May 30, | nursing, med, NURS, Paper
Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
Objective Data Collection: 15 of 15 (100.0%)
Correct
Partially correct
Incorrect
Missed
Inspected eyes and orbital area
1 of 1 point
Orbital Area (1/4 point)
No visible abnormal findings
Ptosis
Eyelid
Lesion
Sclera (1/4 point)
White
Yellow tint
Redness
ORDER SHADOW HEALTH HELP HERE
Conjunctiva (1/4 point)
Moist and pink
Dry appearance
Redness
Swelling
Conjunctival Discharge (1/4 point)
No discharge
Clear, watery discharge
Purulent discharge
Inspected nasal cavities
1 of 1 point
Color (1/4 point) – Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
Pink
Red
Bluish
Discharge (1/4 point)
No discharge
Clear discharge
Bloody discharge
Purulent discharge
Turbinate Patency (1/4 point)
Patent
Decreased patency
Not patent
Observations (1/4 point)
No additional visible abnormal findings
Foreign body present
Polyp
Septum perforated
Septum deviated
Lesion
Inspected ears
0.8 of 1 point
Right: Auditory Canal Color (No point)
Pink
Red
Pallor
Right: Tympanic Membrane Color (No point)
Pearly gray
Red
Opaque
Yellow
Not visible because of cerumen
Right: Tympanic Membrane Appearance (1/10 point)
No visible abnormal findings
Fluid observed
Visible scars
Bulging
Perforation
Retraction
Right: Cone Of Light (1/10 point)
5:00
Cone of light distorted
Right: Discharge (1/10 point)
No discharge
Cerumen
Clear discharge
Bloody discharge
Purulent discharge
Left: Auditory Canal Color (1/10 point)
Pink
Red
Pallor
Left: Tympanic Membrane Color (1/10 point)
Pearly gray
Red
Opaque
Yellow
Not visible because of cerumen
Left: Tympanic Membrane Appearance (1/10 point)
No visible abnormal findings
Fluid observed
Visible scars
Bulging
Perforation
Retraction
Left: Cone Of Light (1/10 point)
7:00
Cone of light distorted
Left: Discharge (1/10 point)
No discharge
Cerumen
Clear discharge
Bloody discharge
Purulent discharge
Inspected mouth and throat
1 of 1 point
Oral Mucosa (1/5 point)
Moist and pink
Dry appearance
Redness
Tonsils (1/5 point)
No visible abnormal findings
Swelling
Redness
Throat Color (1/5 point)
Pink
Red
Throat Texture (1/5 point)
No abnormal findings
Cobblestoning
Exudate
Post Nasal Drip (1/5 point)
No discharge
Clear discharge
Purulent discharge
Inspected neck
1 of 1 point
Symmetry (1/2 point)
Symmetric
Asymmetric
Appearance (1/2 point)
No visible abnormal findings
Swelling
Visible pulsation
Visible mass
Discoloration
Inspected chest
1 of 1 point
Symmetry (1/2 point)
Symmetric
Asymmetric
Appearance (1/2 point)
No visible abnormal findings
Rash
Barrel chest
Intercostal retraction while breathing
Excessive use of accessory muscles while breathing
Skin growths (freckles or moles)
Auscultated breath sounds
1 of 1 point
Breath Sounds (1/3 point)
Present in all areas
Diminished in some areas
Absent in some areas
Adventitious Sounds (1/3 point)
No adventitious sounds
Wheezing
Fine crackles
Stridor
Rhonchi
Rales
Location (1/3 point)
All areas clear
Adventitious sounds in anterior right upper lobe
Adventitious sounds in anterior right middle lobe
Adventitious sounds in anterior right lower lobe
Adventitious sounds in anterior left upper lobe
Adventitious sounds in anterior left lower lobe
Adventitious sounds in posterior right upper lobe
Adventitious sounds in posterior right lower lobe
Adventitious sounds in posterior left upper lobe
Adventitious sounds in posterior left lower lobe
Auscultated for bronchophony
1 of 1 point
Bronchophony (1/1 point)
Positive
Negative
Auscultated heart sounds
1 of 1 point
Heart Sounds (1/2 point)
S1 and S2 audible
S1, S2, and S3 audible
S1, S2, and S4 audible
S1, S2, S3, and S4 audible
Extra Heart Sounds (1/2 point)
No extra sounds
Gallops
Murmur
Friction rub
Valve clicks
Percussed chest wall
1 of 1 point
Observations (1/2 point)
All areas resonant
Some areas dull, some resonant
Some areas hyperresonant, some resonant
Location (1/2 point)
No areas of dullness
Dullness, anterior right upper lobe
Dullness, anterior right middle lobe
Dullness, anterior right lower lobe
Dullness, anterior left upper lobe
Dullness, anterior left lower lobe
Dullness, posterior right upper lobe
Dullness, posterior right lower lobe
Dullness, posterior left upper lobe
Dullness, posterior left lower lobe
Measured diaphragmatic excursion
1 of 1 point
Range (1/1 point)
3-5 cm
Greater than 3-5 cm
Less than 3-5 cm
Palpated sinuses
1 of 1 point
Frontal (1/2 point)
None reported
Tenderness reported
Maxillary (1/2 point)
None reported
Tenderness reported
Palpated lymph nodes
1 of 1 point
Head And Neck (1/3 point)
No palpable nodes
Palpable nodes on right side
Palpable nodes on left side
Supraclavicular (1/3 point)
No palpable nodes
Palpable nodes on right side
Palpable nodes on left side
Axillary (1/3 point)
No palpable nodes
Palpable nodes on right side
Palpable nodes on left side
Palpated fremitus
1 of 1 point
Symmetry (1/2 point)
Equal bilaterally
Unequal bilaterally
Vibration (1/2 point)
Expected fremitus
Decreased fremitus
Palpated chest expansion
1 of 1 point
Symmetry (1/1 point)
Equal bilaterally
Unequal bilaterally
Subjective Data Collection: 22 of 22 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports cough
(Found)
Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source.
