Model Documentation
Subjective
Social History: She is not aware of any environmental exposures or irritants at her job or home……
Review of Systems:
- General: Denies changes in…
- Nose/Sinuses:
- Gastrointestinal:
- Respiratory:
Objective
- General: Ms. Jones is a pleasant….
- Respiratory: Chest expansion is….
Assessment
- Mild-persistent….
Plan
Diagnostics
- Obtain office….
Education
- Encourage Ms. Jones to continue t….
Referral/Consultation
- Refer to…..
Follow-up Planning
- Order ….
- Instruct Ms. Jones …..
- Revisit….
- Tina’s second cousin was diagnosed with asthma at age 5. What would be included in your treatment plan? What factors might concern you related to compliance?
The treatment plan for this child would be to….
- Consider that Tina’s uncle is now 68 years old and has smoked heavily every day since he was fifteen. What would you expect to find in his respiratory assessment? How would this affect your oxygenation goals for this patient?
Common significant deviations of the chest for older adults include marked dorsal curvature, kyphosis, increased AP diameter of the chest (barrel chest), and diminished chest expansion (Hogstel & Curry, 2005). Bones become thinner, more rigid, and change shape, and muscles may become weakened. This results in a lower oxygen level with less carbon dioxide removed from the body, and decreased ability to cough. Osteoporosis causes decreased thoracic vertebrae height. Aging also causes the alveoli to lose their shape causing shortness of breath. Due to diminished cough reflex with decreased sensitivity, large amounts of particles that are more difficult to expectorate can collect in the lungs. In addition, the brain is less sensitive to hypoxia (low oxygen) and hypercapnea (higher than normal carbon dioxide) and higher residual volume. As a result of these changes, older persons are at increased risk for pneumonia and bronchitis (Minaker, 2011; Sharma & Goodwin, 2006).
In the respiratory assessment of this patient, I expect to find marked dorsal curvature, increased AP diameter of the chest, diminished chest expansion, and kyphosis. The weakened muscles will result in lower oxygen levels and lower elimination of carbon dioxide leading to decreased coughing capacity. Alveoli will also will also lose their shape leading to dypnea. Therefore, oxygenation goals will have to take in cognizance these realities and advise the patient accordingly. Consequently, efforts to increase exercise tolerance, treat complication, and relieve symptoms will be initiated.
- If Tina had mentioned that she was just diagnosed with pneumonia, what would you have expected to find during percussion?
- If the results of Tina’s pulse oximetry had been 97%, which of the following would have been true?
- Suppose that, during your lung exam on Tina, you had heard bronchial breath sounds in the left lower lung posteriorly. What would you have suspected based on this finding?
- Suppose that while auscultating, you assessed a few scattered expiratory wheezes. Why would this be an expected finding for a patient with Tina’s history
- When you observe a patient like Tina throughout an exam, there are many ways to determine whether a patient is experiencing respiratory distress. Identify one indicator of respiratory distress that can be assessed through observation alone.
- Describe how you would assess Tina for dyspnea
Dyspnea can be assessed both……
- Explicitly describe the tasks you undertook to complete this exam.
The examination…..
- Explain the clinical reasoning behind your decisions and tasks.
- Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional practice.
My performance could be improved by seeking more history from the patient…..
NR 509 Week 1 Shadow Health History Assignment
- | Overview
- | Transcript
- | Subjective Data Collection
- | Objective Data Collection
- | Education & Empathy
- | Documentation / Electronic Health Record
- | Information Processing
- | Lab Pass: Certificate of Completion
NR 509 Week 2 Alternate Writing Assignment: Respiratory Summer 2018
Purpose
As a family nurse practitioner, you must possess excellent physical assessment skills. This alternative writing assignment mirrors the discussion content of the debriefing session and will allow the student to expand their knowledge of physical health assessment principles specific to the advanced practice role.
Course Outcomes
This assignment is guided by the following Course Outcomes (COs):
- Apply advanced practice nursing knowledge to collecting health history information and physical examination findings for various patient populations. (PO 1, 2)
- Differentiate normal and abnormal health history and physical examination findings. (PO 1, 2)
- Adapt health history and physical examination skills to the developmental, gender-related, age-specific, and special population needs of the individual patient. (PO 1, 2)
The purposes of this assignment are to: (a) identify and articulate advanced assessment health history and physical examination techniques which are relevant to a focused body system (CO 1), (b) differentiate normal and abnormal findings with regard to a disease or condition that impacts the body system (CO 2), and (c) adapt advanced assessment skills if necessary to suit the needs of specific patient populations (CO 4).
NOTE: You are to complete this alternative writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week.
Due Date: This alternative written assignment is due no later than the Sunday of the week in which you did not attend the weekly debriefing session. The standard MSN Participation Late Assignment policy applies to this assignment.
Preparing the Paper:
- Select a focused body system from the weekly lesson which corresponds with the week of the written assignment.
- Carefully read and review the selected body system in your course textbooks.
- Incorporate at least onescholarly peer-reviewed journal article that relates to the body system. It may be useful to identify an article that relates to a disease that impacts the body system.
