NURS 6512N Assignment: Comprehensive Physical Assessment -

Sample Answer for NURS 6512N Assignment: Comprehensive Physical Assessment Included After Question

Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.

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To Prepare

Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment 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 Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.

DCE Comprehensive Physical Assessment:

Complete the following in Shadow Health:

Episodic/Focused Note for Comprehensive Physical Assessment 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 9 Day 7 deadline.

NURS 6512N Assignment Comprehensive Physical Assessment

Submission and Grading Information

By Day 7 of Week 9

Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment 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 copy and paste the same Documentation Notes into your Assignment submission link below.
Download, sign, date, and submityour Student Acknowledgement Form found in the Learning Resources for this week.

Grading Criteria

To access your rubric:

Week 9 Assignment 3 DCE Rubric

Submit Your Assignment by Day 7 of Week 9

To submit your Lab Pass:

Week 9 Lab Pass

To participate in this Assignment:

Week 9 Documentation Notes for Assignment 3

To Submit your Student Acknowledgement Form:

Submit your Week 9 Assignment 3 DCE Student Acknowledgement Form

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A Sample Answer For the Assignment: NURS 6512N Assignment: Comprehensive Physical Assessment

Title: NURS 6512N Assignment: Comprehensive Physical Assessment

Chief Complaint (CC): Tina Jones is a 28-year-old African American that came to the unit for her pre-employment physical examination.

History of Present Illness (HPI): Tina Jones has come today for her pre-employment physical assessment. According to her, she has been employed at Smith, Stevens, Stewart, Silver & Company, and is required to undertake the assessment before reporting at her new workplace. Jones no acute health problems currently. She reports that her last visit to a healthcare provider was four months ago for annual gynecological exam. Her last general physical examination as five months ago where she was prescribed daily inhaler and metformin twice a day. She currently uses daily inhaler (Proventil rescue inhaler, twice daily) and diabetes medication (Metformin 850 mg twice daily). She is also taking birth control pills prescribed for polycystic ovarian syndrome diagnosed during her last gynecological visit. Her diabetes is controlled with metformin, exercise and diet.

Medications: Jones noted that she is currently on the following medications

Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
Metformin, 850 mg PO BID (last use: this morning)
Drospirenone and ethinyl estradiol PO QD (last use: this morning)
Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)
Acetaminophen 500-1000 mg PO prn (headaches)
Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)

Allergies: Jones denies no new allergies as well as seasonal allergies. She reports that she is allergic to penicillin, dust and cats. The associated allergic symptoms include rhinorrhea, exacerbated asthma symptoms, and swollen eyes. She does not have food or latex allergy.

Past Medical History (PMH): Jones reports that her last health visit was 4 months ago when she underwent her annual gynecological exam. She was diagnosed with polycystic ovarian syndrome, which she has been treating with oral contraceptives. She has a history of asthma and diabetes. She was diagnosed with diabetes when she was 24 years. She controls diabetes with metformin, dietary modifications, and exercise. Her blood glucose levels are currently controlled. She performs daily self-monitoring of blood glucose, with her blood glucose levels being around 90. She has adequate supplies for blood glucose monitoring. She was diagnosed with asthma at the age of two and half years and has been using albuterol inhaler to manage and prevent it. She denies recent asthma exacerbations or current asthma symptoms. Last asthma exacerbation was three months ago. She has a history of hospitalization due to asthma when she was in high school. She also has a history of hypertension, which resolved following her dietary modifications and engaging in physical activity. She has a history of optometrist visit (3 months ago) where she was prescribed eyeglasses to improve vision.

Past Surgical History (PSH): She reported that she has no history of surgery.

Sexual/Reproductive History: Her menarche was when she was 11 years. Her first sexual encounter was when she was 18 years. Identifies herself as heterosexual. Her menarche pattern is every four weeks, which last five days, with medium flow. Her last menstrual period was 2 weeks ago. She was diagnosed with polycystic ovarian syndrome four months ago and has been on treatment. Her menstrual period lasts about five days. She reports that she is currently in a new month-old relationship. She intends to use condoms with any sexual activity. Tested negative for HIV/AIDS and STIs four months ago. She has never been married nor pregnant.

Personal/Social History: Jones currently lives with her sister and mother and intends to live alone in a month’s time close to her workplace. She is a graduate with accounting degree. She secured a job with Smith, Stevens, Steward, Silver & Company to start in 2 weeks’ time as an accounting clerk. She has strong support system comprising her friends, family, and church. She spends her time with friends, reading, attending bible study, volunteering in her church and dancing. No history of tobacco use. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin.

Health Maintenance: Jones utilizes health screening services. Her last gynecological exam was four months ago where she was diagnosed with polycystic ovarian syndrome. Her dental examination was done last five months ago. She reports that their home has smoke detectors. She drinks 2-3 alcohol drinks per month and 2 or 3 single drinks (rum and diet coke) when out with friends. Her typical diet comprises of fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt. Lunch comprises of dinner leftovers or tuna or chicken sandwich on wheat bread. Her typical dinner is vegetables with a protein and brown rice or quinoa. Her snack is carrot sticks or an apple. She limits intake of caffeine due to sleep and heart problems. She does not drink coffee. She drinks about 2 diet cokes per day. She engages in mild to moderate exercises by walking four or five times a week, lasting 30-40 minutes. She also swims weakly at YMCA. She reports improved ability to cope with stress after passing graduating and passing CPA exam. She sleeps 8-9 hours a night.

Immunization History: Jones reports that she believes that all her immunizations are current.

Significant Family History: The following are Jones’ significant family histories

Her father died of car accident. He had a history of high cholesterol, type 2 diabetes, and hypertension
Her brother, Michael is overweight
Her sister, Britney is asthmatic
Her deceased maternal grandmother had hypertension, stroke, and high cholesterol
Her deceased maternal grandfather had hypertension, high cholesterol, and stroke
Her paternal grandmother has hypertension
Her deceased paternal grandfather had colon cancer and type 2 diabetes
Her paternal uncle is alcoholic
There is no history of kidney disease, thyroid problems or any other cancers in the family

Review of Systems:

General: Jones denies chills, fatigue, recent illness, or night sweats She reports recent weight loss of about 10 pounds due to diet and increased exercise

HEENT: Jones denies headache, head injuries, changes in hearing, ear pain or discharge. She denies eye pain, discharge, itchiness, redness, or dry eyes. She uses corrective lenses. She denies changes in smell, sneezing, nosebleeds, sinus pain, sinus pressure, or rhinorrhea. Her dental visit was five months ago. She denies changes in senses of taste, dry mouth, mouth pain, sores, tongue, or gum problems. She denies dysphagia, sore throat, chronic throat problems, neck pain, lymphadenopathy, or swollen glands.

Respiratory: Denies current breathing problems, wheezing, chest tightness, pain when breathing, or cough.

Cardiovascular/Peripheral Vascular: She denies palpitations, irregular heartbeat, easy bruising, edema, or circulation problems.

Gastrointestinal: She denies nausea, vomiting, stomach pain, constipation, diarrhea, or flatulence.

Genitourinary: She denies dysuria, nocturia, polyuria, frequency, blood in urine, flank pain, vaginal itchiness, or abnormal discharge. She denies breast lumps or pain

Musculoskeletal: She denies muscle or joint pain, muscle weakness, or swelling.

Neurological: She denies dizziness, vision disturbance, numbness, tingling, loss of coordination, seizures, or balance problems.

Psychiatric: She denies history of mental problems

Skin/hair/nails: Reports using sunscreen when exercising outdoors, no recent slow healing wounds, improving acne, and some male-hair like pattern. Denies no changes in moles, dandruffs, sores, nail fungus, or dry skin.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Respiration- 15

Temp- 37.2 C

Heartrate – 78

SpO2- 99%

Height: 170 cm
Weight: 84 kg
BMI: 29.0
Blood Glucose: 100
RR: 15
HR: 78
BP:128 / 82
Pulse Ox: 99%
Temperature: 99.0 F

General: Jones is alert oriented, seated upright on examination table, and is in no distress. She is well-nourished, developed, and dressed appropriately with good hygiene.

HEENT: Head is normocephalic, atraumatic. Eyes bilateral with equal hair distribution on lashes and eyebrows. No lesions on lids, no edema or ptosis. Pink conjunctiva, white sclera, PERRLA bilaterally, intact extraocular eye movements, and no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection.