Example Question:
Do you have a cough?
History of Presenting Illness
Finding:
Asked about onset of cough
Finding:
Reports cough started 3 days ago
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, in this case the patient’s cough, inquiring about onset assesses the severity and the progression of the problem.
Example Question:
How long have you had a cough?
Finding:
Asked about characteristics of cough
Finding:
Reports cough is wet
(Found)
Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can indicate key information about the type of illness the patient has.
Example Question:
Is your cough a wet cough?
Finding:
Reports clear sputum with cough
(Found)
Pro Tip: The characteristics of a cough, such as whether it is productive, can indicate key information about the type of illness the patient has.
Example Question:
Do you produce any phlegm or sputum with your cough?
Finding:
Asked about frequency and duration of cough
Finding:
Reports coughing every few minutes
(Found)
Pro Tip: Establishing how frequently Danny coughs will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How frequently are you coughing?
Finding:
Reports coughs last a few seconds
(Available)
Pro Tip: Establishing how long Danny’s coughs last will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How long do your coughs last?
Finding:
Asked about aggravating factors for cough
Finding:
Reports cough is worse at night
(Found)
Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
Is the cough worse at night?
Finding:
Denies smoking
(Available)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking even young patients about whether they consume tobacco products helps you assess this risk factor.
Example Question:
Do you smoke?
Finding:
Reports being exposed to secondhand smoke through father
(Found)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking about whether a patient is exposed to secondhand smoke allows you to assess this risk factor.
Example Question:
Are you ever around cigarette smoke?
Finding:
Reports he doesn’t know what triggers the cough
(Found)
Pro Tip: Asking about aggravating factors of Danny’s cough will allow you to determine potential causes and educate the patient on what to avoid.
Example Question:
What makes your cough worse?
Finding:
Asked about exposure to germs
Finding:
Reports playing with an ill classmate
(Found)
Pro Tip: Asking about Danny’s exposure to illnesses will allow you to counsel him on effective hygiene, as well as potentially determine the cause of his current symptoms.
Example Question:
Have you come in contact with anyone sick?
Finding:
Asked about hand hygiene
Finding:
Reports infrequent hand washing
(Found)
Pro Tip: Asking about Danny’s hand washing practices will allow you to counsel him on effective hygiene.
Example Question:
How often do you wash your hands?
Finding:
Reports occasionally putting fingers in eyes, nose, or mouth
(Available)
Pro Tip: Asking about Danny’s hand washing practices will allow you to counsel him on effective hygiene.
Example Question:
Do you ever touch your eyes, nose, or mouth?
Finding:
Asked about cough etiquette
Finding:
Denies covering mouth when coughing
(Found)
Pro Tip: Asking about Danny’s cough etiquette will allow you to counsel him on effective hygiene and reduce the risk of him infecting other people.
Example Question:
Do you cover your mouth when you cough?
Finding:
Asked about relieving factors for cough
Finding:
Reports cough is temporarily relieved by cough medicine
(Found)
Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.
Example Question:
Have you done anything to treat your cough?
Finding:
Followed up on cough medicine
Finding:
Reports cough medicine was purple
(Found)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the cough medicine’s color may help you identify the type of medication it is.
Example Question:
What color was the cough medicine?
Finding:
Reports taking one spoonful of cough medicine
(Found)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the dose of cough medicine allows you to determine whether it is being taken correctly.
Example Question:
How much medicine did you take?
Finding:
Reports mother gave him the medicine
(Found)
Pro Tip: Children should only take medication under the supervision of an adult who can assure it is taken as directed. You should ask younger patients whether the medicine was given to them and by whom.
