| Excellent | Good | Fair | Poor | ||
| Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score. |
Points Range: 56 (56%) – 60 (60%)
DCE score>93 |
Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92 |
Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85 |
Points Range: 0 (0%) – 45 (45%)
DCE Score <79 No DCE completed. |
|
| Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: You should list these in bullet format and document the systems in order from head to toe. |
Points Range: 16 (16%) – 20 (20%)
Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 0 (0%) – 5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. |
|
| Objective Documentation in Provider Notes – this is to be completed in Shadow Health
Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). |
Points Range: 16 (16%) – 20 (20%)
Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. |
Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. |
Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. |
Points Range: 0 (0%) – 5 (5%)
Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. |
|
| Total Points: 100 | |||||
Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.