NURS 6512 DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: COUGH ASSIGNMENT

NURS 6512 DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: COUGH ASSIGNMENT

NURS 6512 DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: COUGH ASSIGNMENT

DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: COUGH
In Week 2, you will begin your Course Project Part 1: Needs Assessment by researching to determine the need for a specific curriculum that you will design for your chosen setting. You will begin gathering data and other information to inform your curriculum development decisions. You will get started in Week 2, with the Part 1 Assignment due in Week 3. Be sure to plan your time accordingly. Refer to the Course Project Part 1 Planning Guide for your chosen setting in the Week 2 Learning Resources for more guidance.

RESOURCES

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

Click the weekly resources link to access the resources.

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WEEKLY RESOURCES

 LEARNING RESOURCES
Required Readings
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 11, “Head and Neck”
This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.
Chapter 12, “Eyes”
In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.
Chapter 13, “Ears, Nose, and Throat”
The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.
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 15, “Earache”
Download Chapter 15, “Earache”

This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.
Chapter 21, “Hoarseness”
Download Chapter 21, “Hoarseness”

This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.
Chapter 25, “Nasal Symptoms and Sinus Congestion”
Download Chapter 25, “Nasal Symptoms and Sinus Congestion”

In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.
Chapter 30, “Red Eye”
Download Chapter 30, “Red Eye”

The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.
Chapter 32, “Sore Throat”
Download Chapter 32, “Sore Throat”

A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
Chapter 38, “Vision Loss”
Download Chapter 38, “Vision Loss”

This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.
Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.
Document: Episodic/Focused SOAP Note Exemplar

Download Episodic/Focused SOAP Note Exemplar
(Word document)
Document: Episodic/Focused SOAP Note Template

Download Episodic/Focused SOAP Note Template
(Word document)
Document: Midterm Exam Review

Download Midterm Exam Review
(Word document)
Shadow Health Support and Orientation Resources
Shadow Health. (2021). Welcome to your introduction to Shadow Health

Links to an external site.
. https://link.shadowhealth.com/Student-Orientation-Video
Shadow Health. (n.d.). Shadow Health help desk

Links to an external site.
. Retrieved from https://support.shadowhealth.com/hc/en-us
Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students

Links to an external site.
. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
Document: DCE (Shadow Health) Documentation Template

Download DCE (Shadow Health) Documentation Template
for Focused Exam: Cough (Word document)
Use this template to complete your Assignment 2 for this week.
Required Media
Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)

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 10, 11, and 12 that relate to the assessment of the head, neck, eyes, ears, nose, and throat. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.

Geeky Medics. (2020, June 5).Fundoscopy (Ophthalmoscopy)
Links to an external site.
– OSCE guide [Video]. YouTube. https://www.youtube.com/watch?v=SVuP5Td23AQ&feature=youtu.be
Health4TheWorld Academy Videos Channel. (2020, February 15).Paranasal sinus imaging
Links to an external site.
[Video]. YouTube. https://www.youtube.com/watch?v=8TQBtdbEY-I
University of Iowa Ophthalmology. (2016, December 19).Fluorescein staining of the cornea
Links to an external site.
. Retrieved from https://vimeo.com/198695974
Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the cornea [Video file]. Retrieved from ​https://vimeo.com/198695974. The author(s) and publishers acknowledge the University of Iowa and EyeRounds.org for permission to reproduce this copyrighted material.
Note: Approximate length of this media program is 25 seconds.
Optional Resources
Hayashi, T., Kitamura, K., Hashimoto, S., Hotomi, M., Kojima, H., Kudo, F., Maruyama, Y., Sawada, S., Taiji, H., Takahashi, G., Takahashi, H., Uno, Y., & Yano, H. (2020). Clinical practice guidelines for the diagnosis and management of acute otitis media in children—2018 update

Links to an external site.
. Auris Nasus Larynx, 47(4), 493–526. https://doi.org/10.1016/j.anl.2020.05.019
Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for Group A streptococcal pharyngitis: A narrative review

Links to an external site.
. Frontiers in Cellular and Infection Microbiology, 10. https://doi.org/10.3389/fcimb.2020.563627
Patel, G. B., Kern, R. C., Bernstein, J. A., Hae-Sim, P., & Peters, A. T. (2020). Current and future treatments of rhinitis and sinusitis

Links to an external site.
. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 1522–1531. https://doi.org/10.1016/j.jaip.2020.01.031
Links to an external site.
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

Chapter 7, “The Head and Neck”
This chapter describes head and neck examinations that can be made with general clinical resources. Also, the authors detail syndromes of common head and neck conditions.

TO PREPARE
Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough 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 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
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?
FOCUSED EXAM: COUGH ASSIGNMENT:
Complete the following in Shadow Health:

Respiratory Concept Lab (Required)
Episodic/Focused Note for Focused Exam: Cough
HEENT (Recommended but not required)
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.

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 WK4Assgn2+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.
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.

By submitting this assignment, you confirm that 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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Rubric

NURS_6512_Week_5_DCE_Assignment_2_Rubric

NURS_6512_Week_5_DCE_Assignment_2_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

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