Example Question:
Who gave you the medicine for your cough?
Finding:
Reports only took the medicine this morning
(Found)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the frequency Danny took cough medicine allows you to determine whether it is being taken correctly.
Example Question:
How many times have you taken the cough medicine?
Finding:
Denies home remedies
(Available)
Pro Tip: Patients sometimes try non-medicinal home remedies to treat coughs, such as breathing steam, or drinking tea with honey. Not all home remedies are effective or advisable, so it’s important to find out what remedies the patient has tried Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data.
Example Question:
Have you tried any home remedies for your cough?
Finding:
Asked about typical medication use
Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
ORDER SHADOW HEALTH HELP HERE
Finding:
Denies taking medication
(Available)
Pro Tip: Knowing a patient’s current medication regimen helps you determine if any future treatments will be safe and effective.
Example Question:
Do you take any medications from a doctor?
Finding:
Reports taking daily vitamin
(Found)
Pro Tip: Some symptoms can occur as a result of a vitamin deficiency, and others as a result of vitamin excess. Vitamins can also interfere with some treatments, so it’s important to know what your patient is taking.
Example Question:
Do you take vitamins?
Finding:
Asked about activity level
Finding:
Reports typical high activity level
(Found)
Pro Tip: Establishing a patient’s typical activity level is an important baseline to help you determine how an illness is affecting his life.
Example Question:
Are you usually active?
Finding:
Reports activity level low since getting sick
(Available)
Pro Tip: Establishing a patient’s activity level, and whether it has been impacted since becoming ill, is an important baseline to help you determine how an illness is affecting his life.
Example Question:
Have you been less active since getting sick?
Finding:
Reports still able to run or play
(Available)
Pro Tip: Ability to remain active indicates that the patient’s breathing is not dangerously affected, and that the patient isn’t seriously fatigued.
Example Question:
Are you able to keep up when you play with your classmates?
Finding:
Reports focusing in class is difficult
(Found)
Pro Tip: Mental lethargy and difficulty concentrating are common symptoms when a patient is sick.
Example Question:
Are you able to focus in class?
Finding:
Asked about nasal symptoms
Finding:
Reports current runny nose
(Found)
Pro Tip: Asking your patient if his nose is running will allow you to determine the symptoms he is experiencing and possible triggers.
Example Question:
Do you currently have a runny nose?
Finding:
Denies sneezing
(Found)
Pro Tip: Asking your patient if he has been sneezing will allow you to determine the symptoms he is experiencing and possible triggers.
Example Question:
Have you been sneezing?
Finding:
Followed up on nasal discharge
Finding:
Reports nasal discharge is clear
(Found)
Pro Tip: The color of a patient’s nasal discharge can provide you key information as to the type of condition the patient has.
Example Question:
What color is your snot?
Finding:
Reports nasal discharge is thin
(Found)
Pro Tip: The consistency of a patient’s nasal discharge can provide you key information as to the type of condition the patient has.
Example Question:
What is the consistency of your nasal discharge?
Finding:
Asked about ear symptoms
Finding:
Denies ear pain
(Found)
Pro Tip: Ear pain is often coincident with coughs and sinus problems. Asking about them allows you to ascertain if Danny needs follow-up care for his ears.
Example Question:
Do you have any ear pain?
Finding:
Reports history of frequent ear infections
(Found)
Pro Tip: Asking about Danny’s history of ear infections allows you to ascertain his risk for current and future ear infections.
Example Question:
Have you ever had ear infections?
Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
Finding:
Denies ear discharge
(Found)
Pro Tip: Asking Danny about ear discharge, which are often coincident with of ear infections, allows you to ascertain his risk for current and future ear infections.
Example Question:
Do you have any ear discharge?
Finding:
Denies hearing problems
(Found)
Pro Tip: Simply talking with the patient assesses his hearing; however, some types of hearing loss are only apparent in specific settings such as noisy environments. Asking the patient about hearing problems identifies conditions that may not be readily apparent.
Example Question:
Do you have any hearing problems?
Finding:
Asked about throat symptoms
Finding:
Reports sore throat
(Found)
Pro Tip: Sore throats are often coincident with coughs and sinus problems. Asking about them allows you to ascertain if Danny needs follow-up care for his throat.
Example Question:
Is your throat sore?
Finding:
Reports a little pain with swallowing
(Found)
Pro Tip: Pain when swallowing helps you understand how severe the patient’s sore throat is.
Example Question:
Does it hurt when you swallow?
Past Medical History
Finding:
Asked about relevant medical history
Finding:
Reports frequent runny noses
(Found)
Pro Tip: Asking how often Danny experiences runny noses like the one he has now may help you determine the source of the problem.
Example Question:
Do you get runny noses often?
