Tina Comprehensive Shadow Health Assessment
Assignment: Shadow Health Respiratory Physical Assessment
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.
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.
Read: Shadow Health Abdmoninal Assessment
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
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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.
• Nose/Sinuses: Denies rhinorrhea with this episode.
Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure.
• Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain
• Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis.
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
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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
• … CONT.
Education
… CONT.
•
Referral/Consultation
• Refer to allergy specialist for evaluation and testing
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.
- Respiratory: Chest expansion is symmetrical with respirations. Normal fremitus, symmetric bilaterally. Chest resonant to percussion; no dullness. Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in posterior lower lobes. No crackles. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%.
Assessment
Mild-persistent asthma with exacerbation
Plan
Diagnostics
… CONT.
- NR 509: Shadow Health Respiratory Physical Assessment Assignment
Education
- Encourage Ms. Jones to continue … CONT. NR 509: Shadow Health Respiratory Physical Assessment Assignment
Referral/Consultation
- Refer to allergy specialist for evaluation and testing
Follow-up Planning
- Order PFTs to be completed after exacerbation to have baseline available for future comparison
- Instruct Ms. Jones on when to seek emergent care including episodes of chest pain or shortness of breath unrelieved by rest, worsening asthma symptoms or wheezing, or the sense that rescue inhaler is not helping
- Revisit clinic in 2-4 weeks for follow up and evaluation. NR 509: Shadow Health Respiratory Physical Assessment Assignment
- 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 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.
- 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? NR 509: Shadow Health Respiratory Physical Assessment Assignment
Common significant deviations …CONT.
In the respiratory assessment of this patient, … CONT.
- 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. NR 509: Shadow Health Respiratory Physical Assessment Assignment
- 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 …CONT.
- Explicitly describe the tasks you undertook to complete this exam.
The examination was … CONT.
- Explain the clinical reasoning behind your decisions and tasks.
The various tasks and decisions undertaken here were to inform … CONT.
- 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. 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.
- | Overview
- | Transcript
- | Subjective Data Collection
- | Objective Data Collection
- | Education & Empathy
- | Documentation / Electronic Health Record
- | Information Processing
- | Lab Pass: Certificate of Completion . NR 509: Shadow Health Respiratory Physical Assessment Assignment
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:
- 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.NR 509: Shadow Health Respiratory Physical Assessment Assignment
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:
- Quickly skim the questions or assignment below and the assignment rubric to help you focus.
- 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.
- Consider the discussion and the any insights you gained from it.
- Create your Assignment submission and be sure to cite your sources, use APA style as required, check your spelling.NR 509: Shadow Health Respiratory Physical Assessment Assignment
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?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
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Question
05/11/18 12:39 PM
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05/11/18 12:40 PM
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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
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Question
05/11/ 12:40 PM
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05/11/ 12:41 PM
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05/11/ 12:42 PM
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Empathize
05/11/18 12:42 PM
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05/11/ 12:43 PM
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05/11/ 12:53 PM
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… CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 3/23
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05/11/18 12:53 PM
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Empathize
05/11/18 12:56 PM
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05/11/18 1:00 PM
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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
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5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 9/23
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Auscultated … CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 10/23
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05/11/18 2:01 PM
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5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 11/23
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Ninety-nine.
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
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5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 13/23
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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
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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
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Empathize
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5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 16/23
Educate
05/11/18 2:32 PM
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5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 17/23
Question
05/11/18 2:54 PM
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05/11/18 2:55 PM
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Educate
05/11/18 2:57 PM
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05/11/18 2:57 PM
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05/11/18 2:58 PM
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05/11/18 2:59 PM
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05/11/18 3:00 PM
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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
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Empathize
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Educate
05/11/18 3:02 PM
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05/11/18 3:02 PM
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Empathize
05/11/18 3:02 PM
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05/11/18 3:03 PM
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Educate
05/11/18 3:03 PM
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CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 19/23
Question
05/11/18 3:04 PM
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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
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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
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