- The paper must clearly articulate the relevance of advanced physical assessment skills, techniques, application of advanced practice knowledge, and assessment modification (when necessary) to accommodate for specific patient populations.
- Provide concluding statements that should summarize key points of the overall assignment content.
- In-text citations and reference page(s) must be written using proper APA format (6thedition).
NR 509 Week 2 Quiz
- A mother brings her two month old daughter in for an examination says “my daughter rolled over against the wall and now I have noticed that she has the spot soft on the top of her head, is there something terribly wrong?” The FNP‘s best response would be:
- During percussion the FNP knows that a dull percussion note elicited over a lung lobe. This most likely results from:
- The patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The FNP suspects Damage to:
- When examining the face, the FNP is aware that the two pairs of salivary gland‘s that are accessible to examination are the _____ glands
- A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The FNP suspects damage to cranial nerve ____ and proceeds with the examination by____
- When examining a patient’s cranial nerve function, the FNP remembers that the muscles in the neck that are innervated by CN XI are the:
- The patient’s laboratory data reveal an elevated thyroxine level. The FNP would proceed with an examination of the _____ gland
- A patient says that she has recently noticed a lump in the front of her neck below her “Adams apple” that seems to be getting bigger. During the assessment, the finding that leaves the FNP to suspect that this may not be a cancerous thyroid nodule is that the lump:
- The FNP notices that the patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the FNP would assess the patient’s:
- The FNP is aware that the four areas in the body were lymph nodes accessible are the:
- A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The FNP should know that floaters are usually not significant and are caused by:
- The FNP is preparing to assess the visual acuity of a 16-year-old patient. How should the FNP proceed?
- A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The FNP interprets these results to indicate that:
- A patient is unable to read even the largest letters on the Snellen chart. The FNP should take which action next:
- A patient’s vision is reported as 20/80 in each eye. The FNP interprets this finding to mean that
- When performing the corneal light reflex assessment, the FNP notes that the light is reflected at 2 o’clock in each eye. The FNP should
- The FNP is performing the diagnostic positions test. Normal findings would be which of these results?
- During an assessment of the sclera of an African-American patient, the FNP would consider which of these an expected finding?
- A 60-year-old man is at the clinic for an examination. The FNP suspects that he has ptosis of one eye. How should the FNP check for this?
- The FNP is doing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale gray and swollen. What would be the most appropriate question to ask the patient?
- The FNP is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
- During an oral assessment of a 30-year-old African-American patient, the FNP notices bluish lips and a dark line along the gingival margin. What would the FNP do in response to these findings
- During an assessment of a 20-year-old patient with a three day history of nausea and vomiting the FNP notices dry mucous and deep vertical fissures on the tongue. These findings are reflective of:
- The FNP is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate FNP reflects a correct understanding of tactile fremitus?
- The FNP student is reviewing physical assessment findings of the HEENT system associated with pregnancy. Which statement by the graduate FNP reflects a correct understanding of expected HEENT changes associated with pregnancy? During pregnancy:
NR 509 Week 2 Quiz Review – (Jarvis 8,9,13,14,15,16,18), (Swartz 4,6,7,8,9,10)
NR 509 Week 2 Quiz
- A mother brings her two month old daughter in for an examination says “my daughter rolled over against the wall and now I have noticed that she has the spot soft on the top of her head, is there something terribly wrong?” The FNP‘s best response would be:
- During percussion the FNP knows that a dull percussion note elicited over a lung lobe. This most likely results from:
- The patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The FNP suspects Damage to:
- When examining the face, the FNP is aware that the two pairs of salivary gland‘s that are accessible to examination are the _____ glands
- A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The FNP suspects damage to cranial nerve ____ and proceeds with the examination by____
- When examining a patient’s cranial nerve function, the FNP remembers that the muscles in the neck that are innervated by CN XI are the:
- The patient’s laboratory data reveal an elevated thyroxine level. The FNP would proceed with an examination of the _____ gland
- A patient says that she has recently noticed a lump in the front of her neck below her “Adams apple” that seems to be getting bigger. During the assessment, the finding that leaves the FNP to suspect that this may not be a cancerous thyroid nodule is that the lump:
- The FNP notices that the patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the FNP would assess the patient’s:
- The FNP is aware that the four areas in the body were lymph nodes accessible are the:
- A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The FNP should know that floaters are usually not significant and are caused by:
- The FNP is preparing to assess the visual acuity of a 16-year-old patient. How should the FNP proceed?
- A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The FNP interprets these results to indicate that:
- A patient is unable to read even the largest letters on the Snellen chart. The FNP should take which action next:
- A patient’s vision is reported as 20/80 in each eye. The FNP interprets this finding to mean that
- When performing the corneal light reflex assessment, the FNP notes that the light is reflected at 2 o’clock in each eye. The FNP should
- The FNP is performing the diagnostic positions test. Normal findings would be which of these results?
- During an assessment of the sclera of an African-American patient, the FNP would consider which of these an expected finding?
- A 60-year-old man is at the clinic for an examination. The FNP suspects that he has ptosis of one eye. How should the FNP check for this?
- The FNP is doing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale gray and swollen. What would be the most appropriate question to ask the patient?