Finding:
Reports past frequent coughs
(Available)
Pro Tip: A patient experiencing a cough should be asked about their history of coughs so you can determine whether their current condition fits into a recurring pattern.
Example Question:
Do you have coughs very often?
Finding:
Reports past pneumonia
(Found)
Pro Tip: Pneumonia is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.
Example Question:
Have you had pneumonia?
Finding:
Denies asthma diagnosis
(Found)
Pro Tip: Asthma is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.
Example Question:
Do you have asthma?
Finding:
Reports immunizations as current
(Found)
Pro Tip: A health assessment should include an evaluation of the patient’s immunization status in order to identify diseases to which the patient is vulnerable.
Example Question:
Do you have current immunizations?
Finding:
Asked about allergies
Finding:
Denies seasonal allergies
(Found)
Pro Tip: Seasonal allergies can cause symptoms like runny nose, cough, and discomfort. Asking Danny if he has seasonal allergies can help you to ascertain possible triggers for symptoms. Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
Example Question:
Do you have seasonal allergies?
Finding:
Denies food allergies
(Available)
Pro Tip: Knowing if your patient has food allergies is important and relevant medical history. Asking your patient about food allergies will allow you to most effectively treat him.
Example Question:
Do you have food allergies?
Finding:
Denies medication allergies
(Available)
Pro Tip: Knowing if your patient has allergies to medicine is important and relevant medical history. Asking your patient about medicine allergies will allow you to most effectively treat him.
Example Question:
Are you allergic to any medication?
Finding:
Asked relevant family history
Finding:
Reports father has history of asthma
(Found)
Pro Tip: Medical problems such as asthma that are present in a patient’s immediate family can represent increased risk factors to respiratory conditions such as the ones the patient currently has.
Example Question:
Do you have a family history of asthma?
Finding:
Denies family history of allergies
(Found)
Pro Tip: Medical problems such as allergies that are present in a patient’s immediate family can represent increased risk factors to respiratory conditions such as the ones the patient currently has.
Example Question:
Do you have a family history of allergies?
Review of Systems
Finding:
Asked about constitutional health
Finding:
Denies chills
(Found)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has chills will illustrate the way his symptoms manifest.
Example Question:
Do you have chills?
Finding:
Denies fever
(Found)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has a fever will illustrate the way his symptoms manifest.
Example Question:
Do you have a fever?
Finding:
Reports feeling somewhat fatigued
(Found)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has fatigue will illustrate the way his symptoms manifest.
Example Question:
Do you have fatigue?
Finding:
Denies night sweats
(Found)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has night sweats will illustrate the way his symptoms manifest.
Example Question:
Do you have night sweats?
Finding:
Reports cough makes it difficult to sleep
(Found)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has had difficulty sleeping will illustrate the way his symptoms manifest.
Example Question:
Have you been sleeping okay?
Finding:
Denies swelling
(Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has had swelling will illustrate the way his symptoms manifest.
Example Question:
Have you noticed any swelling?
Finding:
Asked about additional review of systems for HEENT
Finding:
Reports frequent colds
(Found)
Pro Tip: A patient such as Danny who is presenting with a cough and a runny nose may have a cold, so you should ask about his history of colds to determine whether this is part of a larger pattern.
Example Question:
Do you have unusually frequent colds?
Finding:
Denies headaches
(Found)
Pro Tip: Headaches are a common complaint that can be caused by a variety of benign conditions. However, headaches can be an indicator of serious underlying neurological conditions such as cerebral hemorrhage, meningitis, or brain tumors. They may also be a symptom of sinus infection.
Example Question:
Do you get headaches?
Finding:
Denies nosebleeds
(Found)
Pro Tip: When a patient presents with symptoms that are often seen with respiratory infections, you should ask about similar signs of respiratory infections such as nosebleeds.
Example Question:
Do you have nosebleeds?
Finding:
Denies vision difficulty
(Found)
Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.
Example Question:
Do you have any problems with your vision?
Finding:
Denies dizziness
(Found)
Pro Tip: Asking about dizziness helps you assess the risk for inner ear, neurological, or cardiovascular problems.
Example Question:
Do you have any dizziness?
Finding:
Denies watery eyes
(Available)
Pro Tip: Whether a patient has watery eyes may help you indicate the type of sinus problem he is experiencing.
Example Question:
Do you have watery eyes?
Finding:
Denies eye redness
(Available)
Pro Tip: Whether a patient has eye redness may help you indicate the type of sinus problem he is experiencing.
Example Question:
Do you have eye redness?
Finding:
Denies eye pain
(Available)
Pro Tip: Eye pain can lower one’s ability to function and can be a major safety risk.
Example Question:
Do you have any eye pain?
Finding:
Denies sinus pain
(Available)
Pro Tip: Patients with sinus problems such as a runny nose may be at greater risk for sinus pain.
