A detailed health history would include multiple systems of the body, however, we will be focusing on the gastrointestinal (GI) system. may make the patient wonder if the c… On Stuvia you will find the most extensive lecture summaries written by your fellow students. Critically appraise the findings as normal or abnormal. University. It is very important to determine whether or not the situation is an emergency and that the underlying cause of Esther’s discomfort. – Education level (health literacy) – Access to health care Insurance/Financial status – Is the patient able to afford medications and health diet, and other out-of-pocket expenses? Liver is 7 cm at the MCL and 1 cm below the right costal margin. Social History: She denies any specific changes in her diet recen but notes that she has increased her water intake. She denies coffee intake, but does drink diet cola on a regular basis. The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the … Course. Try to think of all the questions you can related to the presenting problem and what kind of problems they might experience in each system. No Yes ____years History of drug abuse? She denies. Established chief complaint Reports sporadic chest pain. Written documentation for clinical management of patients within health care settings usually include one or more of the following components. Students must register to attend the debriefing session. All you need to do is ORDER NOW for an equivalent of 4 pages and score 100% in this assignment and all other Shadow Health Assignments. Shadow Health Respiratory Assessment Pre Brief. She is alert and oriented. No CVA tenderness. • Respiratory: Chest is symmetrical with respirations. Faculty will lead virtual debriefing sessions during Weeks 1-6. She denies use of tobacco and illicit drugs. She denies use … She does not exercise. No Yes, type: _____ Occasionally Weekly Daily History of alcohol abuse? She describes it “kind of like, heartburn” but states that it can be sharper. Spleen and bilateral kidneys are not palpable. To patients, the word 'stomach' can mean anywhere from the diaphragm to the groin and includes the genitals. No bruits with auscultation over abdominal aorta. She noticed the pain about a month ago. She does notice that she has increased, burping after meals. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. She does not exercise. DON’T STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW. A combination of open and closed questions will yield better patient data. She notes it to increase with consumption of food and specifically fast food and spicy food make pain worse. History of Present Illness. HISTORY AND PHYSICALS Lois E. Brenneman, M.S.N., C.S., A.N.P., F.N.P. Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough. pumpkin bread, lunch is a sandwich with chips, vegetable, snacks are French fries or pretzels. She, notes it to increase with consumption of food and, specifically fast food and spicy food make pain, worse. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. After successful completion of this course, you will be able to: 1. The following details are facts of the patient's case. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. Gastrointestinal Results | Turned In Advanced Health Assessment - Spring 2019, NSG516 Online Return to Summary - shadow health gastrointestinal physical assessment review questions 35. She denies use of tobacco and illicit, drugs. The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. Shadow Health History Assignment. Discuss the components of a focused gastrointestinal assessment. Complete the Shadow Health Concept Lab (Weeks 2, 4, and 5) prior to beginning the graded assignment. Pain is a 5/10 and is located in her upper stomach. Bowel sounds present and normoactive in all quadrants. She, noticed the pain about a month ago. 2. She states that time generally makes the pain better, but notes that she does treat the pain "every few days" with an over the counter antacid with some relief. “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. Presenting to shadow health hospital clinic for a complete health assessment for a pre-employment physical. Your patient is Esther Park, a 78-year-old Korean-American woman presenting with abdominal pain in Shadow General Hospital’s Emergency Department. 'Do you have a hard stool?' No Social drinker (rarely) 2 or less/day 3 or greater/ day Do you use recreational drugs? She maintains eye contact throughout interview and examination. She states that time generally, makes the pain better, but notes that she does treat, the pain “every few days” with an over the counter, Social History: She denies any specific changes in, her diet recently, but notes that she has increased, her water intake. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. Hope that helps. Tympanic throughout. NR 509 Week 1 Assignment Debriefing . • Cardiac: Denies a diagnosis of, hypertension, but states that she has been told her, blood pressure was high in the past. Shadow Health Gastrointestinal Documentation Documentation / Electronic Health Record • Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. Course Resources: NR 509 Week 5 Shadow Health Gastrointestinal Physical Assessment Assignment. • Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify … and the . Patient is not taking any other new, medications other than her inhalers and OTC pain, HPI: Ms. Jones is a pleasant 28-year-old African, American woman who presented to the clinic with, complaints of upper stomach pain after eating. Useful guide for Chamberlain students in the United States. Educate on lifestyle changes including weight loss, engagement in daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coffee, alcohol, and spicy foods. During the debriefing process, students reflect upon their simulation experience and … No tenderness to light or deep palpation. Gastrointestinal | Completed | Shadow Health 5.pdf, NR 509 Abdominal Pain Documentation Shadow.pdf, Esther Parks _Abdominal Pain _ Objective.Data_ Shadow Health.pdf, NR 509 Abdominal Pain Objective Shadow.pdf, NR 509 Abdominal Pain Subjective Shadow.pdf, California State University, Long Beach • NURSING 305, Gastrointestinal Physical Assessment Assignment _ Documentation.pdf, Shadow Health Gastrointestinal Documentation.docx, Gastrointestinal Results...DOCUMENTATION.PDF.docx, Copyright © 2021. General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. Case - Nr 509 week 1 shadow health conversation concept lab complete. Location: Upper stomach, "under the breastbone". No blood in emesis. Hunter College CUNY. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. Chief Complaint. Review of Systems: General: Denies changes in. She notes it to increase with … Breakfast is usually a muffin or. Pain starts 10 to 15 minutes, Characteristics: Pain at the worst is "6 or 7" out of, Aggravating Factors: Eating, especially larger meals, or spicy foods.   