- The FNP is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
- During an oral assessment of a 30-year-old African-American patient, the FNP notices bluish lips and a dark line along the gingival margin. What would the FNP do in response to these findings
- During an assessment of a 20-year-old patient with a three day history of nausea and vomiting the FNP notices dry mucous and deep vertical fissures on the tongue. These findings are reflective of:
- The FNP is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate FNP reflects a correct understanding of tactile fremitus?
- The FNP student is reviewing physical assessment findings of the HEENT system associated with pregnancy. Which statement by the graduate FNP reflects a correct understanding of expected HEENT changes associated with pregnancy? During pregnancy:
NR 509 Week 2 Quiz Review – (Jarvis 8,9,13,14,15,16,18), (Swartz 4,6,7,8,9,10)
1. What does dullness when percussing lung fields: Jarvis pg 427
2. Facial sensation controlled by which CN: Jarvis 283,
3. Know what two salivary glands are accessible during exam
4. What CN is being … when pt shrugs shoulders Jarvis 646
5. What muscles are being …. when …. CN 11 (spinal accessory nerve)
6. Concern for malignant nodules versus benign lymph nodule
7. Know what you’d do next if you palpated a submental lymph node: Jarvis pg 253
8. Define visual acuity
9. Know what to do if your patient can’t read the largest number on the Snellen chart: Jarvis 289
10. Example of good visual acuity : Jarvis 289
11. Example of poor visual acuity: Jarvis 289
12. What is …. with corneal light reflex-
13. Know normal variances of sclera : Jarvis 283
14. Know how to check for Ptosis: Jarvis 292
15. What does ptosis indicate: Jarvis 292
16. Nasal fissure of pt with chronic allergies : Jarvis 271
· Acute allergies : Jarvis p 363 .
17. What is an abnormal palpation of sinuses: Jarvis 362
· Normal palpation of sinuses
18. Know normal variations in gingival margin
19. Know what a dehydrated oral cavity will look like: Jarvis 387
20. What is tactile fremitus, how do you test for it and what does it indicate. Jarvis 425
N 518 Module 2: THE GENERAL SURVEY AND HEENT
Module 2: Discussion Question
Start by reading and following these instructions:
You are responsible for minimally at least 3 posts for each question in your discussion boards; your initial post and reply to two of your classmates. Your initial post(s) should be your response to the questions posed in the discussion question. You should research your answer and cite at least one scholarly source when appropriate, and always use quality writing.The discussion board is never a place to use text language or emoticons. You will also be asked to respond to your classmates. This is designed to enhance the academic discussion around the topic. It is all right to disagree with something posted by another, however your responses should always be thoughtful and respectful and reflect your opinions professionally.
Discussion Question:
In your professional opinion, what is the difference between chronic and acute pain? How is the assessment for each type of pain different? What must you keep in mind when assessing acute pain? What must you keep in mind when assessing chronic pain? Reflect upon a time when you assessed a patient in pain. What did you do well? What points could you have improved upon? How did the pain impact the patient? What specific treatments could have lessened the impact of the pain on the patient?
Your initial posting should be 200 to 300 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 100 words in length. To properly “thread” your discussion posting, please click on REPLY.
When you are ready for the discussion, do the following:
- Click on the discussion link above.
- Start your answer by clicking “Start a New Thread” button with the title of your answer and the body of text following the guidance above.
- To properly post your answer, please click on the “Post” button.
- After posting your contribution, you must read what others have posted, reply to at least two of those posts, and respond (when appropriate) to those you have responded to you.
To reply to a classmate’s post:
- Click on the title of another student’s post.
- Click “Reply to Thread” and type your response to the student.
- Click the “Post” button to post your reply.
N 581 Module 2: Assignment
Remember to submit your work following the file naming convention FirstInitial.LastName_M01.docx. For example, J.Smith_M01.docx. Remember that it is not necessary to manually type in the file extension; it will automatically append.
Start by reading and following these instructions:
1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.
2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
3. Consider the discussion and the any insights you gained from it.
4. Create your Assignment submission and be sure to cite your sources, use APA style as required, check your spelling.
Assignment:
Exercises:
- Complete the Shadow Health HEENT assessment.
Professional Development
- Write a reflection essay of your experience with the Shadow Health virtual assessment. At least two scholarly sources in addition to your textbook should be utilized. Please be sure to address each of the following prompts:
- What went well in your assessment?
- What did not go so well? What will you change for your next assessment?
- What findings did you uncover?
- What questions yielded the most information? Why do you think these were effective?
- What diagnostic tests would you order based on your findings?
- What differential diagnoses are you currently considering?
- What patient teaching were you able to complete? What additional patient teaching is needed?
- Would you prescribe any medications at this point? Why or why not? If so, what?
- How did your assessment demonstrate sound critical thinking and clinical decision making? What could you change to make it better?
N 581: SHADOW HEALTH ASSIGNMENT
Shadow Health Physical Assessment Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
|
This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript) |
|
25.0 pts
|
||||
|
This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation |
|
20.0 pts
|
||||
|
This criterion is linked to a Learning OutcomeSelf-Reflection |
|
