NR 509 Week 2 Assignment: Shadow Health HEENT Physical Assessment

NR 509 Week 2 Assignment: Shadow Health HEENT Physical Assessment

Debriefing

Faculty will lead virtual debriefing sessions during Weeks 1-6. The date, time, and duration of the weekly debriefing session will be posted by the course faculty. Students must register to attend the debriefing session.

During the debriefing process, students reflect upon their simulation experience and revisit their assessments, interventions, observations, and patient responses. Faculty coach students to review patient data and reflect upon the interventions performed in response to the clinical situation presented during the simulation experience. This process facilitates students to analyze their own thought processes and supports transference of knowledge gained from simulation experiences to actual clinical practice.

Welcome to Health Assessment

Hello class: my name is, and I will be the instructor for this class. For more information on how to get a hold of me, please go under my profile for specific information. However, my email is: ***The best way to contact me though, is through the Private forum***

This course will focus on methods of health history taking, physical examination skills, documentation, and health screening. The course emphasizes the individual as the client, functional health patterns, community resources, and the teaching learning process. This course will take us through infancy to an older adult.

To find course material, go under your Dashboard, then you will see PATH. There are two links to find information regarding this course; course material and syllabus.

  • The course material tab shows what textbook is used for this class.
  • The syllabus will show what this course is, the assignments for the course, the topics of the course, the grading system, and how to refer to the student policy handbook. **there has been some problems downloading the syllabus, thus the PATH is also the syllabus…but 1 week and topic at a time.

Under your Assignments, will have the due date and the rubric posted to look at.

Under the Planner tab, assignments are listed along with the due dates. Clicking the collaborative reminder within the calendar tab will show the assignment, any information that is needed for the assignment, and give the rubric of how the assignment will be graded.

Please refer to all other announcements for Class Policies and Week 1 class.

Feel free to contact me anytime. I look forward to this 5 week journey with each of you

The goals of each debriefing session are to:

  • Answer questions
  • Address perspectives, perceptions, and concerns
  • Emphasize and reinforce learning objectives and clinical outcomes
  • Create linkages to the “real world”
  • Assess and validate what was learned

Each student is expected to contribute to the debriefing session by:

  • Reflecting on personal strengths, limitations, beliefs, prejudices, or values
  • Identify improvement goals and strategies
  • Discuss the simulation experience and provide comments and suggestions to student peers
  • Transfer knowledge from the simulation experience to actual clinical practice

Please refer to the Debriefing Session Guidelines and Grading Rubric located in the Course Resource section.

NR 509 Week 2 Assignment Alternate Writing Assignment

NOTEYou will complete this alternate writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week.

As a family nurse practitioner, you must possess excellent physical assessment skills. This alternate 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.

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).

Please refer to the Alternate Writing Assignment Guidelines and Grading Rubric located in the Course Resource section.

NR 509 Week 2 Assignment : Shadow Health Respiratory Concept Lab

Learn about the differences between normal and abnormal lung sounds with the Respiratory Concept Lab.

This tool needs to be loaded in a new browser window

NR 509 Week 2 Assignment: Shadow Health HEENT Physical Assessment Assignment

NR 509 Week 2 Assignment Rubric

Shadow Health Physical Assessment Rubric
Shadow Health Physical Assessment Rubric
Criteria Ratings Pts

Subjective Data, Organization, Communication, and Summary (DCE Score or transcript)

25.0 pts

Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.

21.0 pts

Average- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.

10.0 pts

Below Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.

0.0 pts

Unsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing.
25.0 pts

Objective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation

20.0 pts

Above Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.

16.0 pts

Average- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).

8.0 pts

Below Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).

0.0 pts

Unsatisfactory- No physical assessment documentation or no treatment plan.
20.0 pts

Self-Reflection

5.0 pts

Above Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.

3.0 pts

Average- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.

2.0 pts

Below Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight

0.0 pts

Unsatisfactory- No reflection posts for the assignment.
5.0 pts
Total Points: 50.0

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:

  1. Click on the discussion link above.
  2. 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.
  3. To properly post your answer, please click on the “Post” button.
  4. 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:

  1. Click on the title of another student’s post.
  2. Click “Reply to Thread” and type your response to the student.
  3. 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

