NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
\nWeek 5: Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
\nPatient Information
\nInitials: D.R
\nAge: 8 years old
\nGender: Male<\/p>\n
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\nSUBJECTIVE DATA:
\nChief Complaint (CC): \u201cI guess I\u2019m kind of sick. . . I\u2019ve been coughing a lot\u2019
\nHistory of Present Illness (HPI): The patient Danny Riviera is a boy aged 8, who comes to the clinic reporting that he has had a cough for the past 4 days. His description of the cough states that it is watery and clear. His cough becomes worse at night, which affects his sleep. As such, he does not focus at school
\nNURS 6512 Week 5 Assignment 2 Digital Clinical Experience Focused Exam Cough
\nand suffers from fatigue. His right ear has pain. His mother decided to use over-the-counter cough medicine, which offered temporal relief. Danny states that he suffers from a frequent runny nose as well as a cold and sore throat. He is also exposed to secondhand smoke from his father. He has also suffered pneumonia in the past year. However, he does not have a fever, breathing difficulties, abdominal pain, and chest tightness and chills.
\nMedications: The patient admits to taking home medications. He also takes a daily vitamin. He also takes a purple cough medication.
\nAllergies: NKDA
\nPast Medical History (PMH): Denies asthma diagnosis. Reports immunizations as current. Reports past frequent coughs and pneumonia.
\nPast Surgical History (PSH): None reported.
\nSexual\/Reproductive History: No history of reproductive disorders.
\nPersonal\/Social History: Reports living in a house with his parents and grandparents. Reports feeling safe at home. Reports park with playground near home. Reports father smokes at home. Denies pets at home
\nImmunization History: Immunizations are current.
\nSignificant Family History: He has a father, mother, and both grandparents. Reports father with a history of asthma as a child. Denies family history of allergies.
\nReview of Systems:
\nGeneral: The patient looks fatigued and also coughs whilst having the interview. He also appears stable. Denies fever, appetite loss, weight loss, chills, or night sweats.
\nHEENT: The mucus membrane is moist; nasal discharge is clear, while he shows redness and clobbestoning at the back of his throat. His eyes are dull while the conjunctiva is pink in color. The right tympanic membrane appears red and inflamed. The patient\u2019s right cervical lymph nodes appear enlarged with a certain tenderness.
\nRespiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds are clear to auscultation, speaks in full sentences while the bronchoscopy is negative. His chest wall was resonant when percussed while the fremitus was expected and equal bilaterally.
\nCardiovascular\/Peripheral Vascular: No chest pain, chest tightness, palpitations, edema, cyanosis, dyspnea.
\nPsychiatric: No depression, anxiety, or history of psychotic disorders.
\nNeurological: Report\u2019s headache. Denies dizziness, loss of consciousness, or vision changes.
\nLymphatics: Right cervical lymph nodes are tender on palpation.
\nOBJECTIVE DATA:
\nPhysical Exam:
\nVital signs:<\/p>\n
Blood Pressure
\n120\/76<\/p>\n
O2 Sat
\n96%<\/p>\n
Pulse
\n100<\/p>\n
Resp. Rate
\n28<\/p>\n
Temperature
\n37.2 c<\/p>\n
General: The patient looks fatigued and also coughs whilst having the interview. He also appears stable.
\nHEENT: Head is normocephalic and atraumatic. The mucus membrane is moist; nasal discharge is clear, while he shows redness and clobbestoning at the back of his throat. His eyes are dull while the conjunctiva is pink in color. The right tympanic membrane appears red and inflamed. The patient\u2019s right cervical lymph nodes appear enlarged with a certain tenderness.
\nRespiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds are clear to auscultation, speaks in full sentences while the bronchoscopy is negative. His chest wall was resonant when percussed while the fremitus was expected and equal bilaterally.
\nCardiology: No murmurs, gallops, or rubs in S1 and S2.
\nLymphatics: Right cervical lymph nodes are tender on palpation
\nPsychiatric: No mental issues noted.<\/p>\n
Diagnostics\/Labs: Routine lab works were ordered including complete blood count, and white blood cell count to determine any signs of infection. Spirometric and peak expiratory flow measurements were collected to further evaluate the patient\u2019s extend of cough. Bronchoprovocation testing was done to rule out differential diagnosis. Other investigations are done to assess the cough and cold include upper airway provocation studies, sinus imaging, CT scan of the thorax, and bronchoscopy (Malesker et al., 2017). For further assessment of the ear pain, nasolaryngoscopy and MRI of the head and neck were ordered.
