Shadow Health Respiratory Assessment Pre Brief
Tina had an asthma 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.NR 509: Shadow Health Respiratory Physical Assessment Assignment
Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.
NR 509: Shadow Health Respiratory Physical Assessment Assignment
Shadow Health Respiratory Assessment Pre Brief
Tina had an asthma 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.NR 509: Shadow Health Respiratory Physical Assessment Assignment
Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.
SAMPLE Shadow Health Respiratory Assessment
Model Documentation
Subjective
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7-8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. ……… NR 509: Shadow Health Respiratory Physical Assessment Assignment
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 uses a hypoallergenic pillow cover and her mattress is one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last use was at age 21 years. She does not exercise.
Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM
https://chamberlain.shadowhealth.com/assignment_attempts/3664486 Page 1 of 6
Respiratory Results | Turned In
…
https://www.coursehero.com/file/32326524/W2-SH-Dr-Documentation-ASTHMA-Respiratory-Completed-Shadow-Healthpdf/
Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM
https://chamberlain.shadowhealth.com/assignment_attempts/3664486 Page 2 of 6
Reports allergies to cats which triggered her asthma symptoms ….
Asthma exacerbation are aggravated by exposure to cats, …
Diagnosed with asthma at 2.5-years-old, She frequented hospital visits and including five hospitalizations before she was 16-years-old. Since then she hasn’t been hospitalized. Pt. denies spirometry inhalor, peak flow meter use, as well as any other asthma medication use. Pt. doesn’t keep asthma record of exacerbations and triggers; denies asthma medication usage except for albuterolresuce inhaler. Pt. not currrently being managed by a pulmonologist or someone for her allergies. Pt. denies using a vaporizer or nebulizer at home.
PMH:
Pt. reports Type 2 Diabetes, possible borderline hypertension (no actual dx).
Allergies:CONT.
Cats: Develops itchy, watery eyes; an itchy, “runny nose”; an itchy, sometimes a sore throat, and often an asthma exacerbation – SOB, DOE, wheezing, coughing, and chest tightness.
Dust: Develops a rash, no tiching.
Penicillin: “Rash, like, hives.”
HPI: …CONT.
Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive cough. She awakens with night-time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities.
Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM
https://chamberlain.shadowhealth.com/assignment_attempts/3664486
Medications:
Rx: Provenal 90 mcg/spray, 2 puffs, for asthma.
OTC: Acetamet:aphen 1000 mg for occasional headaches related to readingfor prolonged periods of . Iburofen OTC
Social History: …
Family History: Pt. states sister has history of asthma and hayfever.
Surgical History: Pt. denies previous surgeries.
ROS:
General: … cont.
Review of Systems:CONT.
General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats.
Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure.
She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.
https://www.coursehero.com/file/32326524/W2-SH-Dr-Documentation-ASTHMA-Respiratory-Completed-Shadow-Healthpdf/
Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM
https://chamberlain.shadowhealth.com/assignment_attempts/3664486 Page 4 of 6
… cont.
Objective
Tina is an obese 28-year-old African American woman who does not seem to be in any acute distress. Alert and oriented, sitting upright, maintains appropriate eye contact, is
conversational, and answers questions appropriately.
Respiratory: … CONT.
Muffled words bilaterally with prominent expiratory wheezes in the posterior lower lobes only.
Spirometry yielded FVC 3.91, FEV/FVC ratio
80.56%, SaO2 97% on room air, HR 89, RR 20, BP
General: … CONT.
Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM
https://chamberlain.shadowhealth.com/assignment_attempts/3664486 Page 5 of 6
140/81, Temperature 98.5 degrees Farenhiet.
Assessment
Mild-Persistent Asthma with Exacerbation. Mild-persistent asthma with exacerbation
Plan
Diagnostics: Obtain oxygen saturation and baseline spirometry and peak flow readings.
Medication: NMI at office one time. Continue albuterol rescue inhalor. Initiate step up inhaled corticosteroid.
Education: … CONT.
Orders: … CONT.
Follow-Up: Return to clinic in 3 weeks for follow-up evaluation regarding coarse of illness, medication use and needs, as well as medication effectiveness.
Diagnostics
Education
… CONT.
Referral/Consultation
Follow-up Planning … CONT.
Review of Systems: … CONT.
Objective
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on exam table. She maintains eye contact throughout interview and examination.
Assessment
Mild-persistent asthma with exacerbation
Plan
Diagnostics
… CONT.
Education
Referral/Consultation
Follow-up Planning
The treatment plan for this child would be to treat the airways of inflammation using medication to prevent asthma attacks. Further, short-acting drugs will be used to treat the asthma attacks. Also, the child will have to avoid triggers of asthma. Lastly, the child will be advised to maintain normal activity levels.
Common significant deviations …CONT.
In the respiratory assessment of this patient, … CONT.
Dyspnea can be assessed …CONT.
The examination was … CONT.
The various tasks and decisions undertaken here were to inform … CONT.
My performance could be improved by seeking more history from the patient. In terms of lessons learned, the present analysis will allow me to become even more aware of the nitty-gritties of respiratory assessment for future practice. NR 509: Shadow Health Respiratory Physical Assessment Assignment
NR 509 Week 1 Shadow Health History Assignment
Pre-brief
Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness…………………… Interviewing patients is an art and should remain an essential skill for successful practice.
In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem list using evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation. NR 509: Shadow Health Respiratory Physical Assessment Assignment.
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.
Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.
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?NR 509: Shadow Health Respiratory Physical Assessment Assignment
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:
To reply to a classmate’s post:
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:
Assignment:
Exercises:
Professional Development
How did your assessment demonstrate sound critical thinking and clinical decision making? What could you change to make it better?NR 509: Shadow Health Respiratory Physical Assessment Assignment
N 581: SHADOW HEALTH ASSIGNMENT
Subjective
HPI: Ms.Jones is a 28 years old African american women who is presented to the clinic with complaints of sore, … Social History: patient is unaware of any environmental exposure / irritants . … CONT. Review systems : General – denies changes in weight, fever and chills. … CONT. |
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.
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. … CONT. • Head: Denies history of trauma or headaches. • Eyes: She does … CONT. • 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, … CONT. Nares appear to be swollen, patient denies difficulty breathing, … CONT.
|
General:
• Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, … CONT. • 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: •Neck: • Respiratory: CONT. |
Assessment
Patient was assessed for sore throat and runny nose … |
Allergic Rhinitis |
Plan
Refer patient for … CONT. |
Shadow Health Physical Assessment Rubric
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
|
|
5.0 pts | |||||
Total Points: 50.0 |
NR 509: Shadow Health Respiratory Physical Assessment Assignment
shadow health respiratory transcript
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304
1/23
Respiratory Results | Turned In
Advanced Health Assessment – Chamberlain, NR509-April-2018
Return to Assignment
Your Results LLaabb PPaassss
Started: May 11, 2018 | Patient Exam Time: 168 min
Transcript
Greet
05/11/18 12:39 PM
CDT
Question
05/11/18 12:39 PM
CDT
Question
05/11/18 12:39 PM
CDT
Question
05/11/18 12:40 PM
CDT
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Pre-Survey
Lifespan
Review Questions
Self-Reflection
Hello my name Sara an FNP student and I will be interviewing you
today.
Hey.
Can you please state your name for me?
Tina Jones.
Your date of birth?
February 17th.
Year of birth please? (Clarified to What year were you born.)
I was born in . . . [Ms. Jones reports correct birth year.] [AUDIO
COMING SOON]
5/11/ Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 2/23
Question
05/11/ 12:40 PM
CDT
Question
05/11/ 12:41 PM
CDT
Question
05/11/ 12:42 PM
CDT
Empathize
05/11/18 12:42 PM
CDT
Question
05/11/ 12:43 PM
CDT
Question
05/11/ 12:53 PM
CDT
Question
05/11/ 12:53 PM
CDT
… CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 3/23
Question
05/11/18 12:53 PM
CDT
Empathize
05/11/18 12:56 PM
CDT
Question
05/11/18 12:56 PM
CDT
Question
05/11/18 12:57 PM
CDT
Question
05/11/18 12:57 PM
CDT
Question
05/11/18 1:00 PM
CDT
Question
05/11/18 1:02 PM
CDT
I don’t know if I’d call it an asthma attack, … CONT.
