ASSIGNMENT: DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

ASSIGNMENT: DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

ASSIGNMENT: DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.

In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.

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Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE

• Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
• Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
• Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

DCE FOCUSED EXAM: CHEST PAIN ASSIGNMENT:

Complete the following in Shadow Health:

• Cardiovascular Concept Lab (Required)
• Respiratory(Recommended but not required)
• Cardiovascular (Recommended but not required)
• Episodic/Focused Note for Focused Exam (Required): Chest Pain

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 7 Day 7 deadline.

SUBMISSION INFORMATION

• Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Canvas.
• Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas 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
• Links to an external site.
• Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
• To submit your completed assignment, save your Assignment as WK7Assgn1+last name+first initial.
• Then, click on Start Assignment near the top of the page.
• Next, click on Upload File and select both files and then Submit Assignment for review.

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Rubric

NURS_6512_Week_7_DCE_Assignment_1_Rubric

CriteriaRatingsPtsThis criterion is linked to a Learning Outcome

Student DCE score(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)Note: DCE Score – Do not round up on the DCE score.60 to >55.0 pts

Excellent

DCE score>93

55 to >50.0 pts

Good

DCE Score 86-92

50 to >45.0 pts

Fair

DCE Score 80-85

45 to >0 pts

Poor

DCE Score <79… No DCE completed.

60 pts

This criterion is linked to a Learning Outcome

Subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.20 to >15.0 pts

Excellent

Documentation is detailed and organized with all pertinent information noted in professional language….Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

15 to >10.0 pts

Good

Documentation with sufficient details, some organization and some pertinent information noted in professional language….Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

10 to >5.0 pts

Fair

Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language….Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

5 to >0 pts

Poor

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.

20 pts

This criterion is linked to a Learning Outcome

Objective Documentation in Provider Notes – this is to be completed using the documentation template that is provided. Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).20 to >15.0 pts

Excellent

Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language….Each system assessed is clearly documented with measurable details of the exam.

15 to >10.0 pts

Good

Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. …Each system assessed is somewhat clearly documented with measurable details of the exam.

10 to >5.0 pts

Fair

Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language….Each system assessed is minimally or is not clearly documented with measurable details of the exam.

5 to >0 pts

Poor

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.

20 pts

Total Points: 100