Advanced Health Assessment NURS 6830 Spring 2021.docx

Advanced Health Assessment NURS 6830 Spring 2021
Advanced Health Assessment NURS 6830 Spring 2021Advanced Health Assessment NURS
6830 Spring 2021Advanced Health Assessment – Spring 2021, NURS 6830
01 ContentsHealth
History……………………………………………………………………………………………………………….. . – 4 –
Example SOAP note Documentation
…………………………………………………………………………………………………… – 6 –Self-Reflection
…………………………………………………………………………………………………………………………………. – 8
–HEENT
…………………………………………………………………………………………………………………………………………
..- 10 –Respiratory
……………………………………………………………………………………………………………………………………..-
11 –
Cardiovascular …………………………………………………………………………………………………………………
……………..- 12 –
Abdominal ………………………………………………………………………………………………………………………
………………- 13 –Musculoskeletal
……………………………………………………………………………………………………………………………….- 14 –
Neurological ……………………………………………………………………………………………………………………
………………- 15 –Mental Health
………………………………………………………………………………………………………………………………….- 16
–Focused Exam: Cough
……………………………………………………………………………………………………………………..- 17 –
Focused Exam: Chest Pain
……………………………………………………………………………………………………………….- 18 –Focused
Exam: Abdominal Pain
…………………………………………………………………………………………………………- 19 –
Comprehensive Assessment
……………………………………………………………………………………………………………..- 20 – Advanced
Health Assessment Welcome!Shadow Health® understands that you want to learn your
core nursing competencies in the most engaging and effective way possible. The Shadow
Health Digital Clinical Experience (DCE) provides you with a dynamic, immersive
experience designed to enrich classroom instruction through the clinical examination of our
Digital Standardized Patients.™ We are committed to providing you with an innovative,

intuitive virtual clinical experience that offers comprehensive participation in a safe
learning environment. Advanced Health Assessment NURS 6830 Spring 2021 Health
HistoryAs healthcare professionals, the health history helps us compile important
information to better care for our patients. You should conduct a thorough patient
interview to collect all the necessary information to treat your patient. Instructions: In the
Health History assignment, you will interview your first Digital Standardized Patient, Tina
Jones, document her comprehensive health history, and complete post-exam activities.
Students spend, on average, two and a half hours on this assignment. Your goal in this
assignment is to conduct a health history that is appropriate for Tina Jones. You will use the
details of the patient case and data you gather to make decisions about which questions and
follow-up opportunities are necessary.Although Ms. Jones can answer over 100,000
questions, you should only need to ask a fraction of these to obtain a complete health
history. You will be evaluated on your ability to use the patient’s context to construct a
health interview that is thorough and relevant for Ms. Jones.Ask questions about each
relevant topic of a patient interview to collect patient dataListen to the patient’s responses
for cues that promptFollow-up questionsEmpathyPatient educationDocument patient data
in the EHRPlan your time: First Turn In Allow Reopening Flexible Turn In~150
minutes ~190 minutes ~260 minutes Getting Started: View this tutorial for
guidance on getting started with the Health History Assignment. Tips for Success:
Unlike the Conversation Concept Lab, there are no prompts during your interview, so you
should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook
and/or reference materials to remind yourself of what taking a health history entails. There
are essential sections of patient information that your interview will need to uncover. As
you learned in the Conversation Concept Lab, there are multiple essential questions for each
of these topics: Chief ComplaintHistory of Present Illness – 4 –AHAV.2 Advanced Health
Assessment Medical
HistoryMedicationAllergiesImmunizationsDiabetesAsthmaHypertensionGynecological and
Sexual History Social HistoryDaily LifeDiet and NutritionSubstance Use Review of Systems
Family History3 GenerationsInherited Risk Factors Know all of your qualifying questions
for any symptom that may be
reported: OnsetLocationDurationCharacteristicsAggravating/alleviating factorsRelated
