NURS 6512 Week 4 Assignment 2: Digital Clinical Experience (DCE): Health History Assessment (SOAP NOTE)
NURS 6512 Week 4 Assignment 2: Digital Clinical Experience (DCE): Health History Assessment (SOAP NOTE)
Digital Clinical Experience (DCE): Health History Assessment
In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool, Shadow Health and finalize for submission.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
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WEEKLY RESOURCE
Learning Resources
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 9, “Skin, Hair, and Nails”
This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
This section explains the procedural knowledge needed prior to performing various dermatological procedures.
Chapter 1, “Punch Biopsy
Download Chapter 1, “Punch Biopsy”
Chapter 2, “Skin Biopsy”
Download Chapter 2, “Skin Biopsy”
Chapter 10, “Nail Removal”
Download Chapter 10, “Nail Removal”
Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
Download Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
Chapter 16, “Skin Tag (Acrochordon) Removal”
Download Chapter 16, “Skin Tag (Acrochordon) Removal”
Chapter 22, “Suture Insertion”
Download Chapter 22, “Suture Insertion”
Chapter 24, “Suture Removal”
Download Chapter 24, “Suture Removal”
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 28, “Rashes and Skin Lesions”
Download Chapter 28, “Rashes and Skin Lesions”
This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.
Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1 and 3)
VisualDx. (2021). Clinical decision support
Links to an external site.: For professionals. Retrieved July 16, 2021, from http://www.skinsight.com/professionals
This interactive website allows you to explore skin conditions according to age, gender, and area of the body.
Bonifant, H., & Holloway, S. (2019). A review of the effects of ageing on skin integrity and wound healing
Links to an external site.. British Journal of Community Nursing, 24(Sup3), S28–S33. https://doi.org/10.12968/bjcn.2019.24.sup3.s28
Document: Skin Conditions
Download Skin Conditions (Word document)
This document contains images of different skin conditions. You will use this information in this week’s Discussion.
Document: Comprehensive SOAP Exemplar
Download Comprehensive SOAP Exemplar (Word document)
Document: Comprehensive SOAP Template
Download Comprehensive SOAP Template (Word document)
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Shadow Health. (2021). Welcome to your introduction to Shadow Health
Links to an external site.. https://link.shadowhealth.com/Student-Orientation-Video
Shadow Health. (n.d.). Shadow Health help desk
Links to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us
Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students.
Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
Document: Shadow Health Nursing Documentation Tutorial
Download Shadow Health Nursing Documentation Tutorial (Word document)
Document: DCE (Shadow Health) Documentation Template for Health History
Download DCE (Shadow Health) Documentation Template for Health History (Word document)
Use this template to complete your Assignment 2 for this week.
Required Media
Module 3 Introduction
Dr. Tara Harris reviews the overall expectations for Module 3. Consider how you will manage your time as you review your media and Learning Resources for your Discussions, Case Study Lab Assignments, DCE Assignments, and your Midterm exam (12m).
Skin, Hair, and Nails – Week 4 (19m)
Suturing Tutorials
The following suturing tutorials provide instruction on the basic interrupted suture, as well as the vertical and horizontal mattress suturing techniques
Tulane Center for Advanced Medical Simulation & Team Training. (2010, July 8). Suturing technique
Links to an external site. [Video file]. Retrieved from https://www.youtube.com/watch?v=c-LDmCVtL0o
Note: Approximate length of this media program is 5 minutes.
Mikheil. (2014, April 22). Basic suturing: Simple, interrupted, vertical mattress, horizontal mattress
Links to an external site. [Video file]. Retrieved from https://www.youtube.com/watch?v=MFP90aQvEVM
Note: Approximate length of this media program is 9 minutes.
Incision and Drainage of an Abscess (a common procedure in primary care)
New England Journal of Medicine (NEJM). (2013, September 30). NEJM abscess incision and drainage
Links to an external site. [Video file]. Retrieved from https://www.youtube.com/watch?v=MwgNdrA18fM&list=PL9UKTUFtRDcNq4–Vf2NYfUANEyObfeNm&index=8
Note: Approximate length of this media program is 10 minutes.
Dermablade Use for Shave Biopsies
Dermablade®. (2012, November 9). PersonnaBlades
Links to an external site. [Video file]. Retrieved from https://www.youtube.com/watch?v=D8u1Y18L9DQ
Note: Approximate length of this media program is 5 minutes.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.
Chapter 6, “The Skin and Nails”
In this chapter, the authors provide guidelines and procedures to aid in the diagnosis of skin and nail disorders. The chapter supplies descriptions and pictures of common skin and nail conditions.
Ethicon, Inc. (n.d.-a). Absorbable synthetic suture material. Retrieved from https://web.archive.org/web/20170215015223/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/absorbable_suture_chart.pdf
Download absorbable_suture_chart.pdf
Ethicon, Inc. (n.d.-b). Ethicon sutures. Retrieved from https://web.archive.org/web/20150921202525/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/suture_chart_ethicon.pdf
Download suture_chart_ethicon.pdf
Ethicon, Inc. (n.d.-c). Wound closure manual
Links to an external site.Retrieved from http://www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Closure_Manual.pdf
MEDSimplified
Links to an external site.. (2019, September 17). Simple interrupted sutures-Suturing techniques for beginners [Video]. YouTube. https://www.youtube.com/watch?v=nT0lOlb5pe8
Surgical Teaching
Links to an external site.. (2019, June 21). Basics of sutures part 1 | Learn the different sizes and shapes of suture needles? [Video]. YouTube. https://www.youtube.com/watch?v=Ec1Fb6eeOcA
VATA. (2017, June 30). Suture techniques course video
Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=Akyr4zlBS9E
To Prepare
Review this week’s Learning Resources as well as the Taking a Health History media program in Week 3, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment.
Review the DCE (Shadow Health) Documentation Template for Health History found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Shadow Health Student Orientation media program and the Useful Tips and Tricks document provided in the week’s Learning Resources to guide you through Shadow Health.
Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.
DCE Health History Assessment:
Complete the following in Shadow Health:
Orientation
DCE Orientation (15 minutes)
Conversation Concept Lab (50 minutes, Required)
Health History
Health History of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 4 Day 7 deadline.
submission information
Complete your Health Assessment DCE assignments in Shadow Health via the Shadow Health link in Canvas.
Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas for your faculty review.
(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
Links to an external site.
Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
To submit your completed assignment, save your Assignment as WK4Assgn2+last name+first initial.
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select both files and then Submit Assignment for review.
Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
By submitting this assignment, you confirm that you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
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Rubric
NURS_6512_Week_4_DCE_Assignment_2_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning Outcome Student DCE score(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)Note: DCE Score – Do not round up on the DCE score. |
|
60 pts | ||||
| This criterion is linked to a Learning Outcome Subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. |
|
40 pts | ||||
| Total Points: 100 | ||||||