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 8/23
Exam Action
05/11/18 1:53 PM
CDT
Exam Action
05/11/18 1:53 PM
CDT
Exam Action
05/11/18 1:53 PM
CDT
Exam Action
05/11/18 1:53 PM
CDT
Exam Action
05/11/18 1:53 PM
CDT
Exam Action
05/11/18 1:53 PM
CDT
Exam Action
05/11/18 1:54 PM
CDT
Exam Action
05/11/18 1:55 PM
CDT
Exam Action
05/11/18 1:55 PM
CDT
Exam Action
05/11/18 1:55 PM
CDT
Exam Action
05/11/18 1:56 PM
CDT
Exam Action
05/11/18 1:56 PM
CDT
Exam Action
05/11/18 1:56 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 9/23
Exam Action
05/11/18 1:56 PM
CDT
Exam Action
05/11/18 1:56 PM
CDT
Exam Action
05/11/18 1:56 PM
CDT
Exam Action
05/11/18 1:57 PM
CDT
Exam Action
05/11/18 1:57 PM
CDT
Exam Action
05/11/18 1:57 PM
CDT
Exam Action
05/11/18 1:57 PM
CDT
Exam Action
05/11/18 1:57 PM
CDT
Exam Action
05/11/18 1:57 PM
CDT
Exam Action
05/11/18 2:01 PM
CDT
Exam Action
05/11/18 2:01 PM
CDT
Auscultated … CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 10/23
Exam Action
05/11/18 2:01 PM
CDT
Exam Action
05/11/18 2:01 PM
CDT
Exam Action
05/11/18 2:01 PM
CDT
Exam Action
05/11/18 2:01 PM
CDT
Exam Action
05/11/18 2:01 PM
CDT
Exam Action
05/11/18 2:01 PM
CDT
Exam Action
05/11/18 2:01 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 11/23
Exam Action
05/11/18 2:02 PM
CDT
Exam Action
05/11/18 2:02 PM
CDT
Exam Action
05/11/18 2:02 PM
CDT
Exam Action
05/11/18 2:02 PM
CDT
Exam Action
05/11/18 2:02 PM
CDT
Exam Action
05/11/18 2:02 PM
CDT
Exam Action
05/11/18 2:02 PM
CDT
Ninety-nine.
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 12/23
Exam Action
05/11/18 2:02 PM
CDT
Exam Action
05/11/18 2:08 PM
CDT
Exam Action
05/11/18 2:08 PM
CDT
Exam Action
05/11/18 2:12 PM
CDT
Exam Action
05/11/18 2:15 PM
CDT
Educate
05/11/18 2:16 PM
CDT
Question
05/11/18 2:16 PM
CDT
Educate
05/11/18 2:17 PM
CDT
Educate
05/11/18 2:17 PM
CDT
Educate
05/11/18 2:18 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 13/23
Question
05/11/18 2:19 PM
CDT
Question
05/11/18 2:20 PM
CDT
Question
05/11/18 2:20 PM
CDT
Question
05/11/18 2:21 PM
CDT
Question
05/11/18 2:21 PM
CDT
Question
05/11/18 2:22 PM
CDT
Question
05/11/18 2:22 PM
CDT
CONT. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 14/23
Educate
05/11/18 2:22 PM
CDT
Question
05/11/18 2:23 PM
CDT
Question
05/11/18 2:24 PM
CDT
Question
05/11/18 2:24 PM
CDT
Question
05/11/18 2:25 PM
CDT
Question
05/11/18 2:26 PM
CDT
Question
05/11/18 2:27 PM
CDT
CONT.
When did your recent asthma problems start? (Clarified to What started your recent asthma problems? .)
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 15/23
Question
05/11/18 2:27 PM
CDT
Question
05/11/18 2:28 PM
CDT
Empathize
05/11/18 2:28 PM
CDT
Question
05/11/18 2:28 PM
CDT
Question
05/11/18 2:30 PM
CDT
Question
05/11/18 2:30 PM
CDT
Question
05/11/18 2:31 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 16/23
Educate
05/11/18 2:32 PM
CDT
Question
05/11/18 2:50 PM
CDT
Question
05/11/18 2:50 PM
CDT
Question
05/11/18 2:51 PM
CDT
Question
05/11/18 2:52 PM
CDT
Question
05/11/18 2:53 PM
CDT
Question
05/11/18 2:54 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 17/23
Question
05/11/18 2:54 PM
CDT
Question
05/11/18 2:55 PM
CDT
Educate
05/11/18 2:57 PM
CDT
Question
05/11/18 2:57 PM
CDT
Educate
05/11/18 2:57 PM
CDT
Question
05/11/18 2:58 PM
CDT
Educate
05/11/18 2:59 PM
CDT
Question
05/11/18 3:00 PM
CDT
I’ve heard of that, but no, I don’t do it.
Do you use a nebulizer?
No, but I have before.
We may consider a nebulizer for home treatments.
That makes sense.
Also a way to track your asthma symptoms and episodes. (No matching questions found.)
Also a way to track your asthma symptoms and episodes.
OK, I understand.
Sending you home with a peak flow meter and document regularly.
I’ve heard of that, but no, I don’t do it.
We will also teach you how to use nebulizer at home.
Sure, I think I understand what you mean.
How often do you change your sheets?