symptomsTreatments tried – 5 –AHAV.2 Advanced Health Assessment Example
SOAP note DocumentationSubjective: The “s”, or subjective data portion of your SOAP note
should include your chief complaint, HPI, and any relevant medical, family, or history
pertaining to the patient’s chief complaint as well as a focused review of systems. This is the
information that the patient reports directly to you.The patient is a 70 year old female
complaining of abdominal pain and indigestion. The S dull, constant pain is located in the
upper right quadrant of her abdomen. It started four days ago and is occasionally also in her
right shoulder blade. Nausea accompanies thepain. Eating worsens the pain, making her
feel excess gas and bloating. Rolaids normally lessens the pain, but did not improve her pain
in the last incident. One a scale of 10, she rates the pain as an 8.PMH – no significant
PMHFamily Hx – Her brother had his gallbladder removed 2 years ago. Mother died of
alzheimer’s, father of heart attack.Social Hx – Married, currently retired after raising her

family and working as a homemaker her whole life. She walks 3 times a week for 30
minutes. Rarely drinks and doesn’t smoke. ROS – General decrease in appetite. Fear of
eating. Skin rash on feet.Objective: The “o” or objective data portion of your SOAP note
should include your vital signs, clinical exam, and any blood work or radiology exams that
have been done recently. In this portion you want to give a clear clinical picture of what is
going on with the patient. This portion of a S.O.A.P note consists of what you, the clinician
can observes. It can be measurable.Vital Signs – BP 125/85, P 70 bpm, R 16 breaths, T 99.1
F̊O The patient is friendly and well groomed. She is not in any obvious distress.HEENT –
pupils round reactive to light. No scleroicteris. MoistMucous membranes. No
lymphadenopathy, no thyromegaly, bruits, neck supple.Respiratory – Lungs clear on
auscultation. Resonant to percussion.Cardiac – regular rate and rhythm. No murmurs or
gallopsAbdominal – No surgical scars, no distention. Normal active bowel sounds in all four
quadrants. No bruits heard in abdominal aorta, renal arteries, or iliac arteries. Discomfort
was felt on light and deep palpation of the right upper quadrant. Liver and spleen are not
enlarged. She had no rebound tenderness or guarding.Breast and pelvic exams done by
previous primary care physician. Extremities/musculoskeletal – 2+ radial and dorsalis
pulses no clubbing or cyanosis or edema. Full range of motion in her shoulders, elbows,
hands, hips, knees and ankles without pain tenderness or swelling. No scapular
tenderness.Neuro – Cranial Nerves 2 – 12 intact. Strength 5/5 bilateral upper and lower
extremities. Deep tendon reflexes 2+ throughout. Romberg normal, gait normal. Advanced
Health Assessment NURS 6830 Spring 2021 – 6 –AHAV.2 Advanced Health Assessment
Assessment: In the “a”, or assessment portion, you are going to synthesize the
subjective and objective data into a list of prioritized differential diagnosis. The likely
diagnosis should be included in this section of the note. The assessment may also include
information on various diagnostic tests that may be ordered, such as x-rays, blood work and
referrals to other specialist. A 1. abdominal pain – presentation suggestive of gallstone
disease. Less likely possibilities include hepatitis, gastritis, peptic ulcer disease, and atypical
ischemic heart disease.Plan: In the “p”, or plan section of your SOAP note, you are going to
discuss how you would like to treat your patient. It should include what type of treatments
will be given, such as medication, therapies, and surgeries. It may also list long-term
treatment plans and recommended changes to lifestyle, as well as short and long term goals
for the patient. It should also detail what kind of follow up is necessary. P Workup will
include a sonogram of the RUQ and complete blood count and liver chemistries, and an EKG.
We will have the patient follow up with results. – 7 –AHAV.2 Advanced Health
Assessment Self-ReflectionIn all assignments, remember to complete your Self-Reflection, if
your instructor has left this activity available for you to complete.What is Self-Reflection?
