NRS 434 Shadow Health: Comprehensive Assessment

NRS Week 4: Comprehensive Assessment Tina Jones

NRS 434 Shadow Health: Comprehensive Assessment

Complete the Comprehensive Assessment on the platform. This homework should take 3 hours on average each time to finish. Please be aware that this is a typical time. Some pupils might require more time.

This clinical encounter serves as a thorough examination. The Shadow Health Digital Clinical Experience requires students to get a “Proficiency” score. There are three chances for students to finish this assignment and receive a Proficiency level grade. Once finished, drop the lab pass into the assignment dropbox.

Students who successfully complete the at the Proficiency level on their first attempt will receive a grade of 150 points; students who complete the Digital Clinical Experience at the Proficiency level on their second attempt will receive a grade of 135 points; and students who complete the Digital Clinical Experience at the Proficiency level on their third attempt will receive a grade of 120 points. If students do not pass the performance-based assessment after three attempts by scoring at the proficiency level, they will receive a failing grade (102 points).

If Proficiency is not achieved on the first attempt, it is recommended that you review your responses with the correct answers on the Experience Overview page. Click on each of the tabs to the left labeled Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work with the report. You could improve your grade by reviewing this summary and the course materials.

Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to Lopes Write.

If Proficiency is not achieved on the first attempt it is recommended that you review your answers with the correct answers on the Experience Overview page. Review the report by clicking on each tab to the left titled; Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Reviewing this overview and course resources may help you improve your score.

Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to LopesWrite.

Also Read:

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Describe the characteristics of the aging process. Explain how some of the characteristics may lead to elder abuse (memory issues, vulnerability, etc.). Discuss the types of consideration a nurse must be mindful of while performing a health assessment on a geriatric patient as compared to a middle-aged adult.

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Replies to Thomas Leen

Aging is an inevitable process in our lifecycle. Older adults are looked to for guidance and wisdom from those younger and far less wise than they are. When the mind or body starts to deteriorate younger generations tend to seek that guidance less and less. Some individuals tend to take in his or her parents when they get to the point where the body or mind start to diminish. After a time, these family members that take in the older aging adult can begin feeling the frustration of caring for someone else and not having them be the same person the family member remembers from younger years. Some examples of this frustration can be expressed through negative outlets such as verbal abuse, physical trauma inflicted, or lack of attention needed for daily living (bathing, eating, toileting, moving).

The population of older adults 65+ has steadily increased over recent years. According to Federal Interagency Forum on Aging-Related Statistics, “The prediction is that older adults comprise 21% of the population by 2030” (2016). The aging process will likely bring about other chronic health conditions in that time. According to Green, “frailty includes the presence of biomedical factors that reduce the older adult’s ability to endure environmental stressors, such as hospitalization” (2018). Alarming numbers are reported by The World Health Organization in regards to elder-abuse or neglect; an estimated 1 out of 6 older adults fall victim. This is saddening because often times the abuser/ person neglecting is a close family member caring for the older adult. Memory loss and decrease physical abilities (different from findings of middle age adults) are a few reasons these older adults fall victim to the hands of caregivers, but identification of the fear and injuries is vital to ensure a safe and caring environment.

Nurses must utilize thorough assessment skills in order to identify signs and symptoms of elder abuse. Scattered bruising around the body that appear different colors. This indicates that the bruises are from different time periods. Elder abuse can also come in the form of malnourishment, pressure injuries, or the far less visible emotional/ verbal abuse. Though emotional and verbal abuse are less noticeable, asking many questions and just listening to the patient will que in certain details that nurses can likely pick up on to further evaluate the safety of his or her environment. Understanding that the older adult will likely not address any mistreatment. Patients and family members alike trust nurses and the care they provide; using that relationship and asking more personal detailed questions about findings is important to keep the patient(s) safe.

References:

Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans 2016: Key Indicators of

Well-Being. Retrieved from 

Key-Indicators-of-WellBeing.pdf

Green, S. Z. (2018). Health assessment of the aging adult. In Grand Canyon University (Eds.), Health

assessment: Foundations for effective practice. 

assessment-foundations-for-effective-practice/v1.1/#/chapter/5

World Health Organization. (2018). Elder abuse. Retrieved from 

room/fact-sheets/detail/elder-abuse

  • MG

Documentation / Electronic Health Record

Vitals

Student Documentation Model Documentation

Vitals

Heght 170m cm, weight: 84 BMI: 29.0 blood:NA, Glucose: 90. RR: 15, HR: 78, BP: 128/82, Pulse Ox: 99%, Temperature: 99.0 F

• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F

Health History

Student Documentation Model Documentation

Identifying Data & Reliability

The patient is a 28-year old singkle African-American woman who comes to the clinic for physical assessment. She gives the information and is cooperative. Her speech is clear and she maintains eye contact during the process.

Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

The patient is alerrt and oriented. He sitting position is upright. She is of good health and appropriately hygienic.

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.

Reason for Visit

“I need to have a health insurance for my new job”

“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”

History of Present Illness

The patient states that she is newly employed at her company. She lacks any concern that may be described as acute. She last underwnt a gynecological exam at the SHGC 120 days ago. Tina was diagnosed with POCS and prescribe well tolerated medications. The patoent suffers from type 2 diabetes that she has been controlijng using metforming, diet and exercise. The drugs do not produce any side effects.

Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.

