(Solution) NR509 Week 6: Shadow Health Assessment Assignment

Introduction and Pre-brief

Daniel “Danny” Rivera is an 8-year-old boy brought to the clinic by a family member for a cough. It is important for you to determine whether or not Danny is in distress, explore the underlying cause of his cough, and look for related symptoms in other body systems. Ask about a variety of psychosocial factors related to home life, such as second-hand smoke exposure. Be sure to observe non-verbal cues as Danny presents with intermittent coughing and visible breathing difficulty. This case study will challenge you to differentiate his presenting symptoms and carefully listen as you auscultate his lungs. You will have the opportunity to also physically examine his eyes, ears, nose, and throat and document your findings using appropriate professional medical terminology. Apply the supportive information learned in the respiratory concept lab to your critical thinking process in this case study.

Tips and Tricks

Upon physical exam, be sure to note clues to specific conditions and pathology. For example, “cobblestoning” is pathognomonic for Allergic Rhinitis. Conversely, understand that an erythemic tympanic membrane is not necessarily pathognomonic for Otitis Media.

You will utilize specific assessment tools with your clinical practice. Be sure you know how to apply and interpret the Centor assessment criteria. The Centor criteria are a set of criteria which may be used to identify the likelihood of a bacterial infection in patients complaining of a sore throat.

Most cough suppressant preparations are marketed as mixtures of dextromethorphan or codeine with antihistamines, decongestants, expectorants, and/or antipyretics. Some nonprescription preparations substitute diphenhydramine or eucalyptus oil in place of codeine or dextromethorphan. Prescription medications may substitute other narcotic agents (hydrocodone or hydromorphone) for codeine and may be more addictive than codeine.

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 Respiratory Assignment

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: D.R. Age: 8 Gender:Male
Height/Weight BP HR RR Temp SPO2 Pain Allergies  
4’2” 90lbs 120/76 100 28 37.2c 96% 3/10 Medication: Denies

Food: Denies

Environment: Denies

  
 History of Present Illness (HPI)
Chief Complaint (CC) Cough 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 Cough started 5 days ago
Location throat
Duration Coughing every few minutes lasting 1-2min , for the past five days.
Characteristics Productive cough rated a 5 out of 10 with clear and thin sputum, cough worsens at night. Associated symptoms of sore throat and earache,(gargly and watery associated with sore throat)
Aggravating Factors Worse at night. Reports cough stays the same no matter what I do. (cough at night think CHF, GERD, Asthma…)
Relieving Factors Cough medicine  “helped a little”
Treatment resting
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

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