Example Question:
Do you have any sinus pain?
Finding:
Asked about review of systems for respiratory
Finding:
Denies chest tightness
(Available)
Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest tightness is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.
Example Question:
Do you have chest tightness?
Finding:
Denies chest pain
(Found)
Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest pain is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.
Example Question:
Do you have any chest pain?
Finding:
Denies difficulty breathing
Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
May 30, | nursing, med, NURS, Paper
NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning
NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning
By Day 3 of Week 1
Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
Building a Health History
The primary purpose of building health history is to gather subjective information from the patient or the patient’s family so that the patient and the healthcare team can develop a collaborative plan that will ensure effective delivery of healthcare (Ball, Dains, Solomon, & Stewart, 2015). In the case of the adolescent Hispanic boy living in a middle-class suburb, the interview would involve first setting an accommodating environment that can help enhance the patient conform in answering the questions NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning. The interview will begin by presenting a proper self-introduction and the reason for the expected interaction to ensure that the patient is aware of the reason for the interview. Besides, the interview would entail covering a health history checklist by obtaining biographical data such as age from the patient. The interaction will also include obtaining information on the reason seeking care, past health history, family health history, functional assessment, and cultural assessment. The interview questions would also be structured in both open-ended and close-ended format.
Moreover, the establishment of the health history requires the employment of proper communication techniques. One of the first techniques that would be used during the communication with the patient is the avoidance of medical jargon. Ideally, it is highly unlikely that the adolescent Hispanic boy would have a grasp of medical-technical terms, and using hard jargon can result in confusion. Besides, active listening is another technique that would be used during the interview. This skill entails not only hearing what is being said but also processing and interpreting the words that are being spoken by the patient (Choudhary & Gupta, 2015). Empathy is another communication technique that will be practiced when building the health history. By expressing empathy, the patient will be more comfortable in answering questions hence ensuring that no relevant information is hidden. Building a rapport is another communication technique that would ensure that no information is withheld during the interview NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
The development of the health history also involves conducting a comprehensive risk assessment. As such, the most applicable risk assessment strategy that would be employed in the case of the patient is identifying mental healthcare risks through the profound evaluation of family health history. Poor mental healthcare among teenagers is one of the major public health concerns not only in the United States but also across the globe. Mental disorders in adolescents are becoming relatively common as at least one in every five youth aged between 9 and 17 are diagnosed with a mental health issue (López, et al., 2017). Since the subject in context is an adolescent, he is also at high risk of possessing or developing a mental health disorder. As such, this risk assessment technique would help in the identification of the possibility of occurrence of the risk and also the development of a proper healthcare plan for the mitigation of the risk NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
The following are the questions that would be asked to the patient in the assessment of his healthcare risks;
What is the reason for seeking care today?
What are some of the past healthcare issues you have been diagnosed with and treated?
Have you been diagnosed or treated for Emotional or psychiatric problems before?
Does your family have any cases of mental health disorders?
Does your family have a record of any significant illness such as heart disease, cancer, diabetes, or hypertension?
Do you engage in any activities and leisure?
References
Ball, J. W., Dains, J. E., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s Guide to Physical Examination. Elsevier Health Sciences.
Choudhary, A., & Gupta, V. (2015). Teaching communications skills to medical students: Introducing the fine art of medical practice. International Journal of Applied and Basic Medical Research, 5(Suppl 1), S41.
López, C. M., Andrews III, A. R., Chisolm, A. M., De Arellano, M. A., Saunders, B., & Kilpatrick, D. (2017). Racial/ethnic differences in trauma exposure and mental health disorders in adolescents. Cultural diversity and ethnic minority psychology, 23(3),.NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning
By Day 6 of Week 1
Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:
You make some good points about including functional and cultural assessments when obtaining your patient’s health history. I agree with keeping the interview questions structured and open-ended, allowing the patient to provide data in their own words without being nudged in any particular direction. Furthermore, effective communication skills cannot be emphasized enough, especially when treating younger patients and adolescents. If developed during formative years, effective communication skills, a core competency for practitioners, can help students and future practitioners alike (Choudhary & Gupta, 2015). However, clinical communication skills with the pediatric and adolescent populations specifically, pose a distinct challenge for health care providers, as research in this area is complex and limited, (Frost et al., 2015).