Medications

Metformin 850 mg po BID Drospitenone and ethinyl estradiol PO QD Albuterol spray that she puffs twice and last use occured 3 months ago. Acetaminophen 500-1000 mg PO prn for headaches. Ibuprofen for menstrual cramps ans last taken 6 weeks ago.

• Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yesterday) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)

Allergies

Allergic to penicillin, cats and dust. She is not allergic to food and latex.

• Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

Medical History

The patient was diagnsoed with asthma at 2 and a half years old. Last asthma exacerbation occured 3 months ago. Never been intubated. Suffers from tyoe 2 diabetes. Uses metforming to manage the condition. Average blood sugar is 90 and the patient monitors it daily. She also uses exercise and diet to manage her sugars. Negative for any history of surgery. OB/GYN: She developed menarche at the age of 11. She has sex with men. She has never been pregnant whilst she had her first sex at the age of 18. Has a new boyfriend.

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she experiences exacerbations, such as around dust or cats. Her last asthma exacerbation was yesterday, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.

Health Maintenance

The patient attends to the doctor’s appointment. Had a pap smear 4 months ago. Had an eye exam 3 months ago. The dental exam was last conducted 150 days ago. She is negative for PPD that was done two years ago. Her immunization status is current bar tetanus and HPV vaccines. Childhood vaccines are up to date ad as well as meningococcal vaccine. Safety: Has smoke detectors in the home. wears safety belts in the car. Does not ride the bike. Uses sunscreen in the sun. she has locked her father’s gun in their bedroom.

Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.

Family History

High blood pressure in all the grandparents from both parents. Both parents and maternal grandparents have high cholesterol. Stroke killed maternal grandparents. Paternal grandmother is alive and 82 years of age whilst fgrandfather died of cancer at 65. The latter also had a history of type 2 diabetes alongside the patient’s father who died in an accident. Has an overweight brother and an asthmatic sister. Alcoholism in paternal uncle whilst no other diseases exist in the family as well as her.

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

The patient does not have children and they were never married. Lives with the mother alongside sister in a single apartment but planning to move to her own once she starts work. She enjoys reading, attending Bible studies, dancing and attending church functions. Has a string social support system including the church and her family. Doesn’t do tobacco whilst she used cannabis from ages 15-21. Does not abuse any other drugs. Uses alcohol in the company of friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch to supper. Does not take coffee yet takes diet coke. Has not travelled outside recently and does not keep pets. Does mild exercise at least four times per week.

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.

Mental Health History

Has enhanced coping mechanism to stress. Does not suffer depression, anxiety, or suicidal thoughts. She is alert to all faculties. She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear.

Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear.

Review of Systems – General

(No Documentation Made)

No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase.

HEENT

Student Documentation Model Documentation

Subjective

Does not report current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visitto the optometrist was 3 months ago. Reports no problems in the heart, change of hearing, ear pain, or discharge. Report no change in sense of smell, sneezing, epistaxis, sinus pain, or pressure. or rhinorrhea. Reports no general mouth issues. Dental concerns nonexistent. Swallowing, is okay, no sore throat, voice changes or swollen nodes.

Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.

Objective

Normocephalic head, and atraumatic as well. Bilateral eyes with equal hair distribution on lashes and eye brows, lids without lesions. No ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMS intact and pearly gray bilaterally, positive light reflex. Whispered wors bilaterally head. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions. Uvula rises midline on phonation. Gag reflex is intact, Dentation minus evidence of carries or infection. Tonsils 2+bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.

Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Respiratory

Student Documentation Model Documentation

Subjective

Reports normal breath, lack of wheezing, chest pain, dyspnea and cough.

Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.

Objective

Chest is symmetric. The lung sounds are clear whilst voice occurs in all areas. Percussion produced resonance throughout. In office spirometry: FVC 3.91, FEV1/FVC ratio 80.56%

Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Cardiovascular

Student Documentation Model Documentation

Subjective

Reports no palpations, tachycardia, easy bruising or edema.

Reports no palpitations, tachycardia, easy bruising, or edema.

Objective

Hear rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral crotides equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts or thrills. Bilateral peripheral pulses equal bilaterally, capillary refills less than 3 seconds. No peripheral edema.

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

Abdominal

Student Documentation Model Documentation

Subjective

Reports no nausea, vomiting, pain constipation, excessive flatulence or diarrhea. Does not have food intolerance. Genitourinary: Does not have dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.

Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.

Objective

Abdomen is protuberant, symmetric without visible masses, scars, or lesions, coarse hair from pubis to ambilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegally. No CVA tenderness.

Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Musculoskeletal

Student Documentation Model Documentation

Subjective

Does not have muscle and joint pains whilst muscle weaknesses and swelling don’t exist.

Reports no muscle pain, joint pain, muscle weakness, or swelling.

Objective

Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.

Bilateral upper and lower extremities without swelling, masses, or deformity and with full range of motion. No pain with movement.

Neurological

Student Documentation Model Documentation

Subjective

Does not have dizziness, tingling, light-headedness, seizures, loss of coordination or sensation, sense of disequilibrium.

Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

Objective

Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Cerebella function tests produced normal results. DTRs 2+ and equal bilaterally in upper and lower exremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin, Hair & Nails

Student Documentation Model Documentation

Subjective

Reports that the oral contraceptives have led to improved acne. Skin has stopped darkening at the neck region and facial and body hair has improved. She reports few moles but no other hair or nail changes.

Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.

Objective

Pustules on the face are scattered whilst the upper lip ha facial hair. The posterior neck has acanthosis nigricans. Nails are free of ridges or abnormalities.

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.

 

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