comprehensive health history on a simulated patient

For this Performance Task Assessment, you will complete a comprehensive health history on a simulated patient in the Shadow Health platform.

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Submission Length: Conduct a 3-hour comprehensive health history using Shadow Health software. As you complete the steps necessary to conduct a comprehensive health history, you will also document your progress in Shadow Health.

Instructions: comprehensive health history on a simulated patient

To complete this Assessment, do the following:

  • Be sure to adhere to the indicated assignment length.
  • Review the Health Assessment Documentation Outline
  • Review Health Assessment Nursing Documentation
  • Review the Shadow Health Student Guide
  • Access the Shadow Health Platform.
    • Complete the Digital Clinical Experience (DCE) Orientation and the Conversation Concept Lab by Achieving a “Lab Pass”
  • Review the instructions that you are given when you log in to Shadow Health.
  • Review the Assignment Overview for the Health History Assignment in Shadow Health.
  • Review the Objectives and Instructions for the Health History in Shadow Health.

You are the nurse providing care for Tina Jones as part of her admission to Shadow General Hospital. Ms. Jones was admitted to the ER for a painful foot wound. After completing your patient interview, you will identify and prioritize potential nursing diagnoses for Ms. Jones. You will then develop plans to address your diagnoses.

In Shadow Health, complete the following:

  1. Perform the comprehensive health history in Shadow Health.
  2. Be sure to document your engagement with Tina Jones as you perform the comprehensive health history in Shadow Health.
  3. Obtain a Lab Pass and a copy of your documentation of the comprehensive health history for submission for this Assessment.

Before submitting your Assessment, carefully review the rubric. This is the same rubric the SME will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.

All submissions must follow the conventions of scholarly writing. Properly formatted APA citations and references must be provided where appropriate. Submissions that do not meet these expectations will be returned without scoring.

This Assessment requires submission of two files: one file containing your “Lab Pass” and a separate file containing the saved documentation from the Health History Assessment.

  1. Save your “Lab Pass” as a PDF file. It should be labeled as HA3004_labpass__firstinitial_lastname (for example, HA3004_labpass_J_Smith).
  2. Save your Health History documentation as a Word document. It should be labeled as HA3004_documentation_firstinital_lastname (for example, HA3004_documentation_J_Smith).

You may submit a draft of your assignment to the Turnitin Draft Check area to check for authenticity. When you are ready to upload your completed Assessment, use the Assessment tab on the top navigation menu.

Important Note: As a student taking this Competency, you agree that you may be required to submit your Assessment for textual similarity review to Turnitin.com for the detection of plagiarism. All submitted Assessment materials will be included as source documents in the Turnitin.com reference database solely for the purpose of detecting plagiarism of such materials. Use of the Turnitin.com service is subject to the Usage Policy posted on the Turnitin.com site.

Health Assessment Outline

Health History

Chief Complaint

This should be a few of the patient’s own words indicating why they have come for care.

History of Present Illness

This is the PQRST or OLD CART of why the patient is here. Detail is important.

Pain Assessment

Document all the information about the patient’s pain. Part of this may be contained in the PQRST or OLD CART information.

Allergies

List all allergens and the reaction.

Immunizations

List all immunizations.

Medications

List all current home medications, dosage, frequency, and route including over the counter and PRN medications.

Medical History

Provide a brief overview of medical history including age of onset of conditions, treatments, and results, last eye, dental, GYN, checkups.

Surgical History

List all previous surgeries

Previous Hospitalizations

Document all hospitalizations including the reason

Gynecological History

Document all GYN history including menses history, sexual history, pregnancy etc. Provide detailed information.

Family History

Include all family members for three generations, illnesses, age, cause of death if applicable in an organized manner. Make sure to correctly identify maternal and paternal relatives.

Social History

Include living situation, education, job, activities, support systems, financial situation, tobacco use, alcohol and recreational drug use, and relationships.

Review of Systems

Document subjective data about past and present health. Each body system needs to be listed and each condition asked about for the related body system needs to be documented. If a positive, other than the Chief Complaint, is noted the PQRST/OLD CART of the issue is to be documented.