Neck: Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Chest/Lungs: Lung sounds clear and voice is present in all areas. Spanish symmetrically. Chest anterior and posterior normal upon inspection. fremitus equal bilaterally. Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Heart/Peripheral Vascular: Pirated 2 + with no thrill or bruit bilaterally. PMI non-discplaced. S1 and S2 only regular rhythm. No bruit in aorta or any other arteries. Capillary refill is less than 3 seconds in fingers and toes no edema is present. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

Abdomen: bowel sounds are normal in all quadrants. moves bowels regularly. Abdomen is soft with no Masses. liver is one centimeter below the right costal margin. Quadrants are tympanic and spleen is Not dull in sound. Kidney is not palpable no masses are present

Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Genital/Rectal: –

Musculoskeletal: Range of motion in all areas of full or muscle strength or 5 out of 5 no CVA tenderness. DTR 2+. Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.

Neurological: for the feet especially left foot area. Patient is able to sense position of body fingers and toes. Graphesthesia normal sense. Patient is oriented to time person and place. Heel to Shin normal. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin: Acne is present on the face. Skin is normal. Norwegians or abnormalities in the nails. Old scar is present on the left shin.

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities.

Diagnostic results: None

ASSESSMENT: Jones is a 28-year-old female that has come today for her pre-employment assessment. She appears well dressed and responsive. She is diabetic and asthmatic, which are controlled. She uses corrective lenses. She has normal sleeping cycle. She engages in active physical activity and has dietary modifications for diabetes control. She monitors her blood glucose levels on a daily basis. She also monitors her peak flow to track asthma and uses albuterol inhaler to manage its symptoms. She denies any current acute health problems.

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

Grading Rubric

Performance Category	100% or highest level of performance 100% 16 points	Very good or high level of performance 88% 14 points	Acceptable level of performance 81% 13 points	Inadequate demonstration of expectations 68% 11 points	Deficient level of performance 56% 9 points	Failing level of performance 55% or less 0 points
Total Points Possible= 50	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Scholarliness Demonstrates achievement of scholarly inquiry for professional and academic topics.	Presentation of information was exceptional and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was good, but was superficial in places and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was minimally demonstrated in all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in one of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in two of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in three or more of the following elements Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information
	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Application of Course Knowledge Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations	Presentation of information was exceptional and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was good, but was superficial in places and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was minimally demonstrated in the all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in one of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from and scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in two of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in three of the following elements Applies principles, knowledge and information and scholarly resources to the required topic. Applies facts, principles or concepts learned scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.
	10 Points	9 Points			6 Points	0 Points
Interactive Dialogue Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic.	Demonstrated all of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 3 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.			Demonstrated 2 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 1 or less of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.
	8 Points	7 Points	6 Points	5 Points	4 Points	0 Points
Grammar, Syntax, APA Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error.	The following was present: 0-3 errors in APA format AND Responses have 0-3 grammatical, spelling or punctuation errors AND Writing style is generally clear, focused on topic,and facilitates communication.	The following was present: 4-6 errors in APA format. AND/OR Responses have 4-5 grammatical, spelling or punctuation errors AND/OR Writing style is somewhat focused on topic.	The following was present: 7-9 errors in APA format. AND/OR Responses have 6-7 grammatical, spelling or punctuation errors AND/OR Writing style is slightly focused on topic making discussion difficult to understand.	The following was present: 10- 12 errors in APA format AND/OR Responses have 8-9 grammatical, spelling and punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand.	The following was present: 13 – 15 errors in APA format AND/OR Responses have 8-10 grammatical, spelling or punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand. AND/OR The student continues to make repeated mistakes in any of the above areas after written correction by the instructor.	The following was present: 16 to greater errors in APA format. AND/OR Responses have more than 10 grammatical, spelling or punctuation errors. AND/OR Writing style does not facilitate communication
	0 Points Deducted					5 Points Lost
Participation Requirements	Demonstrated the following: Initial, peer, and faculty postings were made on 3 separate days					Failed to demonstrate the following: Initial, peer, and faculty postings were made on 3 separate days
	0 Points Lost					5 Points Lost
Due Date Requirements	Demonstrated all of the following: The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.					Demonstrates one or less of the following. The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.