This article covers NR 509 Week 6: Shadow Health Mental Health Physical Assessment Assignment
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NR 509 Week 6: Shadow Health Pediatric Physical Assessment Assignment
Pre Brief
Daniel “Danny” Rivera is an 8-year-old boy who is brought to the clinic by a family member for a cough. It is important for you to determine whether or not Danny is in distress, explore the underlying cause of his cough, and look for related symptoms in other body systems. Ask about a variety of psychosocial factors related to home life, such as second-hand smoke exposure. Be sure to observe non-verbal cues as Danny presents with intermittent coughing and visible breathing difficulty. This case study will challenge you to differentiate his presenting symptoms and carefully listen as you auscultate his lungs. You will have the opportunity to also physically examine his eyes, ears, nose, and throat and document your findings using appropriate professional medical terminology. Apply the supportive informative learned in the respiratory concept lab to your critical thinking process in this case study.
Welcome to Health Assessment
Hello class: my name is, and I will be the instructor for this class. For more information on how to get a hold of me, please go under my profile for specific information. However, my email is: ***The best way to contact me though, is through the Private forum***
This course will focus on methods of health history taking, physical examination skills, documentation, and health screening. The course emphasizes the individual as the client, functional health patterns, community resources, and the teaching learning process. This course will take us through infancy to an older adult.
To find course material, go under your Dashboard, then you will see PATH. There are two links to find information regarding this course; course material and syllabus.
- The course material tab shows what textbook is used for this class.
- The syllabus will show what this course is, the assignments for the course, the topics of the course, the grading system, and how to refer to the student policy handbook. **there has been some problems downloading the syllabus, thus the PATH is also the syllabus…but 1 week and topic at a time.
Under your Assignments, will have the due date and the rubric posted to look at.
Under the Planner tab, assignments are listed along with the due dates. Clicking the collaborative reminder within the calendar tab will show the assignment, any information that is needed for the assignment, and give the rubric of how the assignment will be graded.
Please refer to all other announcements for Class Policies and Week 1 class.
Feel free to contact me anytime. I look forward to this 5 week journey with each of you
Reason for visit: Patient presents complaining of coughing.
Students will have until Sunday at 11:59pm MT on Week 7 to complete this assignment.
NR 509 Week 6: Shadow Health Pediatric Physical Assessment Assignment Rubric
Shadow Health Physical Assessment Rubric
| NR 509 Week 6: Shadow Health Pediatric Physical Assessment Assignment Criteria | NR 509 Week 6: Shadow Health Pediatric Physical Assessment Assignment Ratings | Pts |
|---|---|---|
| This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript) | 25.0 ptsAbove Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.21.0 ptsAverage- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.10.0 ptsBelow Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.0.0 ptsUnsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing. | 25.0 pts |
| This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation | 20.0 ptsAbove Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.16.0 ptsAverage- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).8.0 ptsBelow Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).0.0 ptsUnsatisfactory- No physical assessment documentation or no treatment plan. | 20.0 pts |
| This criterion is linked to a Learning OutcomeSelf-Reflection | 5.0 ptsAbove Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.3.0 ptsAverage- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.2.0 ptsBelow Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight0.0 ptsUnsatisfactory- No reflection posts for the assignment. | 5.0 pts |
| Total Points: 50.0 |
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NR 509 Week 6: Shadow Health Mental Health Physical Assessment Assignment
Pre Brief
Tina’s recent sleep disturbance has lasted a month. She states that her sleep is “shallow and not restful”. She complains of difficulty falling asleep at least 5 nights per week, but states that she is able to stay asleep without difficulty. On average she sleeps 4 or 5 hours per night and awakens at 8:00 AM daily. She does not take any prescription or over the counter sleep aids. This case study is an opportunity for you to ask probing interview questions and take a thorough history of the presenting complaint. Be sure to compile a list of positive and negative findings during the patient interview to support each potential differential diagnosis.
Reason for visit: Patient presents complaining of sleep problems and feelings of anxiety.
Students will have until Sunday at 11:59pm MT on Week 7 to complete this assignment.
Rubric
Shadow Health Physical Assessment Rubric
| Criteria | Ratings | Pts |
|---|---|---|
| This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript) | 25.0 ptsAbove Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.21.0 ptsAverage- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.10.0 ptsBelow Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.0.0 ptsUnsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing. | 25.0 pts |
| This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation | 20.0 ptsAbove Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.16.0 ptsAverage- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).8.0 ptsBelow Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).0.0 ptsUnsatisfactory- No physical assessment documentation or no treatment plan. | 20.0 pts |
| This criterion is linked to a Learning OutcomeSelf-Reflection | 5.0 ptsAbove Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.3.0 ptsAverage- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.2.0 ptsBelow Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight0.0 ptsUnsatisfactory- No reflection posts for the assignment. | 5.0 pts |
| Total Points: 50.0 |
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Week 6: Immersion
NR509 Immersion Student Equipment (Links to an external site.)Links to an external site.
NR509 Immersion Exam (Links to an external site.)Links to an external site.