Hair, Skin, and Nails (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

    • Subjective
      • Include the PQRST of any positive answer.
      • Past history of skin disease
      • Injury
      • Change in pigmentation
      • Change in moles
      • Excessive dryness
      • Pruritus
      • Excessive bruising
      • Rashes or lesions
      • Hair loss or growth
      • Change in nails
      • Foot wound
    • Objective
      • General Survey
      • General pigmentation
      • Moisture
      • Texture
      • Thickness
      • Edema
      • Mobility and Turgor
      • Lesions
      • Foot Wound
      • Moles (ABCDE)
      • Hair
      • Nails

 

 

HEENT (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

  • Subjective
    • Head
      • Headache
      • Head Injury
      • Dizziness
      • Neck pain
      • Lumps or swelling
      • History of head or neck surgery
    • Eyes
      • Vision difficulty
      • Pain
      • Diplopia or strabismus
      • Redness/Swelling
      • Discharge/Watering
      • Use of glasses or contacts
    • Ears
      • Earache
      • Infections
      • Discharge
      • Hearing loss
      • Environmental noise
      • Tinnitus
      • Vertigo
    • Nose
      • Discharge
      • Colds
      • Sinus issues/pain
      • Trauma
      • Epistaxis
      • Allergies
      • Altered smell
    • Mouth/Throat
      • Sores or lesions
      • Sore throat
      • Bleeding gums
      • Tooth pain
      • Hoarseness
      • Dysphagia
      • Altered taste
      • Tobacco and alcohol use
  • Objective
    • General Survey
    • Head
      • Size and shape
      • Hair
      • Scalp
      • Facial structures
      • Neck
      • Lymph
    • Eyes
      • Visual acuity
      • General ocular structures
      • Diagnostic positions/EOMs
      • Pupillary response
    • Ears
      • Size, shape
      • External structures
      • Ear canal
      • Tympanic membranes
      • Whispered test
    • Nose
      • External structures of nose
      • Patency of nares
      • Sinuses
    • Mouth and Throat
  • Teeth
  • Gums
  • Tongue
  • Buccal mucosa
  • Palate
  • Throat
  • Tonsils

 

Respiratory (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

  • Subjective
  • Cough
  • SOB
  • Chest Pain
  • Respiratory Infections
  • Smoking
  • Environmental Exposure
  • Objective
  • General Survey
  • HEENT-Brief
  • Cardiac-Brief
  • Chest Symmetry
  • Fremitus
  • Percussion
  • Diaphragmatic Excursion
  • Breath Sounds

 

Cardiovascular (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

  • Subjective
  • Chest pain
  • Dyspnea
  • Orthopnea
  • Cough
  • Fatigue
  • Cyanosis or Pallor
  • N/V
  • Edema
  • Nocturia
  • Cardiac History
  • Leg Pain/Cramps
  • Skin Changes
  • Surgical history
  • Objective
  • General Survey
  • Carotid
  • JVD
  • Precordium
  • Apical Impulse
  • Auscultation/Heart Sounds
  • pulses upper and lower and grade of pulses
  • Edema

 

Abdominal (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

  • Subjective
      • Appetite
      • Dysphasia
      • Abdominal Pain
      • Nausea/Vomiting
      • Bowel habits
      • Change in bowel habits
      • Dark or blood in stool
      • Abdominal History
  • Objective
      • General Survey
      • Abdominal Contour
      • Symmetry
      • Skin
      • Pulsations
      • Hair Distribution
      • Bowel Sounds
      • Vascular Sounds
      • Percussion
      • CVA Tenderness
      • Light and Deep Palpation
      • Liver
      • Spleen

 

Musculoskeletal (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

  • Subjective
  • Joints
  • Pain
  • Stiffness
  • Swelling, Heat, Redness
  • Limitation of Movement
  • Muscles
  • Pain (cramps)
  • Weakness
  • Bones
  • Muscle Pain
  • Deformity
  • Trauma (fractures, sprains, dislocations)
  • Functional Assessment (ADLs) Brief statement
  • Objective
  • General Survey
  • Joints (size, contour)
  • ROM (List each joint tested. Do not need to include degrees. State if full or limited. If limited, explain the limitation.)
  • Crepitus
  • Strength of major joints/muscle groups and the grade
  • Spine ROM and strength
  • Foot wound