Self-reflection enables us to look at our performance – be it on the job, in the classroom, or
out on the field – and critique our practice in a systematic and rigorous way. This process
enables us to develop a greater sense ofself awareness and to create a plan to improve on
areas of weakness in our performance. We gain critical insights from this reflection that
help us move from novices to experts in our fields. Self-reflection is proven1 to improve our
skills as providers,which leads to better patient outcomes. How do I begin? As you reflect on
your practice, thinking about things that have gone well will help you to understand how

you can make this happen more often. Conversely, thinking about things that haven’t gone
so well helps you to think about how things could be different in the future. Here are some
questions to ask yourself:1. What are you reflecting on?a.) What assignment did you
complete?b.) How did you do on the assignment?c.) Did you meet your goal and achieve a
score you were happy with? 2. How were you thinking and feelinga.) What were you feeling
while completing the assignment?b.) How do you feel about your score? 3. Evaluatea.)
What are the highs and lows of your experience?b.) Were there any factors that influenced
the outcome? 4. Analyzea.) What could I have done differently?b.) What did I do that was
successful that I will continue to do?c.) What did I do that was unsuccessful that I will
discontinue? 5. Conclusiona.) How do I feel about the overall experience?b.) What have I
learned about my practice?c.) How will this experience change my nursing practice?d.) Are
there any factors in a real life scenario that may be different than this virtual environment
that may prevent me from reaching my goal that I can anticipate? —————Gustafsson, C.,
and Fagerberg, I. (2004), Reflection, the way to professional development? Journal of
Clinical Nursing, 13: 271-280 – 8 –AHAV.2 Advanced Health Assessment Excerpt
from an Excellent Self- Reflection Excerpt from a Satisfactory Self- Reflection
Excerpt from an Unsatisfactory Self-ReflectionI asked Mrs. Smith about her health
history and tried to find more information about her low back pain, cough, and frequent
urinary tract infections. OLDCARTS helped guide me through the 7 dimensions of her
complaints. I assumed that if I went through OLDCARTS I would capture all of the
information, and it seems that it really helped me get a very clear picture of the problem. I
asked about her self-care related to her frequent urinary tract infections to get a good idea
of what education and care she would need to prevent them. I should have addressed Mrs.
Smith’s nutrition plan. This would help her manage her obesity, which is probably
contributing to her low back pain. I should have askedMrs. Smith about the possibility of
quitting smoking and about whether she had ever tried to quit (Stead et al., 2008).When I
reviewed my transcript,it became apparent that I kept it purely medical and rarely asked
any social or cultural questions. I used Jarvis to ask the subjective questions but didn’t think
much about finding much else out. This has been really good for me to remember to think of
my patients as people with families and lives as well as medical problems.Citation: Stead, L.
F., Bergson, G., & Lancaster, T. (2008). Physician advice for smoking cessation. Co- chrane
Database Syst Rev, 2 (2).This reflection describes the experience. It also describes clinical
reasoning and supporting citation. It demonstrates analysis of missed items. It recognizes
assumptions and failings, and it addresses how these may be addressed in the future.
Mrs. Smith was a very easy patient to interview. I used OLDCARTS to interview her,
and it worked well. I think I really did well. I missed a few things about her diet and
personal hygiene, but I won’t forget about these things in the future. –While the student
identified areas that should improve, he or she does not make a specific and measurable
improvement plan or challenge any of his or her assumptions or practices. The reflection is
incomplete with limited introspection. I loved this experience! –This is an
incomplete reflection. A deep reflection should explain what about the experience was
found to be meaningful and how it can help one become a better nurse. Deep reflections
involve practitioners examining and questioning their practices and assumptions. – 9 –

AHAV.2 Advanced Health Assessment HEENTThe HEENT exam is an interview and
physical exam that is concerned with the head, eyes, ears, nose and throat. It is performed
when a patient presents with a problem with the HEENT system.Patient narrative: For the
last week your patient, Tina Jones, has experienced sore, itchy throat, itchy eyes, and runny
nose. She states that these symptoms started spontaneously and have been constant in
nature. She states that her nose “runs all day”.Plan your time:Review the assignment
settings your instructor selected on the assignment overviewEvery assignment setting
allows you to stop and resume an assignment until you leave the patient’s room. Your
progress is automatically saved every 30 Assignment First Turn In Allow Reopening
Flexible Turn InTime Estimate~75 minutes ~115 minutes ~160 minutes Getting
Started: View this tutorial for guidance on getting started with the HEENT Assignment.
