NRS 420 Shadow Health Comprehensive Assessment

NRS 420 Shadow Health Comprehensive Assessment

In this GCU you will conduct a full health assessment on a patient in a single clinic visit. Within the Shadow Health platform, you will have one opportunity to complete the Comprehensive Exam. On average, this assignment should take 180 minutes to complete. Students may need additional time. Upon completion, submit the lab pass through the assignment dropbox.

Please review the “Shadow Health Comprehensive Assessment Documentation” assignment before you begin to ensure you understand the documentation expectations within Shadow Health for this assignment.

After completing this Comprehensive Assessment, you will be awarded a Digital Clinical Experience (DCE) score. The DCE score will appear on your Lab Pass which you will submit to the classroom drop box. The DCE score will be used as your percentage grade for this assignment.

You are not required to submit this assignment to LopesWrite.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 2.2, 2.3, 2.7.

Shadow Health: Comprehensive Assessment Documentation

The purpose of this assignment is to communicate the findings of a comprehensive health assessment through the effective use of electronic communication tools. When completing the Shadow Health Comprehensive GCU, you will need to ensure that you are documenting vital signs and nursing notes within Shadow Health.

Your work will be assessed in Shadow Health to award points based on your documentation.

No additional submission is needed.

Please review the assignment rubric prior to starting the Shadow Health Comprehensive Assessment.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 2.3, 8.1, 8.2, 8.4.

NR 509 Tina Jones Comprehensive Health Assessment

Documentation / Electronic Health Record

Vitals

Student Documentation	Model Documentation
BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height 5’6″ BMI 29 BS 100	• 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 Ms. Jones is a pleasant 28 year old African American female who presents to the clinic today for a physical for employment. Pt’s responses are appropriate, maintains eye contact throughout exam.	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 Pt in no apparent distress, alert and oriented x 4, calm and cooperative, appropriately dressed wtih good hygiene.	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 Pt states she needs an employment physical for a new job she will be beginning in two weeks.	“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 Pt presents to the clininc for an employment physical that she will begin in two weeks. Pt denies any medical issues or concerns. Since last visit pt has had her annual PAP smear resulting diagnosis of PCOS with treatment using birth control, had her annual eye exam resulting in prescription glasses, pt states her diabetes is now controlled with medication and exercise. Pt. states she is eating healthier and has reduced her soda intake. Pt’s perception of health and self is good.	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 Flovent 110mcg 2 puffs BID Albuterol 90mcg 2 puffs PRN Metformin 850mg PO BID Advil OTC regular strength PRN for cramps Yaz PO QD birth control	• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)
Allergies PCN- skin rash Cats- exacerbates asthma Dust-exacerbates asthma, itchy	• 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 Asthma- diagnosed at 2 years old, uses daily and rescue inhaler, last exacerbation 3 months ago Diabetes- diagnosed at 24 years old, currently takes Metformin with gasiness upon inital use wtih no current side effects, pt taking BS QD, readings on average 90. HTN- controlled with diet and exercise Polycysic Ovarian Syndrome- diagnosed approximately 4 months ago, controlled with birth control, menstrual cycles normal and regular.	Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, 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 Since last encounter at teh clinic pt has had an OBGYN exam approximately 4 months ago, pt had had an eye exam approximately 3 months ago. Pt states she is now exercising regularly, has been eating healthier, and has cut back on her caffiene and soda intake.	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 not 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 Mother 50- high cholesterol and HTN Father- deceased at 58, high cholesterol, diabetes, and HTN Maternal grandmother- deeased at 73 from stroke, had HTN and high cholesterol Maternal grandfather- deceased at 80 from heart attack, had HTN and cholesterol Paternal grandmother 82- high cholesterol, HTN Paternal grandfather- deceased from colon cancer mid sixties, had high cholesterol, diabetes, and HTN Sister 15- Asthma Brother 26- obese Paternal uncle- alcholism Denies any other family medical history.	• 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 Pt just graduated college with an accounting degree, never married, no children, pt in a relationship with a male, pt denies smoking or drug use, occasional alcohol with friends. Pt likes to read, currently lives at home with her mother and sister but has plans to move out next month.	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 Pt denies any mental health history. Pt states stress has decerased and she is feeling better these days. Pt does report some issues sleeping and some depression after her father passed.	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 General: no weakness, fatigue or fevers. Positive weight loss of 10 pounds. Skin: no rashes, lesions, dry skin, ithcing or clor changes, no dandruff, or changes in nails. HEENT: No headaches, eye pain, dizziness or blurry vision. No ear pain or drainage. No mouth or teeth pain. No sinus pressure, sneezing, runny nose, change in smell. Pt does wear prescription glasses. Cardiac: No chest pain, palpitaitons, or edema. Pt has history of HTN, now controlled. Respiratory: No SOB, difficulty breathing, or wheezing. Pt has a diagnosis of asthma. GI: No diarhhrea, constipation, vomiting or nausea. No abdominal pain. GU: No issues with urination. Neuro: No dizziness, motor issues, lack of coordination, numbness or tingling sensations. Musculoskeletal: No muscle pain or joint inflammation. No recent injuries or deformities, no difficulty or pain with movement. Psych: No anxiety, depression or stress.	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 Denies headaches, eye pain or issues, no sinus pressure, sneezing or runny nose. No mouth or tooth pain, no difficulty swallowing. No ear pain or discharge. No dandruff or scalp lesions. Pt does have prescriptive glasses.	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 No obvious injuries or bruising. Head is normocephalic. Eyes, ears and nose symmetrical with no edema. Even hair distribution on the head and eyelashes. Eyes show no ptosis. PERRLA, fundus and disc margins clear bilaterally. Snellen 20/20 right eye, 20/20 left eye with corrective lenses. Extraocular movement intact, normal convergence. No TMJ noted, no redness to throat, no goiters, or lymphadenopathy, thyroid smooth. Sinus non-tender to palpation. Whisper test negative, tympanic membrane pearlly gray and intact. Mouth moist, no sores or thrush, tonsils 2+ bilaterally, uvula midline, tongue symmetric, gag reflex intact. Nasal cavities moist and pink.	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 Pt denies shortness of breath, difficult breathing, wheezing or cough. Pt has history of asthma. Denies sinus pressure or rhinnorhea.	Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.
Objective Peak flow x3: FVC 3.91, FEV 3.15= FEV1/FVC ratio of 80.5% Pt in no obvious distress, breathing unlabored, chest symmetrical, rise and fall of chest even. Breath sounds clear and equal bilaterally in all fields. Tympanic resonance to percussion anterior and posterior chest with no dullness. Fremitus normal.	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 Pt denies chest pain, palpitaitons, or edema. No history of anemia or easy bruising.	Reports no palpitations, tachycardia, easy bruising, or edema.
Objective S1, S2 heard with normal rate and rythm, no murmurs or gallops noted on auscultation. Pulses present in all extremeties 2+, no thrills. No edema in extremities, PMI MCL 5th intercostal space. Carotid pulsespresent with no bruit. Capillary refill <3 sec in all extremities. No abdominal, iliac, renal or femoral bruits. No JVD.	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, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