Privacy Shadow Health’s patient cases are designed for both novice and expert students to practice communicating with and examining patients. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chip dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. Course Hero is not sponsored or endorsed by any college or university. weight and general fatigue. She describes it "kind of like heartburn" but states that it can be sharper. stomach pain after eating. She denies known history of murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. Tina Jones is a 28year old African America female with a history of diabetes and Asthma presenting to get a complete health … NB: We have all the questions and documented answers in the SUBJECTIVE DATA, OBJECTIVE DATA, ASSESSMENT AND CARE PLAN format. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. No Yes ____years Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. Your role in this simulation is that of a healthcare provider who will conduct a focused history and physical examination of Ms. Park in order to assess her condition and transfer her care. She denies coffee intake, but does drink diet cola on a regular basis. known history of murmurs, dyspnea on exertion. Denies nausea, vomiting, diarrhea, and constipation. HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. Shadow Health will grade you on what you ask and will deduct points for what you omitted. She noticed the pain about a month ago. Asked about location of pain Reports pain is in center of the chest … Gather subjective and objective data by completing a focused, detailed health history and physical examination for each physical assessment assignment. She describes it kind of like heartburn but states that it can be sharper. Ask open questions and give the patient time to elaborate. Shadow Health Gastrointestinal Documentation. dvanced ealth ssessment health history tina got this scrape on my foot while ago, and thought it would heal up on its own, but now looking pretty nasty. Make sure that you understand what the patient means and get amplification of specific points. Bowel movements are daily and generally brown in color. (Abdominal Pain) Pre Brief: Ms. 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. She drinks alcohol occasionally, last was 2. weeks ago, and was 1 drink. In order to obtain an accurate health history regarding the GI system, appropriate questions need to be asked with terms the patient will understand. Social History Questionnaire Page 5 Patient’s Name_____ SUBSTANCE ABUSE HISTORY Have any of your family members had problems with alcohol and/or drug abuse?_____ Please describe who, their relationship to you, and the substances they abused._____ NURS 612 Shadow Health All Modules Cases Instructor Keys. She denies fevers, chills, and night sweats. Sign in Register; Hide. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past.   Terms. Do you drink alcohol? Denies any change in stool color, consistency, or frequency. She drinks alcohol occasionally, last was 2 weeks ago, and was 1 drink. How would you have proceeded? During a gastrointestinal exam the purpose of light … She denies fevers, chills, and night sweats. She denies coffee intake, but does drink cola on a regular basis. Shadow Health All Modules Cases Instructor Keys. reports frequently occurring stomach pain, how many times a week does your stomach hurt, reports 3-4 episodes a week that are more severe, how long after a meal does the pain start, how many hours does the stomach pain last, center of upper stomach, below the breasbone, doesn't want to eat out of anticipation of pain, what medications do you take for stomach pain, do you have trouble holding your urine in, what was your most recent meal and what did you eat, how many times a week do you drink alcohol, do you think you could have food poisoning, how far away is the grocery store from you, do you have nausea, vomiting, diarrhea, constipation, bloating, do you have sore throat, coughing, dysphagia, difficulty breathing, chest pain, palpitations, change in taste, family history of GERD, IBS, cholecystitis, liver/kidney/bladder disease. Reports that she takes between 2 to 4 "every, few days". Screening/Risk Assessment – Identified health concerns based on screening assessments and demographic information Nutrition/Activity The date, time, and duration of the weekly debriefing session will be posted by the course faculty. Duration: Pain occurs everyday with 3 to 4 episodes, a week that are worse. She does notice that she has increased burping after meals. She states that, she experiences pain daily, but notes it to be worse, 3-4 times per week. Avoid technical terms, jargon or abbreviations. This preview shows page 1 - 2 out of 4 pages. Shadow Health Gastrointestinal Documentation Documentation / Electronic Health Record • Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. Uncategorized. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She noticed the … • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks, precordial movements. Course Hero, Inc. She denies use of tobacco and … Denies blood in stool, dark stools, or maroon stools. No known jaundice, problems with liver or spleen. Pain is a 5/10 and is located in her upper stomach. View Gastrointestinal | Completed | Shadow Health 2.pdf from NSG 516 at Rivier University. The purpose of this course is to offer the healthcare provider an overview of basic gastrointestinal (GI) assessment including normal and abnormal findings. She noticed the pain about a … NR 509 Week 5 Shadow Health: Gastrointestinal Physical Assessment – REVIEW QUESTIONS Which of the following physical exam tests could … used if you suspected cholecystitis in Tina? Suppose that you were concerned that Tina may have had an enlarged spleen. Advnc Health Assessm (NURS 751.00) … Pain is a 5/10 and is located in, her upper stomach. Avoid resits and get better grades with material written specifically for your studies. Introduce yourself – name / role Confirm patient details – name / DOB Explain the need to take a history Gain consent Ensure the patient is comfortable Asked about onset of pain Reports chest pain started appearing in the past month. She, denies coffee intake, but does drink diet cola on a, regular basis. Review of Systems: General: Denies changes in weight and general fatigue. No femoral, iliac, or renal bruits. N522 Assignment 4 physical assessment – Focused Note - Esther ParkAfter you complete the focused assessment (virtual simulation), please write a paper using the following as headings/subheadings in APA format.Introduction (with purpose statement – one paragraph)Focus of the Assessment (i Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or … Pain is worse when lying down or, Relieving Factors: Time between meals, sitting, Current Medications: OTC Tums to relieve stomach, pain. 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