Subjective

HPI: Ms.Jones is a 28 years olf african american women who is presented to the clinic with complaints of sore, itcy throat and running nose that wont stop for one week . She states that the throat pain is bad and rates it a 4/10 . she states that she has treated her throat pain with occcasional throat lozenges which has ” helped her a little” . patient mentions that it hurts to swallow and that her eyes are itchy . she denies taking anything to stop her nasal irritation and ichy eyes. patient denies exposure to sick individuals , denies symptoms of fever and chills. patient has never been diagnosed with seasonal allerges but states that her sister has ” hay fever” Social History: patient is unaware of any environmental exposure / irritants . she mention that she keeps the house ” pretty clean” . patient mentions that she used” pot when in highschool,and after highschool but definitely dont anymore ” she states she hasnt smoked pot since she was twenty one. patient does not excersie however is on her feet most of the time at work . Review systems : General – denies changes in weight, fever and chills. Head: denies history of trauma but mentions headches due to studying that last a few hours, takes Tylenol to help allivate pain. Eyes- patient denies wearing glasess or contacts however notes the vision is sort of blurry when reading and is currently getting worse Ears- denies hearing loss, tinnitus,vertigo or discharge. patieny states that her ears are ” fine” Nose- Denies any problems with nose proior to this issues, denies getting stuffiness, sneezing, previous allergies prior Mouth- denies bleeding gums, hoarseness, swollen lymph nodes Respirtory- patient denies shorness of breath, cough, history of tuberculosis, or bronchitis, patient has asthma and uses inhaler 2-3 times per week . He last chest x-ray wass in highschool .

HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose “runs all day” and is clear discharge. She has not attempted any treatment for her nasal symptoms. She states that her eyes are constantly itchy and she has not attempted any eye specific treatment. She denies cough and recent illness. She has had no exposures to sick individuals. She denies changes in her hearing, vision, and taste. She denies fevers, chills, and night sweats. She has never been diagnosed with seasonal allergies, but does note that her sister has “hay fever”. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma or headaches. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week.

Objective

patient c/o 4/10 pain in her throat, has been using drops and tylenol ovet the counter for pain patient also c/o headaches when reading or doing homework, hasn’t had an eye exam in years. Patient’s head normocephalic, acne bialaterally to cheeks. Eyes watery with clear drianage, PERRLA. Vision 20/20 in left and 2/30 in the right eye. patent reports blurry vision at times, when reading, denies glasses or contacts. Nares appear to be swollen, patient denies diffculty breathing, states that hher norse has been “runny” with clear drainage. patient denies any issues with hearing. Tympanci memrane intact and pink bilaterally. Mouth erythrmic with cabblestoning, gag reflex intact. Visible drainage- Clear. Denies dizziness, problems with gum, sinus infection or any recent cold symptoms. Patient denied any neck pain or stiffness- no palpable nodes on exam. Lungs sounds clear. Denies any shortness of breath/ diffculty breathing General : Patient Ms. Joes is a 28 year old aferican american women. o acute distress identified. Patient is alert and oriented. She maintains eye contact throughout examination/asessment Head: head is normocephalic and atraumatic. Scalp has no masses , normal hair distribution. Eye: Bilateral with equal hair distriibution,no lesions, no ptosis, no edma, conjectivia clear and injected. Extraocular movements intact bilateral. Pupils equal, round nad reactive bilaterally. Normal convergence. Left fundoscopic exam revals mild retinopathic changes. Left eys vision:20/20. Right eye vision :20/40 Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Reinne, weber and wisper test was normal bilaterally. Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain palpations of frontal or maxillay sinuses Mouth/ throat – Moist buccal muccosa, no wounds identified. Adequate dental hygiene. Uvula midline. Tonsils 1 + and without evidence of inflammations. Posterior pharynx is slightly erythematous with mild cobblestoning Neck : No cervical, infraclavicular lymphadenopathy. Thyriods is smooth without nodules or goiter carotid pulses 2, no thrill . Jaw with no clicks, full range of motion. Bilateral carotid arty auscultation without bruit . Respirtory : Chest is symmetricall with respirations. Lungs sounds clear to ausculttion without wheezes, crackles or cough. No evidence of shortness of breath

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. • Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough.

Assessment

patient was acessed for sore throat and runny nose Inspection of the Head, eyes, nasal cavities, Ears, Mouth, Neck Palpation of the scalp, sinuses, temporal arteries, carotid arteries, Jaw, Lymph nodes, Thyroid Ascultation of breath sounds, Temporal arteries, and carotid arteries

Allergic Rhinitis

Plan

Refer patient for medical specialist examinination. Refer patient to ophthaltmologist for eye exam Rapid strep test obtained and throat culture for strep throat Possible need for antibitics however lab results required (culture and sensitivity rerquired ) Encourage Ms. Jones continues to monitor symptoms and cahrt episodes of allergic symptoms and other associated factors Start LORATADNE 10MG PO per MD order. Encourage fluid intake and proper hand hygiene Educate patients of techiques to aviod triggers and signs and symptoms to report Educates patient to seek advane care for worsening headaces or fever Refer patient for follow up evaluation in two weeks after reassessment by the physcian .

Is this the question you were looking for? If so, place your order here to get started!

Related posts

Open chat