Tips for Success:You should prepare prior to entering Ms. Jones’ room. We suggest
taking out your textbook to remind yourself of what doing an HEENT exam entails. There
are essential sections of patient information that your interview will need to uncover. There
are multiple essential questions for each of these topics:Chief ComplaintHistory of Present
IllnessMedical History pertaining to the HEENT systemTargeted Review of Symptoms
related to the HEENT systemTargeted Family History related to the HEENT systemKnow all
of your qualifying questions for any symptom that may be
reported:OnsetLocationDurationCharacteristicsAggravating/alleviating factorsRelated
symptomsTreatments triedRemember when you are doing these exams that this simulation
is designed to help you improve your assessment skills. Preparing ahead of time will help to
set you up for success. – 10 –AHAV.2 Advanced Health Assessment RespiratoryThe
respiratory exam is an interview and physical assessment that is performed when a patient
presents with a respiratory problem or a history that is suggestive of a pathology of the
lungs.Patient narrative: Tina had an asthma episode 2 days ago. At that time she used her
albuterol inhaler and her symptoms decreased although they did not completely resolve.
Since that incident she notes that she has had 10 episodes of wheezing and has shortness of
breath approximately every four hours. Tina presents with continued shortness of breath
and wheezing.Plan your time:Review the assignment settings your instructor selected on
the assignment overviewEvery assignment setting allows you to stop and resume an
assignment until you leave the patient’s room. Your progress is automatically saved every
30 Assignment First Turn In Allow Reopening Flexible Turn InTime Estimate~75
minutes ~95 minutes ~130 minutes Getting Started: View this tutorial for guidance
on getting started with the Respiratory Assignment. Tips for success:You should prepare
prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself
of what doing a respiratory assessment entails. There are essential sections of patient
information that your interview will need to uncover.There are multiple essential questions
for each of these topics:Chief ComplaintHistory of Present IllnessMedical history pertaining
to the respiratory systemSocial history pertaining to the respiratory systemTargeted review
of systems related to the respiratory systemFamily history related to the respiratory
systemKnow all of your qualifying questions for any symptom that may be
symptomsTreatments tried – 11 – AHAV.2 Advanced Health

Assessment CardiovascularThe cardiovascular exam is an interview and physical
assessment that is performed when a patient presents with symptoms suggestive of a
pathology of the heart such as chest pain or high blood pressure.Patient narrative: Over the
last month, Tina has experienced 3-4 episodes of perceived rapid heart rate. She describes
these episodes as “thumping in her chest” with a heart rate that is “way faster than
usual”.Plan your time:Review the assignment settings your instructor selected on the
assignment overviewEvery assignment setting allows you to stop and resume an
assignment until you leave the patient’s room. Your progress is automatically saved every
30 Assignment First Turn In Allow Reopening Flexible Turn InTime Estimate~75
minutes ~95 minutes ~130 minutes Getting Started: View this tutorial for guidance
on getting started with the Cardiovascular Assignment. Tips for success:You should
prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind
yourself of what doing a cardiovascular assessment entails. There are essential sections of
patient information that your interview will need to uncover. There are multiple essential
questions for each of these topics:Chief ComplaintHistory of Present IllnessMedical history
pertaining to the cardiovascular systemSocial history pertaining to the cardiovascular
systemTargeted review of systems related to the cardiovascular systemFamily history
related to the cardiovascular systemKnow all of your qualifying questions for any symptom
that may be reported:OnsetLocationDurationCharacteristicsAggravating/alleviating
factorsRelated symptomsTreatments tried – 12 –AHAV.2 Advanced Health
Assessment AbdominalThe abdominal exam is an interview and physical assessment that
aims to pick up on any gastrointestinal pathology that may be causing symptoms such as
abdominal pain, distention, or altered bowel habits. Patient narrative: For “at least a
month,” Tina has been experiencing burping after she eats and pain in her upper stomach
after eating, which she describes as “kind of like heartburn, but sharper.”Plan your
time:Review the assignment settings your instructor selected on the assignment
overviewEvery assignment setting allows you to stop and resume an assignment until you
