WK 7 Assignment 1 Chest Pain Comprehensive
WK 7 Assignment 1 Chest Pain Comprehensive
WK 7 Assignment 1 Chest Pain Comprehensive
Instructions and Rubric
Welcome to week 7! I think as nurses we are all aware of the impact of cardiovascular disease in the United States and worldwide.
This week, you will evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.
You will be working on another episodic note with in Shadow Health. Also, there is required media videos that I believe is of great value to them.
To access the videos, click on the required media. Click on Continue at the bottom of the video and it will take you to 3 scenarios.
You will have the following Required Digital Clinical Experience Assignments (Chest Pain and Cardiovascular Concept Lab) and 2 Optional Lab Assignments this week.
These are listed below. I have attached a SOAP NOTE Template to use for this assignment.
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Assignment 1
To Prepare
Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? WK 7 Assignment 1 Chest Pain Comprehensive
DCE Focused Exam: Chest Pain Assignment:
Complete the following in Shadow Health:
Cardiovascular Concept Lab (Required)
Respiratory (Recommended but not required)
Cardiovascular (Recommended but not required)
Episodic/Focused Note for Focused Exam: Chest Pain (Required)
Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System
Photo Credit: [Squaredpixels]/[E+]/Getty Images
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale.
How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health.
Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
To Prepare
Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
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 Focused Exam: Chest Pain 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 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what history would be necessary to collect from the patient. WK 7 Assignment 1 Chest Pain Comprehensive
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
DCE Focused Exam: Chest Pain Assignment:
Complete the following in Shadow Health:
Cardiovascular Concept Lab (Required)
Respiratory(Recommended but not required)
Cardiovascular (Recommended but not required)
Episodic/Focused Note for Focused Exam (Required): Chest Pain
Name:
Section:
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the past month.”
History of Present Illness (HPI): Mr. Brian Foster, a 58-year-old Caucasian male, presented to the with chest pain that manifested itself in three separate episodes over the course of a month, which is currently occurring on a regular basis.
The client characterized the pain as tightness, giving it a severity rating of 5/10. The pain persists for a few minutes and is situated in the center of the chest, according to the client’s description.
Patient says that strenuous tasks like gardening and climbing stairs exacerbate the chest pain, which is not accompanied by any other symptoms.
He said that he was not using any medicine to alleviate the pain since resting helped him. The client denies having a headache, nausea, cough, chills, or fever.
He also denies smoking or taking illegal substances, though he does drink two to three beers on the weekends.
Medications:
Ibuprofen 400mg as needed for muscle discomfort
Lisinopril 20mg P.O. daily
Atorvastatin 20 mg P.O. daily
Omega 3 Fish Oil 1200mg PO BID
Allergies: Codeine allergy reported. Denies food, latex, and environmental allergies.
Past Medical History (PMH): Hypertension and hyperlipidemia stage II diagnosis one year ago.
Past Surgical History (PSH): denies any surgical history
Sexual/Reproductive History: Heterosexual. Sexually active for 27 years with his wife. Has two children aged 26 and 19.
Personal/Social History: Brian says that he drinks two to three beers each week on average. He denies smoking cigarettes or using illegal substances. Brian does not follow a strict diet, but he does consume four to five servings of fruit per week as well as four glasses of water per day on average.
Since his bicycle broke down, he has not been able to exercise for almost two years. Mr. Foster said that he has healthcare coverage and that he does not have financial difficulties in paying for his medicines. WK 7 Assignment 1 Chest Pain Comprehensive
Immunization History: influenza vaccine is current. Took Tdap in October 2014.
Significant Family History:
Mother is 80 years old with a medical history of types two diabetes and hypertension.
Father deceased at the age of 75 from colon cancer, health history of hypercholesterolemia, obesity, and hypertension.
Brother died at 24 years old in a car accident
Sister is 52 years old, medical history of hypertension and type 2 diabetes.
The daughter is 19 years old with asthma.
The son is 26 years old, in good health.
The paternal grandmother deceased at 78 from pneumonia.
