(Solution) NR509 Week 4: Shadow Health Assessment Assignment

Introduction and Pre-brief

This assignment provides the opportunity to conduct a focused exam on Brian Foster, who presents with recent episodes of chest pain in a non-emergency setting. Interview Mr. Foster and be sure to thoroughly assess the cardiovascular system as well as related body systems in order to compile a list of differential diagnoses. This case study offers you the opportunity to evaluate Mr. Foster’s personal and family history with heart disease and identify lifestyle risk factors. During the physical examination, thoroughly examine the cardiovascular system and carefully evaluate and document the patient’s heart sounds.

Tips and Tricks

The sounds in the Shadow Health Concept Labs and Physical Assessment Assignments are medically accurate.

Distinguishing normal from abnormal heart sounds requires practice and carefully listening for sometimes subtle and easily missed sounds. Be sure to take advantage of the Cardiovascular Concept Lab to sharpen your skills prior to beginning this assignment.

Optimize your listening experience by using headphones with your computer and listen to both normal and abnormal sounds multiple times to improve your proficiency with recognizing subtle differences.

Often patients present with a specific complaint or problem. However, during the history and physical examination, a new problem may be discovered that takes precedence during the visit. Be alert to such a situation with this case study assignment.

Purposes

The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e) differentiate normal from abnormal physical examination findings, (f) summarize, organize, and appropriately document findings using correct professional terminology, (g) practice developing primary and differential diagnoses, (h) practice creating treatment plans which include diagnostics, medication, education, consultation/referral, and follow-up planning; and (i) analyze and reflect on own performance to gain insight and foster knowledge.

Activity Learning Outcomes

Through this assignment, the student will demonstrate the ability to:

  1. Apply knowledge and understanding of advanced practice physical assessment skills and techniques (CO1)
  2. Perform focused and comprehensive histories and physical assessments for various patient populations (CO4 and CO5)
  3. Adapt skills and techniques to suit the individual needs of the patient (CO4)
  4. Differentiate normal from abnormal physical examination findings (CO2)
  5. Summarize, organize, and document findings using correct professional terminology (CO3)

Due Date

Sunday 11:59 PM MT at the end of each respective week.

Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment. 

In the event of an emergency that prevents timely submission of an assignment, students may petition their instructor for a waiver of the late submission grade reduction. The instructor will review the student’s rationale for the request and make a determination based on the merits of the student’s appeal. Consideration of the student’s total course performance to date will be a contributing factor in the determination. Students should continue to attend class, actively participate, and complete other assignments while the appeal is pending. 

Total Points Possible: 75 Points

Assignment

Step One: Complete the designated Shadow Health (SH) Assignment on the SH platform.

Step Two: Document your findings on the  Fillable Soap Note Template  download or the Printable Soap Note  download.

Step Three:  Upload the Lab Pass and completed SOAP Note as separate documents to the same assignment tab in the gradebook.

Requirements

NOTE: Before initiating any activity in Shadow Health, complete the required course weekly readings and lessons as well as review the introduction and pre-brief.

  1. Complete the Shadow Health Concept Lab (Weeks 2, 4, and 5) prior to beginning the graded assignment.
  2. Gather subjective and objective data by completing a focused, detailed health history and physical examination for each physical assessment assignment.
  3. Critically appraise the findings as normal or abnormal.
  4. Complete the post activity assessment questions for each assignment .
  5. Complete all reflection questions following each physical assessment assignment.
  6. Digital Clinical Experience (DCE) scores do not round up. For example, a DCE score of 92.99 is a 92, not a 93.
  7. You have a maximum of two (2) attempts per Shadow Health assignment to improve your performance. However, you may elect not to repeat any assignment. NOTE: If you repeat an attempt, ONLY the second attempt will be graded, regardless of the DCE score. Please refer to the grading rubric categories for details.
  8. Download the Lab Pass for the final attempt on the assignment.

Solution: 

S:Subjective

Information the patient or patient representative told you

SOAP Note Template

 

 

Initials: BF Age: 58 Gender:Male
Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction)
5’11” 197lbs 146/90 104 19 36.7 98% 5/10 Medication: Codeine (nausea/vomiting)

Food: N/A

Environment: N/A
 History of Present Illness (HPI)
Chief Complaint (CC) Chest pain CC is a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.  Sometimes a patient has more than one complaint.  For example: If the patient presents with cough and sore throat, identify which is the CC  and which may be an associated symptom
Onset Earlier in the month, off and on
Location Middle of chest
Duration Lasts a couple of minutes
Characteristics Tight and uncomfortable
Aggravating Factors Activity/moving
Relieving Factors Rest
Treatment No medications used/rest
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication

(Rx, OTC, or Homeopathic)

 Dosage Frequency Length of Time Used Reason for Use

Please click the icon below to purchase full answer at only $20