leave the patient’s room. Your progress is automatically saved every 30 Assignment First
Turn InAllow Reopening Flexible Turn InTime Estimate~75 minutes ~95 minutes
~130 minutes Getting Started: View this tutorial for guidance on getting started
with the Abdominal Assignment. Tips for success:You should prepare prior to entering
Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what doing an
abdominal assessment entails. There are essential sections of patient information that your
interview will need to uncover. There are multiple essential questions for each of these
topics:Chief ComplaintHistory of Present IllnessMedical history pertaining to the
gastrointestinal systemSocial history pertaining to the gastrointestinal systemTargeted
review of systems related to the gastrointestinal systemFamily history related to the
gastrointestinal systemKnow all of your qualifying questions for any symptom that may be
symptomsTreatments tried – 13 –AHAV.2 Advanced Health
Assessment MusculoskeletalThe musculoskeletal exam is an interview and physical
assessment that assesses the overall functionality of the muscles and bones.Patient
narrative: Three days ago, Ms. Jones injured “tweaked” her back lifting a box. She has pain is

in her lower back and bilateral buttocks. She presents today as the pain has continued and
is interfering with her activities of daily living.Plan your time:Review the assignment
progress is automatically saved every 30 AssignmentFirst Turn In Allow Reopening
Started: View this tutorial for guidance on getting started with the Musculoskeletal
Assignment. Tips for success:You should prepare prior to entering Ms. Jones’ room. We
suggest taking out your textbook to remind yourself of what doing a musculoskeletal
assessment entails. There are essential sections of patient information that your interview
will need to uncover. There are multiple essential questions for each of these topics:Chief
ComplaintHistory of Present IllnessMedical history pertaining to the musculoskeletal
systemSocial history pertaining to the musculoskeletal systemTargeted review of systems
related to the musculoskeletal systemFamily history related to the musculoskeletal
systemKnow all of your qualifying questions for any symptom that may be
Assessment NeurologicalThe neurologic exam is an interview and physical assessment that
assesses the nervous system, which includes the brain and spinal cord.Patient narrative:
Two days after a minor, low-speed car accident, Tina noticed daily headaches along with
neck pain and stiffness.Plan your time:Review the assignment settings your instructor
selected on the assignment overviewEvery assignment setting allows you to stop and
resume an assignment until you leave the patient’s room. Your progress is automatically
saved every 30 Assignment First Turn In Allow Reopening Flexible Turn InTime
Estimate ~90 minutes ~115 minutes ~160 minutes Getting Started: View this
tutorial for guidance on getting started with the Neurological Assignment. Tips for
success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your
textbook to remind yourself of what doing a neurologic assessment entails. There are
essential sections of patient information that your interview will need to uncover.There are
multiple essential questions for each of these topics:Chief ComplaintHistory of Present
IllnessMedical history pertaining to the neurologic systemSocial history pertaining to the
neurologic systemTargeted review of systems related to the neurologic systemFamily
history related to the neurologic systemKnow all of your qualifying questions for any
symptom that may be
symptomsTreatments tried – 15 –AHAV.2 Advanced Health Assessment NURS 6830
Spring 2021 Mental HealthThe mental health exam is an interview and that will give you an
idea of how your patient is doing emotionally and cognitively. In this exam you will have the
opportunity to will take note of how your patients look, their mood, behavior, thinking,
reasoning, and their capacity to remember things.Patient narrative: Tina has been having
disturbed sleep 4- 5 nights a week. She complains of difficulty falling asleep at least 4 or 5
nights per week, but states that she is able to stay asleep without difficulty.Plan your
time:Review the assignment settings your instructor selected on the assignment

overviewEvery assignment setting allows you to stop and resume an assignment until you
leave the patient’s room. Your progress is automatically saved every 30 Assignment First
Turn InAllow Reopening Flexible Turn InTime Estimate~90 minutes ~115 minutes
~160 minutes Getting Started: View this tutorial for guidance on getting started
with the Mental Health Assignment. Tips for success: You should prepare prior to
entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what
