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Exam (elaborations)

NUR 3069C Health Assessment: Shadow Health Focused Exam: Cough Results – Danny Rivera (Week 4)

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This report documents the completion and analysis of the Shadow Health Digital Clinical Experience™ focused exam for NUR 3069C, featuring Danny Rivera, an 8-year-old Puerto Rican male presenting with a cough in the Shadowville Elementary School nurse's office . The simulation required the performance of a focused history and physical examination to collect subjective and objective data, assess the patient's condition, and facilitate care transfer. Subjective Data Collection: The interview assessed the patient's chief complaint of a cough present for 3-5 days, described as "wet" with clear sputum production . Key findings include cough worsening at night, sore throat with mild pain on swallowing, runny nose with clear thin discharge, and reports of fatigue and difficulty sleeping . Danny denies fever, chest pain, difficulty breathing, and ear pain, though he has a history of frequent ear infections . Aggravating factors include nighttime and activity; relieving factors include over-the-counter cough medicine (purple liquid, one spoonful) . Risk factors identified include secondhand smoke exposure through father (who has asthma), playing with an ill classmate, infrequent hand washing, and not covering mouth when coughing .

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Week 4: SBAR Focused Exam: Cough Results | Turned In
NUR 3069C Health Assessment and Communication - May '18 (Gannon - Jacksonville Only), 3069C
Return to Assignment




Notice:
The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.




Your Results Lab Pass




Overview Experience Overview
Transcript

Subjective Data Collection Patient: Danny Rivera Student Performance Index




a
vi
32.95 out of 34
Objective Data Collection


d
Documentation
re
ha
SBAR
s
as
w




Proficiency Level: Proficient
m e
co rc
o. ou




Beginning Developing Proficient
er res




Digital Clinical Experience Score
Students rated as “proficient” demonstrate entry-level
expertise in nursing competencies and clinical
se dy




96.9%
reasoning skills. In comparable nursing programs, the
ur stu




top 25% of students perform at the level of a proficient
nurse.
H
Co is




Subjective Data Objective Data Collection
Th




This score measures your performance on the Student
Performance Index in relation to other students in
Collection 13.95 out of 15
comparable academic programs. Your instructor has
19 out of 19
chosen to scale your Student Performance Index score
so that the average score on the index is a 80.0%. This
score may not be your final grade if your instructor
Time
chooses to include additional components, such as
documentation or time spent. 72 minutes total spent in assignment

Interaction with patient
72 minutes

Objective Data Collection: 13.95 of 15 (93%)
https://www.coursehero.com/file/31999060/SBAR-Cough-Objectivepdf/



Correct Incorrect
Partially correct Missed

, Inspected eyes and orbital area 1 of 1 point


Orbital Area (1/4 point) Sclera (1/4 point)

No visible abnormal findings White
Ptosis Yellow tint
Eyelid Redness
Lesion

Conjunctiva (1/4 point) Conjunctival Discharge (1/4 point)

Moist and pink No discharge
Dry appearance Clear, watery discharge
Redness Purulent discharge
Swelling



Inspected nasal cavities 0.75 of 1 point




a
Color (No point) Discharge (1/4 point)




vi
Pink No discharge
Red
d Clear discharge
re
Bluish Bloody discharge
ha
Purulent discharge
s
as


Turbinate Patency (1/4 point) Observations (1/4 point)
w



Patent No additional visible abnormal findings
Decreased patency Foreign body present
m e
co rc




Not patent Polyp
o. ou




Septum perforated
Septum deviated
er res




Lesion
se dy




Inspected ears
ur stu




0.8 of 1 point
H




Right: Auditory Canal Color (No point) Right: Tympanic Membrane Color (No point)
Co is
Th




Pink Pearly gray
Red Red
Pallor Opaque
Yellow
Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 Right: Cone Of Light (1/10 point)
point)
5:00
No visible abnormal findings
Cone of light distorted
Fluid observed
Visible scars
Bulging
https://www.coursehero.com/file/31999060/SBAR-Cough-Objectivepdf/ Perforation
Retraction

Right: Discharge (1/10 point) Left: Auditory Canal Color (1/10 point)

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