NURS 6512 Digital Clinical Experience Comprehensive Physical Assessment

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NURS 6512 Digital Clinical Experience Comprehensive Physical Assessment

NURS 6512 Digital Clinical Experience Comprehensive Physical Assessment

Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.

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To Prepare
• Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
• 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 Comprehensive (Head-to-Toe) Physical Assessment 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 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
• Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format. Refer to Chapter 2 of the Sullivan text and the Week 4 Complete Physical Exam template and use the template below for your submission.

Week 9 Shadow Health Comprehensive SOAP Note Documentation Template

Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.
DCE Comprehensive Physical Assessment:
Complete the following in Shadow Health:
• Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes)
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 9 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 9
• Complete your Comprehensive (Head-to-Toe) Physical Assessment 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
• Review the Week 9 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
• Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
• Complete the Code of Conduct Acknowledgement.
• Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
Grading Criteria

To access your rubric:
Week 9 Assignment 3 DCE Rubric

Submit Your Assignment by Day 7 of Week 9

To submit your Lab Pass:
Week 9 Lab Pass

To sumit this required part of the Assignment:
Week 9 Documentation Notes for Assignment 3

To Submit your Student Acknowledgement:

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.

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What’s Coming Up in Week 10?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will examine how to assess problems with the breasts, genitalia, rectum, and prostate while making the patient feel safe, listened to, and cared about using a non-invasive approach. Once again, you will use a SOAP note format to complete your Lab Assignment for this week.
Week 10 Required Media

Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Lab Assignment on time.
Next Week

To go to the next week:
Week 10

Week 9: Assessment of Cognition and the Neurologic System
A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.
An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.
This week, you will explore methods for assessing the cognition and the neurologic system.
Learning Objectives
Students will:
• Evaluate abnormal neurological symptoms
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
• Assess health conditions based on a head-to-toe physical examination
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Learning Resources

Required Readings (click to expand/reduce)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

• Chapter 7, “Mental Status”

This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.

• ·Chapter 23, “Neurologic System”

The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.

Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.

Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.

Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.

Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
• Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.

Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.

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NURS 6512 Digital Clinical Experience Comprehensive Physical Assessment

NURS 6512 Digital Clinical Experience Comprehensive Physical Assessment

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.

This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.

Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: Challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127

Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001

Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for classification of Alzheimer’s disease, mild cognitive impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/

Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Use this template to complete your Assignment 3 for this week.

Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

• Chapter 14, “The Neurologic Examination” (pp. 683–765)

This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.

• Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)

In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.

Required Media (click to expand/reduce)

Neurologic System – Week 9 (16m)

Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: 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. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. 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. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
• Grid View
• List View
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. Points Range: 56 (56%) – 60 (60%)
DCE score>93 Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92 Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85 Points Range: 0 (0%) – 45 (45%)
DCE Score <79

No DCE completed.
Documentation in Provider Notes Area

Subjective documentation of the comprehensive exam in Provider Notes is detailed, organized, and includes documentation of identifying data, general survey, reason for visit/chief complaint, history of present illness, medications, allergies, medical history, health maintenance, family history, social history, mental health history, and review of systems.

The review of systems is clearly defined by each body system (skin, eyes, cardiac, etc.) and all conditions or illnesses asked of the patient are documented along with the patient response. Points Range: 16 (16%) – 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). Points Range: 11 (11%) – 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). Points Range: 6 (6%) – 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). Points Range: 0 (0%) – 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).

or

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”.

Diagnostic result- Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). Points Range: 16 (16%) – 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. Points Range: 11 (11%) – 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. Points Range: 6 (6%) – 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. Points Range: 0 (0%) – 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.

or

No documentation provided.
Total Points: 100
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: 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. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. 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. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.

 

 

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