\nASSESSMENT:
\nPriority Diagnosis: Acute Viral Rhinitis: It is also known as common cold. It is associated with inflammation of the nasal mucosa lining as a result of respiratory viral infection. It is common among children, characterized by sneezing, running nose, congestion, cough, postnasal drip, sore throat, watery eyes, ear pain, difficulties in swallowing, and fatigue among others (Malesker et al., 2017). The patient in the case study displayed most of the above symptoms, qualifying for a common cold diagnosis.
\nDifferential Diagnosis:<\/p>\n
Acute sinusitis: This normally occurs when a cold virus infects the patient\u2019s sinuses. The patient may display headache, fever, cough which is worse at night, severely stuffed up nose, green, or thick yellow mucus, itchy and watery eyes, and ear pain. The patient in the case study displayed most of these symptoms (Shoukat et al., 2019). However, he denied fever, and the nasal discharge is clear and thin, which disqualifies the diagnosis.
\nInfluenza (flu): This is a common viral infection of the respiratory tract among children. It is characterized by fever, headache, running nose, fatigue, cough, eye, and ear pain. The patient in the case study displayed most of the above symptoms (Badyda et al., 2020). Consequently, this condition is common among patients with a history of pneumonia, just like in the provided case study.
\nEar Infection: Sinus and cold infections can lead to the accumulation of fluids in the patient\u2019s ears behind the eardrum. As a result, viruses and bacteria can grow leading to infection of the ears. Patients may display ear pressure or fullness, ear pain, drainage, muffled hearing, and loss of balance (Badyda et al., 2020). Given that most ear infections among children might start as a common cold, then the patient\u2019s right ear pain and associated upper respiratory symptoms may be as a result of ear infection.<\/p>\n
Treatment Plan:
\nPrevious Diagnosis: Pneumonia and cough which were managed appropriately.
\nPresent Diagnosis: Acute Viral Rhinitis
\nPharmacological Intervention: Cold remedies such as Dimetapp 10mL every 4 hours to a maximum of 6 doses\/24 hours (Malesker et al., 2017). Acetaminophen to manage the pain and fever. Dexamethasone\/gentamicin drops for ear pain.
\nNon-pharmacological Intervention: Honey and saline nose spray to help with soothing the sore throat and cough, and managing congested nose respectively (Fernandez, & Olympia, 2017). Extra fluid and a cool-mist humidifier are also necessary for helping manage the patients\u2019 cold symptoms.
\nPatient Education: Inform the patient\u2019s mother on the importance of sticking to the treatment plan. It is also important to educate the patient\u2019s parents on expected side effects, and adverse reactions which might call for medical attention (Malesker et al., 2017).
\nHealth Promotion: Encourage the patient\u2019s mother to ensure that he is always warm, with a healthy diet, and enough sleep (Badyda et al., 2020).
\nFollow-up: The patient should be advised to report back to the clinic in case of worsened symptoms, or if the prescribed drugs fail to relieve the patient\u2019s symptoms within one week.
\nReferences
\nBadyda, A., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & D\u0105browska, A. (2020). Upper respiratory symptoms in children (3-12 years old) exposed on different levels of ambient particulate matter. DOI: 10.1183\/13993003.congress-2020.1303
\nFernandez, F. G., & Olympia, R. P. (2017). Ear pain, nasal congestion, and sore throat. URGENT CARE MEDICINE, 77.
\nBadyda, A. J., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & D&# 261; browska, A. (2020). Influence of Particulate Matter on the Occurrence of Upper Respiratory Tract Symptoms in Children Aged 3-12 Years. In D24. LUNG INFECTION (pp. A6346-A6346). American Thoracic Society. DOI:10.1164\/ajrccm-conference.2020.201.1_
\nMalesker, M. A., Callahan-Lyon, P., Ireland, B., Irwin, R. S., Adams, T. M., Altman, K. W., \u2026 & Weir, K. (2017). Pharmacologic and nonpharmacologic treatment for acute cough associated with the common cold: CHEST Expert Panel Report. Chest, 152(5), 1021-1037. https:\/\/doi.org\/10.1016\/j.chest.2017.08.009
\nShoukat, N., Kakar, A., Shah, S. A., & Sadiq, A. (2019). 10. Upper respiratory tract infections in children age 2 to 10 years in Quetta: A prevalence study. Pure and Applied Biology (PAB), 8(2), 1084-1091. http:\/\/dx.doi.org\/10.19045\/bspab.2019.80050
\nAssignment 2: Digital Clinical Experience: Focused Exam: Cough<\/p>\n
In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.<\/p>\n
Photo Credit: Getty Images<\/p>\n
To Prepare<\/p>\n
Review this week\u2019s Learning Resources and consider the insights they provide related to ears, nose, and throat.
