View Gastrointestinal | Completed | Shadow Health 2.pdf from NSG 516 at Rivier University. How would you have proceeded? During a gastrointestinal exam the purpose of light … She drinks alcohol occasionally, last was 2 weeks ago, and was 1 drink. Hunter College CUNY. Try to think of all the questions you can related to the presenting problem and what kind of problems they might experience in each system. Terms. Do you drink alcohol? In order to obtain an accurate health history regarding the GI system, appropriate questions need to be asked with terms the patient will understand. She noticed the pain about a … She denies use of tobacco and illicit drugs. Reports that she takes between 2 to 4 "every, few days". A detailed health history would include multiple systems of the body, however, we will be focusing on the gastrointestinal (GI) system. She denies fevers, chills, and night sweats. NB: We have all the questions and documented answers in the SUBJECTIVE DATA, OBJECTIVE DATA, ASSESSMENT AND CARE PLAN format. The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the … Useful guide for Chamberlain students in the United States. • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. The date, time, and duration of the weekly debriefing session will be posted by the course faculty. No Social drinker (rarely) 2 or less/day 3 or greater/ day Do you use recreational drugs? – Education level (health literacy) – Access to health care Insurance/Financial status – Is the patient able to afford medications and health diet, and other out-of-pocket expenses? She noticed the … A combination of open and closed questions will yield better patient data. She denies coffee intake, but does drink cola on a regular basis. and the . Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify … No Yes ____years History of drug abuse? Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough. She describes it "kind of like heartburn" but states that it can be sharper. Breakfast is usually a muffin or. (Abdominal Pain) Pre Brief: Ms. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain.She reports that the pain isn’t severe, but that her daughter was concerned and brought her in. NR 509 Gastrointestinal Documentation Shadow.pdf - Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health Gastrointestinal Physical, 814 out of 839 people found this document helpful, Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health, Gastrointestinal Physical Assessment Assignment Results | Turned In, Advanced Health Assessment - Chamberlain, NR509-October-2018, Patient info: Tina Jones, 28, African-American, Onset: Pain has been happening for "at least a. The following details are facts of the patient's case. Denies blood in stool, dark stools, or maroon stools. Hope that helps. She describes it “kind of like, heartburn” but states that it can be sharper. HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. • Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. pumpkin bread, lunch is a sandwich with chips, vegetable, snacks are French fries or pretzels. Course Hero is not sponsored or endorsed by any college or university. Gastrointestinal | Completed | Shadow Health 5.pdf, NR 509 Abdominal Pain Documentation Shadow.pdf, Esther Parks _Abdominal Pain _ Objective.Data_ Shadow Health.pdf, NR 509 Abdominal Pain Objective Shadow.pdf, NR 509 Abdominal Pain Subjective Shadow.pdf, California State University, Long Beach • NURSING 305, Gastrointestinal Physical Assessment Assignment _ Documentation.pdf, Shadow Health Gastrointestinal Documentation.docx, Gastrointestinal Results...DOCUMENTATION.PDF.docx, Copyright © 2021. On Stuvia you will find the most extensive lecture summaries written by your fellow students. NR 509 Week 5 Shadow Health: Gastrointestinal Physical Assessment – REVIEW QUESTIONS Which of the following physical exam tests could … used if you suspected cholecystitis in Tina? Suppose that you were concerned that Tina may have had an enlarged spleen. She denies. Shadow Health Gastrointestinal Documentation. Review of Systems: General: Denies changes in. She noticed the pain about a month ago. Pain is worse when lying down or, Relieving Factors: Time between meals, sitting, Current Medications: OTC Tums to relieve stomach, pain. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. She notes it to increase with consumption of food and specifically fast food and spicy food make pain worse. University. She does notice that she has increased, burping after meals. This preview shows page 1 - 2 out of 4 pages. dvanced ealth ssessment health history tina got this scrape on my foot while ago, and thought it would heal up on its own, but now looking pretty nasty. Pain is a 5/10 and is located in her upper stomach. N522 Assignment 4 physical assessment – Focused Note - Esther ParkAfter you complete the focused assessment (virtual simulation), please write a paper using the following as headings/subheadings in APA format.Introduction (with purpose statement – one paragraph)Focus of the Assessment (i Written documentation for clinical management of patients within health care settings usually include one or more of the following components. No bruits with auscultation over abdominal aorta. Uncategorized. Asked about onset of pain Reports chest pain started appearing in the past month. Social History Questionnaire Page 5 Patient’s Name_____ SUBSTANCE ABUSE HISTORY Have any of your family members had problems with alcohol and/or drug abuse?_____ Please describe who, their relationship to you, and the substances they abused._____ Screening/Risk Assessment – Identified health concerns based on screening assessments and demographic information Nutrition/Activity reports frequently occurring stomach pain, how many times a week does your stomach hurt, reports 3-4 episodes a week that are more severe, how long after a meal does the pain start, how many hours does the stomach pain last, center of upper stomach, below the breasbone, doesn't want to eat out of anticipation of pain, what medications do you take for stomach pain, do you have trouble holding your urine in, what was your most recent meal and what did you eat, how many times a week do you drink alcohol, do you think you could have food poisoning, how far away is the grocery store from you, do you have nausea, vomiting, diarrhea, constipation, bloating, do you have sore throat, coughing, dysphagia, difficulty breathing, chest pain, palpitations, change in taste, family history of GERD, IBS, cholecystitis, liver/kidney/bladder disease. She notes it to increase with … She does not exercise. known history of murmurs, dyspnea on exertion. Educate on lifestyle changes including weight loss, engagement in daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coffee, alcohol, and spicy foods. She denies use … Shadow Health Gastrointestinal Documentation Documentation / Electronic Health Record • Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. • Respiratory: Chest is symmetrical with respirations. Avoid resits and get better grades with material written specifically for your studies. Denies any