I agree with your techniques of avoiding medical jargon, actively listening, and expressing empathy. I would add to the questionnaire more focused inquiries regarding this patient’s mental health status. For example, is the home environment chaotic, has the teen experienced any physical/verbal abuse, bullying at school, history of substance use, does he or his friend drink at parties, use cannabis in any form (vape, smoke, edibles.) Here in California cannabis is legalized and this has resulted in the trickle-down effect of substance use becoming common ground even in middle schools, unfortunately. Vaping is prevalent in the middle and high school populations and as providers, it’s important we ask questions in such a manner that the patient is reassured we’re not judging and we are genuinely concerned for their overall well-being. This is where patient-specific communication skills apply NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
Including questions on signs or symptoms of anxiety & depression may also be useful. Perhaps you can ask about this patient’s sleep pattern, eating habits, racing thoughts, thoughts of suicide, history of self-harm behaviors…etc. Self-harm is a crucial part of the mental health assessment, as it is one of the major reasons for admission to an adolescent inpatient psychiatric facility and a major risk factor for suicidal ideation and suicide attempts (Boylan et al., 2019). I would definitely add the risk assessment tool of the Well-Being Index (WBI) to assess the health of the whole child. This is a reliable tool to assess the adolescent, along with perceptions of school climate to foster their overall well-being by assessing four symptom areas: depression, anxiety, rule-breaking, and substance use (Luthar et al., 2020).
I’m sure that as providers if we were to ask such questions, the adolescent patient would gradually begin to open up and share details he would otherwise keep from his family for fear of repercussion or judgment.
References
Boylan, K., Chahal, J., Courtney, D. B., Sharp, C., & Bennett, K. (2019). An evaluation of clinical practice guidelines for self-harm in adolescents: The role of borderline personality pathology. Personality Disorders: Theory, Research, and Treatment, 10(6), 500-510. https://doi.org/10.1037/per0000349
Choudhary, A., & Gupta, V. (2015). Teaching communications skills to medical students: Introducing the fine art of medical practice. International Journal of Applied and Basic Medical Research, 5(4), 41. https://doi.org/10.4103/2229-516x.162273
Frost, K., Metcalf, E., Brooks, R., Kinnersley, P., Greenwood, S., & Powell, C. (2015). Teaching pediatric communication skills to medical students. Advances in Medical Education and Practice, 35. https://doi.org/10.2147/amep.s68413
Luthar, S. S., Ebbert, A. M., & Kumar, N. L. (2020). The well-being index (WBI) for schools: A brief measure of adolescents’ mental health. Psychological Assessment, 32(10), 903-914. https://doi.org/10.1037/pas0000913
response 2
Thank you for such a detailed post. Your approach in communication techniques with this teenager is professional and definitely empathic and establishing trust is very important. Adolescence is a critical developmental period associated with increased vulnerability for depressive symptoms and gender differences in depression generally emergence during adolescence (Lorenzo-Blanco et al., 2012). Although the reasons and details of the visit are not indicated, it would be important to inquire about thoughts of wanting to hurt himself or anyone else. (Caplan, 2019) reports that the rate of self-reported mental illness for Latinos are similar to or slightly less than those of the population as a whole, which is a very large population NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning. I found it interesting that as of 2019, the Hispanic population in the United States is over 60.47 million (2021).
I worked on an inpatient acute child/adolescent behavioral unit for over 3yrs and I have found that being compassionate, yet open and asking teenagers directly, what their thoughts and feelings are about self-harm, suicide, etc has not only opened the space for trust, but for truth-building. I have witnessed how the approach of the health providers can both, be helpful and therapeutic, as well as observing how a teen will shut-down due to a lack of trust. Again, I enjoyed reading your post and your selection of questions were great.
References
Caplan, S. (2019). Intersection of cultural and religious beliefs about mental health: Latinos in the faith-based setting. Hispanic Health Care International, 17(1), 4–10. https://doi.org/10.1177/1540415319828265
Hispanic population by state 2021. (2021). worldpopulationreview.com. https://worldpopulationreview.com/state-rankings/hispanic-population-by-state
Lorenzo-Blanco, E. I., Unger, J. B., Baezconde-Garbanati, L., Ritt-Olson, A., & Soto, D. (2012). Acculturation, enculturation, and symptoms of depression in hispanic youth: The roles of gender, hispanic cultural values, and family functioning. Journal of Youth and Adolescence, 41(10), 1350–1365. https://doi.org/10.1007/s10964-012-9774-7
Week 1: Building a Comprehensive Health History
According to a 2011 Gallup poll, nurses are ranked as the most trusted professionals in the United States. One of the most admired nursing skills is the ability to put patients at ease. When patients enter into a healthcare setting, they are often apprehensive about sharing personal health information. Caring nurses can alleviate the hesitance of patients and encourage them to be forthcoming with this information NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
The initial health history interview can be an excellent opportunity to develop supportive relationships between patients and nurses. Nurses may employ a variety of communication skills and interview techniques to foster strong bonds with patients and to effectively facilitate the diagnostic process. In conducting interviews, advanced practice nurses must also take into account a range of patient-specific factors that may impact the questions they ask, how they ask those questions, and their complete assessment of the patient’s health.
