NURS 6512 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.
Photo Credit: Sam Edwards / Caiaimage / Getty Images
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 and Grading Information
By Day 7 of Week 4
- Complete your Health Assessment DCE assignments in Shadow Health via the Shadow Health link in Blackboard.
- Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard 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
- Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
- Complete the Code of Conduct Acknowledgement.
- 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.
Grading Criteria
To access your rubric:
Week 4 Assignment 2 DCE Rubric
Submit Your Assignment by Day 7 of Week 4
To submit your Lab Pass:
Week 4 Lab Pass
To submit this required part of the Assignment:
Week 4 Documentation Notes for Assignment 2
To Submit your Student Acknowledgement:
Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
Assignment 3 (Optional) Practice Assessment: Skin, Hair, and Nails Examination
Advanced practice nurses are required to have the skills and knowledge necessary to perform many different physical assessments and health examinations. In this course, you will demonstrate your abilities in this area by conducting various optional examinations on a volunteer “patient.”
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice conducting an assessment of the skin, hair, and nails this week.
Note: This is an optional practice physical assessment.
To Prepare
- Arrange an appropriate time and setting with your volunteer “patient” to perform a skin, hair, and nails examination.
- Download and review the Skin, Hair, and Nails Student Checklist and Key Points, provided in this week’s Learning Resources, and review the Seidel’s Guide to Physical Examination online media.
Optional Lab Assignment
- Perform the skin, hair, and nails examination, covering all of the areas listed in the checklist.
What’s Coming Up in Week 5?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you examine how to properly assess the head, neck, eyes, ears, nose, and throat in order to form accurate diagnoses as you complete your Case Study Assignment of the Skin, Hair, Nails, and HEENT. You will once again complete a DCE related to a Focused Exam for cough. Make sure to plan ahead with your Please plan your time accordingly.
Week 5 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Case Study Assignment. There are several videos of various lengths. Please plan ahead to ensure you have time to view these videos and animations to complete your Assignment on time.
Next Week
Week 4: Assessment of the Skin, Hair, and Nails
Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.
This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.
Learning Objectives
Students will:
- Apply assessment skills to diagnose skin conditions
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the skin, hair, and nails
- Analyze dermatologic procedures to include skin biopsy, punch biopsy, suture insertion and removal, nail removal, skin lesion removal
Learning Resources
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th 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 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
ChaptNURS 6512 Health History Assessmenter 16, “Skin Tag (Acrochordon) Removal”
Chapter 22, “Suture Insertion”
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.
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)
Document: Skin Conditions (Word document)
Document: Comprehensive SOAP Exemplar (Word document)
Document: 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:
Document: Shadow Health Support and Orientation Resources (PDF)
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Shadow Health Nursing Documentation Tutorial (Word document)
Document: DCE (Shadow Health) Documentation Template for Health History (Word document)
Use this template to complete your Assignment 2 for this week.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th 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.
Required Media (click to expand/reduce)
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)
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s media, it is highly recommended that you access and view the online resources included with the text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 8 that relate to the assessment of the skin, hair, and nails.
Note: To access the online resources included with the text, you need to complete the FREE online registration that is located at https://evolve.elsevier.com/cs/product/9780323172660?role=student .
To Register to View the Content
- Go to https://evolve.elsevier.com/cs/product/9780323172660?role=student
- Enter the name of the textbook, Seidel’s Guide to Physical Examination (name of text without the edition number) in the Search textbox.
- Complete the registration process.
To View the Content for this Text
- Go to https://evolve.elsevier.com/
- Click on Student Site.
- Type in your username and password.
- Click on the Login button.
- Click on the plus sign icon for Resources on the left side of the screen.
- Click on the name of the textbook for this course.
- Expand the menu on the left to locate all the chapters.
- Navigate to the desired content (checklists, videos, animations, etc.).
Note: Clicking on the URLs in the APA citations for the Resources from the textbook will not link directly to the desired online content. Use the online menu to navigate to the desired content.
Suturing Tutorials
The following suturing tutorials provide instruction on the basic interrupted suture, as well as the vertical and horizontal mattress suturing techniques
Note: Approximate length of this media program is 5 minutes.
Note: Approximate length of this media program is 9 minutes.
Incision and Drainage of an Abscess (a common procedure in primary care)
Note: Approximate length of this media program is 10 minutes.
Dermablade Use for Shave Biopsies
Note: Approximate length of this media program is 5 minutes.
NURS 6512 Health History Assessment Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6512_Week_4_DCE_Assignment_2_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
| Excellent | Good | Fair | Poor | ||
| 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. |
Points Range: 56 (56%) – 60 (60%)
DCE score>93 |
Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92 |
Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85 |
Points Range: 0 (0%) – 45 (45%)
DCE Score <79 No DCE completed. |
|
| Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes 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: You should list these in bullet format and document the systems in order from head to toe. |
Points Range: 36 (36%) – 40 (40%)
Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 31 (31%) – 35 (35%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 26 (26%) – 30 (30%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 0 (0%) – 25 (25%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. |
|
| Total Points: 100 | |||||
Name: NURS_6512_Week_4_DCE_Assignment_2_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
Properly identifying the cause and type of a patient’s skin condition involves a process of
elimination known as differential diagnosis. Using this process, a health professional can
take a given set of physical abnormalities, vital signs, health assessment findings, and
patient descriptions of symptoms, and incrementally narrow them down until one
diagnosis is determined as the most likely cause.
In this Lab Assignment, you will examine several visual representations of various skin
conditions, describe your observations, and use the techniques of differential diagnosis to
determine the most likely condition.
To Prepare
Review the Skin Conditions document provided in this week’s Learning Resources, and
select one condition to closely examine for this Lab Assignment.
Consider the abnormal physical characteristics you observe in the graphic you selected.
How would you describe the characteristics using clinical terminologies?
Explore different conditions that could be the cause of the skin abnormalities in the
graphics you selected.
Consider which of the conditions is most likely to be the correct diagnosis, and why.
Search the Walden library for one evidence-based practice, peer-reviewed article based
on the skin condition you chose for this Lab Assignment.
Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to
guide you as you prepare your SOAP note.
Download the SOAP Template found in this week’s Learning Resources, and use this
template to complete this Lab Assignment.
The Lab Assignment
Choose one skin condition graphic (identify by number in your Chief Complaint) to
document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan)
note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan
text and the Comprehensive SOAP Template in this week's Learning Resources for
guidance. Remember that not all comprehensive SOAP data are included in every patient
case.
Use clinical terminologies to explain the physical characteristics featured in the graphic.
Formulate a differential diagnosis of three to five possible conditions for the skin graphic
that you chose. Determine which is most likely to be the correct diagnosis and explain
your reasoning using at least three different references, one reference from current
evidence-based literature from your search and two different references from this week’s
Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: NURS 6512 Health History Assessment
Lopes Write Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
Important information for writing discussion questions and participation
Welcome to class
Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to
I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.
Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.
If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.
Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.
Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource