Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System
Cardiovascular disease (CVD) is the largest cause of death worldwide. Accounting for 610,000 deaths annually (CDC, 2017), CVD frequently goes unnoticed until it is too late. Early detection and prevention measures can save the lives of many patients who have CVD. Conducting an assessment of the heart, lungs, and peripheral vascular system is one of the first steps that can be taken to detect CVD and many more conditions that may occur in the thorax or chest area.
This week, you will evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.
Learning Objectives
Students will:
- Evaluate abnormal cardiac and respiratory findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system .
- Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient's history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient's initial symptoms can result in very different diagnoses when further assessment is conducted.
Also Read: Shadow Health Assessment Help
To Prepare
- Review this week's Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
- Consider what history would be necessary to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?
DCE Focused Exam: Chest Pain Assignment:
Complete the following in Shadow Health:
- Cardiovascular Concept Lab (Recommended but not required)
- Abdominal Concept Lab (Recommended but not required)
- Episodic/Focused Note for Focused Exam: Chest Pain
- Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 7 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 7
- Complete your Focused Exam: Chest Pain DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
- Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
- (Note: Please save your lab pass as “LastName_FirstName_
AssignmentName”.) You can find instructions for downloading your lab pass here: https://link. shadowhealth.com/download-lab- pass - Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.
- Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.
NURS 6512 Week 7 DCE_
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
-
Excellent Good Fair Poor Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)
Note: DCE Score - Do not round up on the DCE score.60 (60%)DCE score>9355 (55%)DCE Score 86-9250 (50%)DCE Score 80-8545 (45%)DCE Score <79
No DCE completed.Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.
You should list these in bullet format and document the systems in order from head to toe.20 (20%)Documentation is detailed and organized with all pertinent information noted in professional language.
Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).15 (15%)Documentation with sufficient details, some organization and some pertinent information noted in professional language.
Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).10 (10%)Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.
Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).5 (5%)Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.
No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
No documentation provided.Objective Documentation in Provider Notes - this is to be completed in Shadow Health
Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use "WNL" or "normal".
You only need to examine the systems that are pertinent to the CC, HPI, and History.
Diagnostic result - Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).20 (20%)Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.
Each system assessed is clearly documented with measurable details of the exam.15 (15%)Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.
Each system assessed is somewhat clearly documented with measurable details of the exam.10 (10%)Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.
Each system assessed is minimally or is not clearly documented with measurable details of the exam.5 (5%)Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.
None of the systems are assessed, no documentation of details of the exam.
No documentation provided.
| Total Points: 100 |
|---|