This week, you will consider how social determinants of health such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve. You will also consider how social determinants of health influence your interview and communication techniques as you work in partnership with a patient to gather data to build an accurate health history.
Learning Objectives
Students will:
Analyze communication techniques used to obtain patients’ health histories based upon social determinants of health
Analyze health-related risk
Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning
Learning Resources
Required Readings (click to expand/reduce)
Required Media (click to expand/reduce)
Assignment: Course Acknowledgement
This mandatory assignment is an acknowledgement that you fully understand the course guidelines.
By Day 3 of Week 1
Submit your Assignment.
Submission and Grading Information
Submit Your Assignment by Day 3 of Week 1.
To complete this assignment, follow the link below and answer the questions provided.
Week 1 Assignment
Discussion: Building a Health History
Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.
Photo Credit: Sam Edwards / Caiaimage / Getty Images
To prepare:
With the information presented in Chapter 1 of Ball et al. in mind, consider the following:
By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
How would your communication and interview techniques for building a health history differ with each patient?
How might you target your questions for building a health history based on the patient’s social determinants of health?
What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
By Day 3 of Week 1
Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 1
Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:
Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
Suggest additional health-related risks that might be considered.
Validate an idea with your own experience and additional research.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 1 Discussion Rubric
Post by Day 3 of Week 1 and Respond by Day 6 of Week 1
To Participate in this Discussion:
Week 1 Discussion NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning
What’s Coming Up in Module 2?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
In Module 2, you explore the impact of functional assessments, diversity, and sensitivity in conducting health assessments. You also examine various assessment tools and diagnostic tests used to gather information about patients’ conditions and examine their validity, reliability, and impact in conducting health assessments.
Next week, you will specifically examine functional assessments as they relate to diversity and sensitivity
Registration for Shadow Health
Throughout this course, you will participate in digital clinical experiences using the online simulation tool Shadow Health. The Shadow Health digital clinical experience provides a dynamic, immersive experience designed to improve nursing skills and clinical reasoning through the examination of digital standardized patients. Using Shadow Health you will participate in health histories, focused exams, and a comprehensive assessment.
There will be four Shadow Health assessment components that you will need to complete in Module’s 2 and 3:
Health History Assessment (Week 3 & 4)
Focused Exam: Cough (Week 5) for a pediatric patient presenting with cough
Focused Exam: Chest Pain (Week 7) for an adult patient presenting with chest pain
Comprehensive (Head-to-Toe) Physical Assessment (Week 9)
Before you can participate in these simulations, you will need to register for a Shadow Health account. To do this:
Go to the Walden Bookstore and purchase access to Shadow Health and the required texts.
Once Shadow Health has been purchased, an access code will be emailed to you from the bookstore.
Review this video explaining how to register in Shadow Health: https://vimeo.com/275921826/c12d50ee6e
Use the Shadow Health link located in the navigation menu on the left in the Blackboard course.
Follow the prompts to register in Shadow Health. You will need the access code provided from the bookstore to register. Once registered, Shadow Health should always be accessed via the link in Blackboard.
Use only Google Chrome when accessing Shadow Health and make sure all other programs are turned off on your computer. Other browsers do not work well and will not allow the Shadow Health speech to text function to work.
Once registered, complete the Shadow Health Orientation in the Shadow Health website/program and review the videos designed to assist with navigating and completing assignments.
Read the Shadow Health Nursing Documentation Tutorial located in the Week 1 Learning Resources.
Note: As nurses you typically use the word assessment to mean completing the physical exam. However, in the SOAP Note format, assessment means diagnosis so start getting in the habit of calling the physical exam exactly that NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
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Week 2 Case Studies
In Week 2, your Instructor will assign you a case study related to your Discussion by Day 1 of the week. Please make sure to review the “Course Announcements” area of the course to verify your assigned case study. Please plan ahead to ensure you have time to review your case study and your Learning Resources so that you can complete your Discussions and Assignments on time.
Photo Credit: Getty Images/iStockphoto
Practicum – Upcoming Deadline
In the Nurse Practitioner programs of study (FNP, AGACNP, AGPCNP, and PMHNP) you are required to take several practicum courses. If you plan on taking a practicum course within the next two terms, you will need to submit your application via Meditrek .
For information on the practicum application process and deadlines, please visit the Field Experience: College of Nursing: Application Process – Graduate web page.
Please take the time to review the Appropriate Preceptors and Field Sites for your courses.
Please take the time to review the practicum manuals, FAQs, Webinars and any required forms on the Field Experience: College of Nursing: Student Resources and Manuals web page.
Field Experience: College of Nursing Quick Answers
Field Experience: MSN Nurse Practitioner Practicum Manual
Student Practicum Resources: NP Student Orientation
Week 2: Functional Assessments and Cultural and Diversity Awareness in Health Assessment
Diversity is not about how we differ. Diversity is about embracing one another’s uniqueness.