NR509 Skin Rash Station Worksheet and Handout (Links to an external site.)Links to an external site.
| NR 509 Physical Examination Grading RubricA head to toe (cephalo-caudal), and anterior-posterior approach should be used when conducting the exam. Students should verbalize each exam step and also identify cranial nerves by name. *Exam should be completed in 30 minutes or less.*No deductions given for exam steps out of order. |
| Introduce yourself to the patient. Have patient sit up |
| HEAD AND FACE |
| Inspects facial skin – note abnormal lesions |
| Inspect head for size, symmetry, midline position |
| Palpates lymph nodes of the head and neck:preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, supraclavicular (verbalize these) |
| CN 5 (Trigeminal)Motor – palpate over the masseter muscle as patient clenches jawSensory – light touch sensation to forehead, cheeks, chin, nose (patient closes eyes and identifies where they are being touched) |
| CN 7 (Facial)Inspect for facial symmetry with smile, frown, raise eyebrows, puff cheeks, pucker lips |
| EAR |
| Inspect outer ear for shape and position |
| Inspect auditory canal and TM (using otoscope) |
| Palpate pinnae and tragus for masses and tenderness |
| CN 8 (Acoustic)Whisper Test (whisper words out of patient’s sight, and patient repeats words back) Test one ear at a time. |
| EYE |
| Inspects sclera and conjunctiva |
| CN 2 (Optic)Assess gross visual acuity and peripheral/central vision |
| CN 2 (Optic)Check pupillary response to light [PERRL] |
| CN 3, 4, 6 (Oculomotor, Trochlear, Abducens)Test for conjugate gaze with EOM |
| NOSE |
| Inspect nose midline and straight |
| Assess nasal turbinates and septum (using light source) |
| Palpates frontal and maxillary sinuses |
| THROAT AND MOUTH |
| Inspect lips, teeth, gums, buccal mucosa, palate, tongue, the floor of the mouth (under the tongue), posterior pharynx, and tonsils (grade tonsils, if present) |
| CN 9 and 10 (Glossopharyngeal, Vagus)Say “Ahh” and soft palate and uvula rise symmetrically with phonation (CN 10)* Gag reflex not tested for this exam (CN 9) |
| CN 12 (Hypoglossal)Stick out tongue and move it left to right |
| Palpate TMJ for any subluxation, tenderness, or crepitus |
| NECK |
| Inspect for obvious deformities and symmetry |
| Palpates trachea – midline |
| Palpates thyroid gland |
| Palpates carotid artery pulsation |
| Auscultate over the carotid for bruits |
| Test ROM – flexion, extension, lateral flexion,rotation |
| CN 11 (Spinal Accessory)Shrug shoulders against resistance |
| HEART |
| Auscultate in all 5 areas with the bell and diaphragm with the patient sitting (if stethoscope does not have a bell then verbalize you would use the bell)Verbalize Areas:AorticPulmonicErb’s pointTricuspidMitral |
| ANTERIOR CHEST |
| Inspect for obvious deformities and symmetry |
| Auscultate lung sounds in anterior lung fields |
| POSTERIOR CHEST (BACK) |
| Auscultate posterior lung fields: Start above scapula alternating side-to-side in intercostal spaces. Go down into bases of lungs.Assess lateral lung fields (get right middle lobe) |
| UPPER EXTREMITIES |
| Inspect the joints of the hands – redness, swelling,deformities |
| Palpate for capillary refill |
| Assess radial pulses |
| Assess hand grips – 5/5 strength |
| Assess ROM of the elbows (flexion, extension) |
| Assess strength of biceps, triceps – flex/extend elbow againstresistance – 5/5 strength |
| Assess ROM of the shoulders (flexion, extension, internal rotation, external rotation, abduction, adduction) |
| Assess cerebellar coordination with rapid alternating movement:Serial finger opposition, hand flip-flop |
| Assess DTRs:Biceps, patellar, achilles |
| Have patient lie down |
| ABDOMEN |
| Inspect abdominal contours and symmetry |
| Auscultate for bowel sounds in all 4 quadrants |
| Auscultate for bruits (verbalize) – aorta, renal arteries, iliac arteries |
| Percuss in all 4 quadrants for tympany, dullness, flatness |
| Palpate in all 4 quadrants for tenderness and masses |
| Palpate liver and spleen (verbalize) |
| Perform Blumberg’s sign (verbalize) |
| LOWER EXTREMITIES |
| Inspect the skin integrity of lower extremities and assess for edema. |
| Assess ROM of hips (flexion, abduction, adduction, internal rotation, external rotation) *extension not tested for this exam |
| Assess ROM of the knees (flexion, extension) |
| Assess strength at the knees – flex/extend against resistance – 5/5 strength |
| Assess ROM of the ankles (dorsiflexion, plantar flexion, rotation) |
| Assess strength at ankles – dorsi/plantar flex against resistance – 5/5 strength |
| Assess dorsalis pedis pulse |
| Have patient stand up |
| Inspect and palpate the spine – expected curvatures, alignment, tenderness |
| Assess ROM of the spine (flexion, extension, lateral flexion, and rotation) |
| Assess Romberg |
| Assess gait (just several steps) |