I change my bedding once a week, I’d say.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 18/23
Question
05/11/18 3:01 PM
CDT
Empathize
05/11/18 3:01 PM
CDT
Educate
05/11/18 3:02 PM
CDT
Question
05/11/18 3:02 PM
CDT
Empathize
05/11/18 3:02 PM
CDT
Question
05/11/18 3:03 PM
CDT
Educate
05/11/18 3:03 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 19/23
Question
05/11/18 3:04 PM
CDT
Question
05/11/18 3:06 PM
CDT
Educate
05/11/18 3:07 PM
CDT
Question
05/11/18 3:07 PM
CDT
Question
05/11/18 3:08 PM
CDT
Question
05/11/18 3:09 PM
CDT
Question
05/11/18 3:09 PM
CDT
Question
05/11/18 3:12 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 20/23
Empathize
05/11/18 3:13 PM
CDT
Educate
05/11/18 3:13 PM
CDT
Question
05/11/18 3:13 PM
CDT
Question
05/11/18 3:13 PM
CDT
Question
05/11/18 3:14 PM
CDT
Question
05/11/18 3:15 PM
CDT
Question
05/11/18 3:17 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 21/23
Question
05/11/18 3:17 PM
CDT
Question
05/11/18 3:17 PM
CDT
Question
05/11/18 3:18 PM
CDT
Question
05/11/18 3:18 PM
CDT
Educate
05/11/18 3:19 PM
CDT
Question
05/11/18 3:20 PM
CDT
Question
05/11/18 3:20 PM
CDT
Question
05/11/18 3:20 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 22/23
Question
05/11/18 3:27 PM
CDT
Question
05/11/18 3:28 PM
CDT
Question
05/11/18 3:29 PM
CDT
Question
05/11/18 3:30 PM
CDT
Question
05/11/18 3:31 PM
CDT
Question
05/11/18 3:34 PM
CDT
Question
05/11/18 3:35 PM
CDT
Question
05/11/18 3:35 PM
CDT
No, my nose has been fine.CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 23/23
Question
05/11/18 3:36 PM
CDT
Question
05/11/18 3:37 PM
CDT
CONT.
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
© Shadow Health 2018 ®
Model Documentation
Subjective
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7-8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. 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 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive cough. NR 509: Shadow Health Respiratory Physical Assessment Assignment. She awakens with night-time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2.5 years. She has no recent use of spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist. NR 509: Shadow Health Respiratory Physical Assessment Assignment
…
Model Documentation
Subjective
Social History: She is not aware of any environmental exposures or irritants at her job or home……
Review of Systems:
Objective
Assessment
Plan
Diagnostics
Education
Referral/Consultation
Follow-up Planning
The treatment plan for this child would be to….
Common significant deviations … CONT.
In the respiratory assessment of this patient, … CONT.
Dyspnea can be assessed both……
The examination…..
My performance could be improved by seeking more history from the patient…..
Pre-brief
Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness…………………… Interviewing patients is an art and should remain an essential skill for successful practice.
In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem listusing evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation.
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.
Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.
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.
This assignment is guided by the following Course Outcomes (COs):
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:
NR 509 Week 2 Quiz
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:
To reply to a classmate’s post:
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:
Assignment:
Exercises:
Professional Development
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
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.NR 509: Shadow Health Respiratory Physical Assessment Assignment
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. NR 509: Shadow Health Respiratory Physical Assessment Assignment
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
This criterion is linked to a Learning OutcomeObjective 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. NR 509: Shadow Health Respiratory Physical Assessment Assignment
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
This criterion is linked to a Learning OutcomeSelf-Reflection NR 509: Shadow Health Respiratory Physical Assessment Assignment
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. NR 509: Shadow Health Respiratory Physical Assessment Assignment
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
Essaywriter.fun is a professional writing service for anyone who needs help with their essay, research paper, or other writing assignments. We provide high-quality content at an affordable price, in a convenient and timely manner.
Get result-oriented writing and worry no longer about your marks. We adhere to the highest quality standards to ensure you receive flawless assignments. Every essay or paper we complete is thoroughly checked before it reaches the customer--we have a strict quality assurance process in place to produce only the best work.
Our writers have experience working with papers at all academic levels. You can confidently rely on our skilled professionals' knowledge. We understand that not everyone has the time they need to meet deadlines--to make it easier for our customers, we offer 24/7 support through different channels such as live chat and email so that there's always help when you need it.
