(Solution) NR509 Week 2: Shadow Health Assessment Assignment

Introduction and Pre-brief

In this graded assignment, Tina Jones had an asthmatic episode 2 days ago. At that time, she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had ten episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing. Be sure to ask pertinent questions during the interview about related body systems. This case study will provide the opportunity to carefully assess lung sounds during the physical examination. Be sure to appropriately document your findings using correct medical terminology.

Tips and Tricks

You will have many opportunities to interact with Tina Jones during the Shadow Health Physical Assessment Assignments in this course. Subjective information, such as details from the health history, do NOT carry forward to the next assessment encounter. Do not assume the answers to questions that you may have previously asked in another encounter. Therefore, you must ask the same history questions again, even if you already think you know how the patient may respond! To obtain data for the health history, you must utilize good interview techniques and communications skills. Record accurately. DO NOT ASSUME. For example, the patient denies having chest pressure, but do not assume that she does not have chest pain – you need to ask this question specifically.

When performing your physical exam, remember to proceed in an organized manner from head to toe i.e. start with the General Survey, then the HEENT exam, and continue to move down the body in a logical manner. This keeps a nice flow for the patient and examiner.

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.

On the Canvas Platform:

  1. Summarize, organize, and appropriately document findings using correct professional terminology on the SOAP Note Template.
  2. Identify three (3) differential diagnoses and provide ICD-10 codes and pertinent positive and negative findings for each diagnosis.
  3. Create a comprehensive treatment plan for each assignment. Must address the following components: Diagnostics, Medication, Education, Referral/Consultation, and Follow-up planning. If no interventions for one or more component, document “none at this time” but do not skip over the component.
  4. Provide rationales and citations for diagnoses and interventions.
  5. Include at least one scholarly source to support diagnoses and treatment interventions with rationales and references on the SOAP note. Only scholarly sources are acceptable for citation and reference in this course. These include peer-reviewed publications, government reports, or sources written by a professional or scholar in the field. The textbooks and lessons are NOT considered to be outside scholarly sources. For the threaded discussions and reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. The best outside scholarly source to use is a peer-reviewed nursing journal.  You are encouraged to use the Chamberlain library and search one of the available databases for a peer-reviewed journal article.  The following sources should not be used: Wikipedia, Wikis, or blogs.  These websites are not considered scholarly as anyone can add to these. Please be aware that .com websites can vary in scholarship and quality.  For example, the American Heart Association is a .com site with scholarship and quality. Each student is responsible for determining the scholarship and quality of any .com site.  Ask your instructor before using any site if you are unsure. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Current outside scholarly sources must be published with the last 5 years.  Instructor permission must be obtained BEFORE the assignment is due if using a source that is older than 5 years.
  6. Upload the Lab Pass to the appropriate assignment area in Canvas Grades

Solution:

S:Subjective

Information the patient or patient representative told you

SOAP Note Template

 

 

Initials: TJ Age: 28 Gender:Female
Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction)
170cm 89kg 140/81 89 20 98.5 97% Choose an item. Medication: PCN (hives)

Food: Click or tap here to enter text.

Environment:Cats, dust (asthma exacerbation)
History of Present Illness (HPI)
Chief Complaint (CC) Shortness of breath 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 Last two days
Location Lungs
Duration Every 4 hours
Characteristics Hard to take in air, wheezing
Aggravating Factors Lying down, moving around too much, cats/dust triggers
Relieving Factors Albuterol inhaler (2-3 puffs, 90 mcg)
Treatment inhaler
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

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