Neurological Exam (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

  • Subjective
      • Headache
      • Head injury
      • Dizziness/vertigo
      • Seizures
      • Tremors
      • Weakness
      • Incoordination
      • Numbness or tingling
      • Difficulty swallowing
      • Difficulty speaking

 

  • Objective
      • General Survey
      • Basic Memory
      • Basic summary statement of cranial nerve function (symmetry of face, pupillary reaction, speech and phonation)
      • Rapid alternating movements
      • Stereognosis
      • Graphesthesia
      • Sensation to all extremities
      • DTRs (Name and grade each tested)
      • Proprioception
      • Romberg

 

Comprehensive Exam (It has been some time since you have seen Tina and all questions and information must be covered and documented as if this were the first meeting.)

Vitals

Document the patient’s vital signs

Health History

Identifying Data and Reliability

Basic identifying data and if the patient is a reliable source for information.

General Survey

Brief statement of overall appearance, dress, attitude, is the patient in distress, smiling, crying, well groomed, etc.

 

Reason for Visit

Why is Ms. Jones here today? In her words.

 

History of Present Illness

Brief statement of why she is here and any related factors.

 

Medications

List all current home medications, dosage, frequency, and route including over the counter and PRN medications.

 

Allergies

List all allergens and the reaction when exposed.

 

Medical History

Provide a brief overview of medical history including age of onset of conditions, treatments, and results.

 

Health Maintenance

Include activities the patient does to maintain health. Immunizations, seat belt use, regular check-ups, last eye exam, dental exam, fire alarms in the home, exercise, diet, etc.

 

Family History

Include all family members for three generations, illnesses, age, cause of death if applicable in an organized manner. Make sure to correctly identify maternal and paternal relatives.

 

Social History

Include living situation, education, job, activities, support systems, financial situation, tobacco use, alcohol and recreational drug use, and relationships.

 

Mental Health History

Any stress, anxiety, depression, etc. A brief statement.

 

Review of Systems-General

Provide a general statement of overall health. Each body system will be reviewed in the next section.

 

HEENT

  • Subjective

Document the basic subjective data from the HEENT exam completed earlier. List the conditions asked about and if the patient denies having. If there is an issue document the PQRST of the issue.

 

  • Objective

Document the assessment data for this system covering all the same aspects as covered in previous exams in Shadow Health.

 

Respiratory

  • Subjective

Document the basic subjective data from the respiratory exam completed earlier. List the conditions asked about and if the patient denies having. If there is an issue document the PQRST of the issue.

 

  • Objective

Document the assessment data for this system covering all the same aspects as covered in previous exams in Shadow Health.

 

Cardiovascular

  • Subjective

Document the basic subjective data from the cardiac exam completed earlier. List the conditions asked about and if the patient denies having. If there is an issue document the PQRST of the issue

 

  • Objective

Document the assessment data for this system covering all the same aspects as covered in previous exams in Shadow Health.

 

Abdominal

  • Subjective

Document the basic subjective data from the abdominal exam completed earlier. List the conditions asked about and if the patient denies having. If there is an issue document the PQRST of the issue.

 

  • Objective

Document the assessment data for this system covering all the same aspects as covered in previous exams in Shadow Health.

 

Musculoskeletal

  • Subjective

Document the basic subjective data from the musculoskeletal exam completed earlier. List the conditions asked about and if the patient denies having. If there is an issue document the PQRST of the issue.

 

  • Objective

Document the assessment data for this system covering all the same aspects as covered in previous exams in Shadow Health.

 

Neurological

  • Subjective

Document the basic subjective data from the neurological exam completed earlier. List the conditions asked about and if the patient denies having. If there is an issue document the PQRST of the issue.

 

  • Objective

Document the assessment data for this system covering all the same aspects as covered in previous exams in Shadow Health.

 

Skin, Hair, and Nails

  • Subjective

Document the basic subjective data from the Skin, Hair, and Nails exam completed earlier. List the conditions asked about and if the patient denies having. If there is an issue document the PQRST of the issue.

 

  • Objective

 

Document the assessment data for this system covering all the same aspects as covered in previous exams in Shadow Health.

 

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