doing a mental health assessment entails. There are essential sections of patient
information that your interview will need to uncover. There are multiple essential questions
for each of these topics:Chief ComplaintHistory of Present IllnessMedical history pertaining
to mental healthPsychological historySocial History – Education, Work, Housing, and
Support NetworkSocial History – Substance AbuseSocial History – Relationship and Sexual
HistoryFamily history related to mental healthKnow all of your qualifying questions for any
symptom that may be
symptomsTreatments tried – 16 – AHAV.2 Advanced Health Assessment Focused Exam:
CoughDaniel “Danny” Rivera is an 8-year-old boy who comes to the clinic with a cough. You
will determine if Danny is in distress, explore the underlying cause of his cough, and look for
related symptoms in other body systems.Plan your time:Review the assignment settings
your instructor selected on the assignment overviewEvery assignment setting allows you to
stop and resume an assignment until you leave the patient’s room. Your progress is
automatically saved every 30 Assignment First Turn In Allow Reopening
Started: View this tutorial for guidance on getting started with the Focused Exam: Cough
Assignment. Tips for success:You should prepare prior to meeting Danny Rivera in the
clinic. We suggest taking out your textbook to remind yourself of what doing a focused,
complaint oriented respiratory exam entails. There are essential sections of patient
for each of these topics:Chief ComplaintHistory of Present IllnessMedical HistorySocial
History related to the respiratory systemTargeted review of systems related to the chief
complaintFamily History related to the chief complaintKnow all of your qualifying questions
for any symptom that may be
symptomsTreatments tried – 17 –AHAV.2 Advanced Health Assessment Focused
Exam: Chest PainMr. Brian Foster, 58, has been having some troubling pain in his chest now
and then for the past month.Plan your time:Review the assignment settings your instructor
tutorial for guidance on getting started with the Focused Exam: Chest Pain Assignment.
Tips for success:You should prepare prior to meeting Brian Foster in the clinic. We
suggest taking out your textbook to remind yourself of what doing a focused, complaint
oriented cardiovascular exam assessment entails. There are essential sections of patient

for each of these topics:Chief ComplaintHistory of Present Illness (HPI)Medical
HistorySocial HistoryFamily history related to the cardiovascular systemTargeted review of
systems related to the chief complaintKnow all of your qualifying questions for any
symptom that may be
symptomsTreatments tried – 18 –AHAV.2 Advanced Health Assessment NURS 6830
Spring 2021 Focused Exam: Abdominal PainMrs. Esther Park is a 78-year-old woman who
comes to the clinic complaining of abdominal pain. She reports that the pain isn’t severe, but
that her daughter was concerned and brought her in.Plan your time:Review the assignment
progress is automatically saved every 30 Assignment First Turn In Allow Reopening
Started: View this tutorial for guidance on getting started with the Focused Exam:
Abdominal Pain Assignment. Tips for success:You should prepare prior to meeting Esther
Park in your clinic. We suggest taking out your textbook to remind yourself of what doing a
focused, complaint oriented abdominal exam assessment entails. There are essential
sections of patient information that your interview will need to uncover. There are multiple
essential questions for each of these topics:Chief ComplaintHistory of Present Illness
(HPI)Medical HistorySocial HistoryTargeted review of systems related to the Chief
ComplaintKnow all of your qualifying questions for any symptom that may be
Assessment Comprehensive AssessmentIn this assignment, your patient, Tina Jones
presents in your outpatient clinic for a complete health assessment for a pre- employment
physical. This visit takes place approximated 18 months after Ms. Jones first established
primary care in your clinic.Plan your time:Review the assignment settings your instructor
tutorial for guidance on getting started with the Comprehensive Assessment Assignment.
Tips for success:You should prepare prior to seeing Ms. Jones. We suggest taking out
your textbook to remind yourself of what taking doing a complete health assessment
entails. There are essential sections of patient information that your interview will need to
uncover. There are multiple essential questions for each of these topics:Reason for
VisitMedicationsAllergiesMedicationsMedical HistoryPsychosocial HistoryHealth
MaintenanceMental Health HistoryGeneral Review of SystemsKnow all of your qualifying
questions for any symptom that may be
symptomsTreatments tried – 20 – AHAV.2 Advanced Health Assessment NURS 6830
Spring 2021

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