change in stool color, consistency, or frequency. She drinks alcohol occasionally, last was 2. weeks ago, and was 1 drink. She, denies coffee intake, but does drink diet cola on a, regular basis. Faculty will lead virtual debriefing sessions during Weeks 1-6. She denies fevers, chills, and night sweats. No Yes ____years Make sure that you understand what the patient means and get amplification of specific points. Location: Upper stomach, "under the breastbone". Your patient is Esther Park, a 78-year-old Korean-American woman presenting with abdominal pain in Shadow General Hospital’s Emergency Department. She denies coffee intake, but does drink diet cola on a regular basis. Chief Complaint. Duration: Pain occurs everyday with 3 to 4 episodes, a week that are worse. Your role in this simulation is that of a healthcare provider who will conduct a focused history and physical examination of Ms. Park in order to assess her condition and transfer her care. Students must register to attend the debriefing session. • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks, precordial movements. The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. Privacy Course. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or … She noticed the pain about a month ago. Sign in Register; Hide. Pain starts 10 to 15 minutes, Characteristics: Pain at the worst is "6 or 7" out of, Aggravating Factors: Eating, especially larger meals, or spicy foods. DON’T STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW. Critically appraise the findings as normal or abnormal. She does notice that she has increased burping after meals. NURS 612 Shadow Health All Modules Cases Instructor Keys. Shadow Health will grade you on what you ask and will deduct points for what you omitted. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. She, noticed the pain about a month ago. No blood in emesis. History of Present Illness. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. stomach pain after eating. Course Resources: NR 509 Week 5 Shadow Health Gastrointestinal Physical Assessment Assignment. Spleen and bilateral kidneys are not palpable. Shadow Health All Modules Cases Instructor Keys. Bowel sounds present and normoactive in all quadrants. No femoral, iliac, or renal bruits. She describes it kind of like heartburn but states that it can be sharper. Shadow Health Respiratory Assessment Pre Brief. Course Hero, Inc. Advnc Health Assessm (NURS 751.00) … She denies coffee intake, but does drink diet cola on a regular basis. Gastrointestinal Results | Turned In Advanced Health Assessment - Spring 2019, NSG516 Online Return to Tympanic throughout. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. may make the patient wonder if the c… Presenting to shadow health hospital clinic for a complete health assessment for a pre-employment physical. 2. 'Do you have a hard stool?' She denies use of tobacco and illicit, drugs. No CVA tenderness. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Avoid technical terms, jargon or abbreviations. She states that time generally, makes the pain better, but notes that she does treat, the pain “every few days” with an over the counter, Social History: She denies any specific changes in, her diet recently, but notes that she has increased, her water intake. HISTORY AND PHYSICALS Lois E. Brenneman, M.S.N., C.S., A.N.P., F.N.P. Asked about location of pain Reports pain is in center of the chest … She states that time generally makes the pain better, but notes that she does treat the pain "every few days" with an over the counter antacid with some relief. Case - Nr 509 week 1 shadow health conversation concept lab complete. No Yes, type: _____ Occasionally Weekly Daily History of alcohol abuse? Complete the Shadow Health Concept Lab (Weeks 2, 4, and 5) prior to beginning the graded assignment. She does not exercise. She denies known history of murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. Tina Jones is a 28year old African America female with a history of diabetes and Asthma presenting to get a complete health … She maintains eye contact throughout interview and examination. Pain is a 5/10 and is located in, her upper stomach. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. Social History: She denies any specific changes in her diet recen but notes that she has increased her water intake. Introduce yourself – name / role Confirm patient details – name / DOB Explain the need to take a history Gain consent Ensure the patient is comfortable No known jaundice, problems with liver or spleen. Discuss the components of a focused gastrointestinal assessment. Pain is a 5/10 and is located in her upper stomach. Ask open questions and give the patient time to elaborate. Bowel movements are daily and generally brown in color. Established chief complaint Reports sporadic chest pain. “I came in because I’m required to have a recent physical exam for the health insurance at my new job.” History of Present Illness. It is very important to determine whether or not the situation is an emergency and that the underlying cause of Esther’s discomfort. Gather subjective and objective data by completing a focused, detailed health history and physical examination for each physical assessment assignment. Shadow Health Gastrointestinal Documentation Documentation / Electronic Health Record • Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. No tenderness to light or deep palpation. • Cardiac: Denies a diagnosis of, hypertension, but states that she has been told her, blood pressure was high in the past. Shadow Health’s patient cases are designed for both novice and expert students to practice communicating with and examining patients. General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She, notes it to increase with consumption of food and, specifically fast food and spicy food make pain, worse. After successful completion of this course, you will be able to: 1. Summary - shadow health gastrointestinal physical assessment review questions 35. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chip dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. However, it is very important to ascertain that you are 'speaking the same language'. weight and general fatigue. Patient is not taking any other new, medications other than her inhalers and OTC pain, HPI: Ms. Jones is a pleasant 28-year-old African, American woman who presented to the clinic with, complaints of upper stomach pain after eating. To patients, the word 'stomach' can mean anywhere from the diaphragm to the groin and includes the genitals. She denies use of tobacco and … All you need to do is ORDER NOW for an equivalent of 4 pages and score 100% in this assignment and all other Shadow Health Assignments. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. Review of Systems: General: Denies changes in weight and general fatigue. She states that, she experiences pain daily, but notes it to be worse, 3-4 times per week. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. She is alert and oriented. 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