Your deadline is our success metric, and we take it extremely seriously. We ensure that you receive your papers before the deadline you choose. You can order an essay and have it delivered to you within 3 hours! If that's not enough for you, we also offer a 24-hour rush option. Don't sweat it! Our writing service can help you brainstorm, find interesting topics, or even do all the work for you. All you have to do is give us a topic and our professional writers will take care of the rest in no time at all.
There is always a member of our customer service staff available to react to your inquiries. Contact us if you have any questions or concerns. We have access to thousands of experts in multiple fields of study and we have been providing our services for years now. You will never have to worry about quality again — our essays are always original and well-researched. We understand the struggle - we've been there too. That's why we offer our customers 24/7 customer support and fixed prices that are always transparent.
Relax while we help you with the writing of your essays. We have a strict policy regarding the confidentiality of your personal and order-related information. We offer a variety of payment methods including credit cards and PayPal which allows for fast transfer of funds into your account after ordering. You can also make payments at any time using your credit card or when funds are due using PayPal automatic withdrawal from your bank account or credit card balance without having to log into your account.
We guarantee that your essay will be thoroughly screened for plagiarism and grammatical issues, as we only use credible, trusted sources. At Essaywriter.fun, everything is done according to your instructions - that means no plagiarism will ever be detected. That also means more money in your pocket as well as a perfect paper to submit as your own work.
Still hesitating to place an order? Our 100% Money-Back Guarantee protects you in the unlikely event that you are not happy with the writing.
At any time, hire your favourite essay writer. Simply indicate if you would like your favourite expert to compose your paper, and we will make it happen. We only select the best, most qualified essay writers to join our team. These people have years of experience in essays, research papers, term papers, dissertations, and more. We also prefer to hire essay writers with English as their first language as we want your satisfaction to be guaranteed every time.
Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.
Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.
Priority is given to customer pleasure, and we try every day to enhance custom essay writing. We ensure that only the most qualified and knowledgeable writer will complete your project. Your directions will be followed precisely, including all specifics. Editors will proofread each sentence, correct typos, and rectify grammatical and lexical errors.
Quality over quantity is a tenet that Essaywriter adheres to. Our team is the best of the best. In addition, we select writers based on their academic credentials, enabling us to increase the overall field specialization depth! This version enables consumers to buy an essay or any other type of project from our fast paper writing service; just be sure to select the most qualified writer.
If you are seeking for a reliable essay writing service that can complete a lengthy report for a reasonable fee, you have come to the perfect place. We recognize that each client has distinct requirements, thus we will tailor each product to meet those specifications! We recognize that it is difficult to balance everything in the agenda. By using our expert writing service, you will no longer need to wonder, "Who can help me with my essay?".
Compared to other essay writing services, our firm cares about its customers and offers premium services that are affordable for any budget. We understand how challenging it can be for students to earn or save money, therefore our costs begin at just $13.99 per page. Because of this, we have a large number of repeat customers that utilize our services frequently. Essaywriter's objective is to provide a cheap online essay service.
You no longer need to be worried about plagiarism. Get a plagiarism report to validate the originality of your work.
Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.
We create perfect papers according to the guidelines.
We seamlessly edit out errors from your papers.
We thoroughly read your final draft to identify errors.
With our essay service, you'll find an essay writer for any task. Their rating is based on previous customer reviews and successful orders. Before you hire a writer, you can familiarize yourself with their track record in detail!
Dedication. Quality. Commitment. Punctuality
Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.
We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.
Essaywriter is a reputable, trustworthy, rapid, and well regarded online essay writing service that offers cheap, high-quality papers. We offer an exceptional service and a multitude of outstanding features, including:
Our authors offer the greatest essay writing service since they hold degrees in a variety of fields. From MBA to law to nursing to business, we cover nearly every degree. Our writers can compose any type of essay, including creative, critical, and scientific articles. We employ the greatest writers in the United States to ensure that you obtain the best essay writing services.We recognize that ordering an essay online may appear intimidating. There is a possibility that the quality or formatting will be inadequate. When working with tight schedules, these dangers cannot be tolerated. Therefore, we evaluate the degrees and qualifications of our authors before hiring them. Our writers are actual persons, and we evaluate samples of their past work to ensure that it corresponds to all American university criteria. We mitigate the hazards, so you can feel secure knowing you're collaborating with a reliable professional essay writing service.
Are you entirely overwhelmed by work? Having difficulty juggling everyday, work, and other responsibilities? You've come to the right location, as we will alleviate your concerns. Request "write my paper for me," and we will provide you with access to hundreds of competent and experienced writers. Choose an essay writer, provide them with all of your instructions, and then catch up on work or other responsibilities, secure in the knowing that you will receive a high-quality assignment before the deadline.