—Ola Joseph
Countless assessments can be conducted on patients, but they may not be useful. In order to ensure that health assessments result in the necessary care, health assessments should take into account the impact of factors such as cultures and developmental circumstances.
Learning Objectives
Students will:
Analyze diversity considerations in health assessments
Apply concepts, theories, and principles related to examination techniques, functional assessments, and cultural and diversity awareness in health assessment NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning
Learning Resources
Required Readings (click to expand/reduce)
Required Media (click to expand/reduce)
Discussion: Diversity and Health Assessments
May 2012, Alice Randall wrote an article for The New York Times on the cultural factors that encouraged black women to maintain a weight above what is considered healthy. Randall explained—from her observations and her personal experience as a black woman—that many African-American communities and cultures consider women who are overweight to be more beautiful and desirable than women at a healthier weight. As she put it, “Many black women are fat because we want to be” (Randall, 2012).
Photo Credit: Getty Images
Randall’s statements sparked a great deal of controversy and debate; however, they emphasize an underlying reality in the healthcare field: different populations, cultures, and groups have diverse beliefs and practices that impact their health. Nurses and healthcare professionals should be aware of this reality and adapt their health assessment techniques and recommendations to accommodate diversity.
In this Discussion, you will consider different socioeconomic, spiritual, lifestyle, and other cultural factors that should be taken into considerations when building a health history for patients with diverse backgrounds. Your Instructor will assign a case study to you for this Discussion NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
To prepare:
Reflect on your experiences as a nurse and on the information provided in this week’s Learning Resources on diversity issues in health assessments.
By Day 1 of this week, you will be assigned a case study by your Instructor. Note: Please see the “Course Announcements” section of the classroom for your case study assignment.
Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient assigned to you.
Consider how you would build a health history for the patient. What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Develop five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
Think about the challenges associated with communicating with patients from a variety of specific populations. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering the pertinent information?
By Day 3 of Week 2
Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 2
Respond on or before Day 6 on 2 different days to at least two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 2 Discussion Rubric
Post by Day 3 of Week 2 and Respond by Day 6 of Week 2
To Participate in this Discussion:
Week 2 Discussion
What’s Coming Up in Week 3?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you examine assessment techniques, health risks and concerns, and recommendations for care related to patient growth, weight, and nutrition. You will also begin your first DCE: Health History Assessment which will be due in Week 4. Plan your time accordingly.
Overview of Digital Clinical Experiences (DCE) and Lab Components
Throughout this course, you are required to not only complete your standard course assignments and discussions, but you will also complete DCE and Lab Components that are either structured as optional or required assignment submissions. Please take the time to review your DCEand Lab Components for this course that are required submissions. See the table below and the attached table for specific DCE and Lab Components for the course.
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total score of 80% or better, but you must take all attempts by the Day 7 deadline. You must pass BOTH the Health History and Comprehensive (head-to-toe) Physical Exam of at least a total score of 80% in order to pass the course.
Week
Digital Clinical Experiences
Lab Components
Module 1: Comprehensive Health History
Week 1: Building a Comprehensive Health History
Module 2: Functional Assessments and Assessment Tools
Week 2: Functional Assessments and Cultural and Diversity Awareness in Health Assessment
Week 3: Assessment Tools, Diagnostics, Growth, Measurement, and Nutrition in Adults and Children
DCE: Health History Assessment (assigned in Week 3, due in Week 4)
Case Study Assignment: Assessment Tools and Diagnostic Tests in Adults and Children
Module 3: Approach to System Focused Advanced Health Assessments
Week 4: Assessment of the Skin, Hair, and Nails
DCE: Health History Assessment
Lab Assignment: Differential Diagnosis for Skin Conditions (SOAP Note for differential diagnosis)
Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
DCE: Focused Exam: Cough
Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat (Episodic SOAP Note)
Week 6: Assessment of the Abdomen and Gastrointestinal System
Lab Assignment: Assessing the Abdomen (Analyze SOAP Note)
Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
DCE: Focused Exam: Chest Pain
Week 8: Assessment of the Musculoskeletal System
Discussion: Assessing Musculoskeletal Pain (Episodic SOAP Note)
Week 9: Assessment of Cognition and the Neurologic System
DCE: Comprehensive (head-to-toe) Physical Assessment
Case Study Assignment: Assessing Neurological Symptoms (Episodic SOAP Note)
Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal
Lab Assignment: Assessing the Genitalia and Rectum (analyze SOAP Note)
Module 4: Ethics in Assessment
Week 11: The Ethics Behind Assessment
Lab Assignment: Ethical Concerns
Next Week
To go to the next week:
Week 3 NURS 6512 Discussions and Assignments: Advanced Health Assessment and Diagnostic Reasoning