Abdominal

Student Documentation	Model Documentation
Subjective Pt denies any nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort. Reports eating healthier but no change in appetite. No difficulty urinating or excessive urinating. Denies bowel or bladder dysfunction.	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 no visible brusing or lesions, protuberant, and excessive hair around umbilicus. Bowels sounds normoactive in all quadrants. No tenderness, guarding, no masses on deep and light palpation. Tympanic on percussion and no CVA tenderness. Organs non-palpable with no masses, liver span palpable at 1 cm below RCM and 7 cm MCL. No bruit in abdominal aorta, renal arteries or iliac arteries. Spleen no dullness.	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 Pt denies no joint or muscle pain, no weakness or edema.	Reports no muscle pain, joint pain, muscle weakness, or swelling.
Objective No obvious injuries or deformities. No edema or lacerations. Full ROM in neck, shoulders, arms, wrists, ankles, hips, spin, knees. Strenght 5+ bilaterally all extremities.	Strength 5/5 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 Pt denies any numbness or tingling sensations, denies issues with coordination and gait. No dizziness, history of seizures. Pt denies any history of head injuries. Pt denies any loss of sensation.	Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.
Objective Graphesthesia, stereognosis intact. Pt alert and oriented x 4. Memory intact, position sense normal in extremeties. DTR’s 2+ in all extremeties, purposeful rapid alternating movements, normal cerebellar functioning. Decrease in sensation with monofilament on bilateral plantar surfaces. Sensation intact Appearance and behavior appropriate, follow commands and engages in activities. Point to point movement smooth and accurate for finger to nose and heel to shin. Gag reflex present.	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 Pt denies rashes, bruising, or lesions. States darkness around neck is diminishing since birth control and metformin. Denies dandruff or hair loss. Denies changes in nail beds or brittle nails.	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 No obvious injuries, lacerations, rashes, dandruff, or bruising. Pt’s hair well groomed with even hair distribution. No nail deformities noted in all extremities, clear with no ridges. Excessive hair growth on umbilicus, thin hair growth on upper lip.	Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails fre

This marks the end of this class. Your next class in this program is NRS-425 Health Promotion and Population Health. See you then.