Paternal grandfather deceased at the age of 85 from “old age.”
Maternal grandfather deceased at 54 from heart attack.
Maternal grandmother deceased at 65 from breast cancer.
Review of Systems:
General: Reports gaining 20 pounds of weight in past few years. Denies fever, chills, fatigue, weakness, palpitations, and loss of appetite.
Cardiovascular/Peripheral Vascular: Denies palpitations, circulation problems, and edema.
Respiratory: Denies cough and dyspnea at rest.
Gastrointestinal: Denies heartburn, diarrhea, vomiting, nausea, and abdominal pain.
Musculoskeletal: Denies muscle problems.
Psychiatric: Occasional anxiety reported. Denies depression.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Pulse rate 104, blood pressure 140/90, respirations 19, pulse oximeter 98%. Height 5’11, Weight 197 lbs. BMI 27.5
General: Mr. Foster is a well-developed, well-nourished Caucasian man who is alert and oriented. He is attentive and provides satisfactory answers to all questions. His speech is clear and coherent.
Cardiovascular/Peripheral Vascular: S1, S2, and S3 audible with gallop. No JVD distension. Right carotid 3+ positive for both a bruit and thrill. Left carotid 2+ without bruit or thrill. Radial, brachial and femoral arteries 2+ amplitude and no thrills noted bilaterally. PMI displaced laterally.
Respiratory: symmetric chest, without observable abnormalities. Breath sounds are present in all areas. Fine crackles on posterior bases.
Gastrointestinal: Abdomen is soft, rounded, and non-tender. No bruit. Liver is palpable, spleen is non-palpable.
Musculoskeletal: Muscle pain denied upon palpation.
Neurological: Alert and oriented x3. Mood and affect are appropriate.
Skin: Warm and dry skin. No rashes. No abnormalities in the nails.
Diagnostic Test/Labs: EKG was regular and no ST elevation. A chest X-ray should be done as soon as possible to assess heart failure since it may also identify pulmonary problems.
A complete blood count (CBC), liver function, blood glucose, BUN, creatinine and electrolytes tests should be taken to see whether the blood is being filtered correctly and to rule out any blood problems that may exist.\
B-type natriuretic peptide (BNP) testing is performed at this lab to determine the concentration of a hormone produced by the left ventricle, which is used to determine the degree of heart failure in the patient (Dharmarajan et al., 2017).
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ASSESSMENT:
Congestive Heart Failure (Left-sided): Heart failure means that the heart muscles are weakened and are unable to adequately pump more blood.
It is because of insufficient circulation that the kidneys do not get sufficient blood to filter fluid out of the circulation and excrete it via the urine.
The remaining fluid collects in the eyes, liver, and lungs, where it becomes toxic (Povsic, 2017).
Angina: This happens when the blood supply to the cardiac muscle is decreased. Radiation-induced symptoms comprise heaviness and tightness.
A physical strain or a stressful situation may cause it to occur. The majority of the time, it will cease after a few minutes of relaxing (Angina, 2021).
Coronary Heart Disease: Most of the time, it is triggered by accumalation of plaque in the coronary arteries, which is very dangerous. The accumulation may partly or completely obstruct blood flow, resulting in damage to the areas of the body that are affected.
When most individuals have chest discomfort and go to the emergency room for assessment, they are unaware that they have CHD (Wirtz & Kanel, 2017).
Controlled Hypertension.
References
Angina. (2021, April 22). NHS. http://nhs.uk
Dharmarajan, K., & Rich, M. W. (2017). Epidemiology, pathophysiology, and prognosis of heart failure in older adults. Heart failure clinics, 13(3), 417-426.
Povsic, T. J. (2017). Emerging therapies for congestive heart failure. Clinical Pharmacology & Therapeutics, 103(1), 77–87.
Wirtz, P. H., & von Känel, R. (2017). Psychological stress, inflammation, and coronary heart disease. Current cardiology reports, 19(11), 1-10 . WK 7 Assignment 1 Chest Pain Comprehensive