\nReview the Shadow Health Resources provided in this week\u2019s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
\nReview the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week\u2019s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
\nAccess and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
\nReview the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
\nConsider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\u2019s condition. How would the results be used to make a diagnosis?<\/p>\n
Focused Exam: Cough Assignment:<\/p>\n
Complete the following in Shadow Health:<\/p>\n
Respiratory Concept Lab (Required)
\nEpisodic\/Focused Note for Focused Exam: Cough
\nHEENT (Recommended but not required)<\/p>\n
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 5 Day 7 deadline.<\/p>\n
Submission and Grading Information
\nBy Day 7 of Week 5<\/p>\n
Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
\nOnce 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.
\n(Note: Please save your lab pass as \u201cLastName_FirstName_AssignmentName\u201d.) You can find instructions for downloading your lab pass here: https:\/\/link.shadowhealth.com\/download-lab-pass
\nOnce 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.
\nComplete the Code of Conduct Acknowledgement.<\/p>\n
Grading Criteria
\nTo access your rubric:
\nWeek 5 Assignment 2 DCE Rubric
\nSubmit Your Assignment by Day 7 of Week 5
\nTo submit your Lab Pass:
\nWeek 5 Lab Pass
\nTo participate in this Assignment:
\nWeek 5 Documentation Notes for Assignment 2
\nTo Submit your Student Acknowledgement:<\/p>\n
Click here and follow the instructions to confirm you have complied with Walden University\u2019s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.<\/p>\n
Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric<\/p>\n
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to Help in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to Help with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to Help in achieving the desired score.<\/p>\n
Grid View
\nList View<\/p>\n
Excellent
\nGood
\nFair
\nPoor<\/p>\n
Student DCE score
\n(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)
\nNote: DCE Score \u2013 Do not round up on the DCE score.<\/p>\n
Points Range: 56 (56%) \u2013 60 (60%)<\/p>\n
DCE score>93<\/p>\n
Points Range: 51 (51%) \u2013 55 (55%)<\/p>\n
DCE Score 86-92<\/p>\n
Points Range: 46 (46%) \u2013 50 (50%)<\/p>\n
DCE Score 80-85<\/p>\n
Points Range: 0 (0%) \u2013 45 (45%)<\/p>\n
DCE Score <79
\nNo DCE completed.<\/p>\n
Subjective Documentation in Provider Notes
\nSubjective narrative documentation in Provider Notes is detailed and organized and includes:
\nChief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
\nROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
\nGeneral: Head: EENT: etc.
\nYou should list these in bullet format and document the systems in order from head to toe.<\/p>\n
Points Range: 0 (0%) \u2013 5 (5%)<\/p>\n
Documentation lacks any details and\/or organization; and does not provide pertinent information noted in professional language.
\nNo information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
\nor
\nNo documentation provided.<\/p>\n
Objective Documentation in Provider Notes \u2013 this is to be completed in Shadow Health
\nPhysical 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 \u201cWNL\u201d or \u201cnormal\u201d.
\nYou only need to examine the systems that are pertinent to the CC, HPI, and History.
\nDiagnostic result \u2013 Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned
\nDifferential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).<\/p>\n
Points Range: 16 (16%) \u2013 20 (20%)<\/p>\n
Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.
\nEach system assessed is clearly documented with measurable details of the exam.<\/p>\n
Points Range: 11 (11%) \u2013 15 (15%)<\/p>\n
Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.
\nEach system assessed is somewhat clearly documented with measurable details of the exam.<\/p>\n
Points Range: 6 (6%) \u2013 10 (10%)<\/p>\n
Documentation with inadequate details and\/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.
\nEach system assessed is minimally or is not clearly documented with measurable details of the exam.<\/p>\n
Points Range: 0 (0%) \u2013 5 (5%)<\/p>\n
Documentation with no details and\/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.
\nNone of the systems are assessed, no documentation of details of the exam.
\nor
\nNo documentation provided.<\/p>\n
Total Points: 100<\/p>\n
Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric<\/p>\n
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to Help in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to Help with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to Help in achieving the desired score.<\/p>\n","protected":false},"excerpt":{"rendered":"
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