Pediatric Cough Shadow Health for Danny Rivera

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Danny Rivera is an 8 year old male patient who reports to have had a cough for the last 4 to 5 days. He reports the cough is worse at night and makes him not sleep well and also gets fatigued. He describes the cough as watery. He also has a running nose. He has mild soreness in his throat which he relieves with over the counter drugs. He had ear infections when young and had pneumonia in the past. He denies any headache, dizziness, fever, sputum, chest pain, , abdominal pain or breathing problems. His cough does not get worse when he is active.	Return to Canvas to complete your SOAP note for this assignment. Pediatric Cough Shadow Health for Danny Rivera
Objective HEET: Mucus membranes are moist, with a clear nasal discharge. Redness, cobblestoning at the back of the throat. Eyes are dull with pink conjuctiva. Right tympanic memebrane is inflamed . It is also red. The right cervical lymph node is tender and enlarged. Cardiovasicular: S1, S2. There is neither murmurs, gallops nor rubs. Respiratory: Respiratory rate is increased but no distress. Breath sounds are clear to auscultation and negative bronchophony. The chest wall is resonant to percusion. Spirom… Pediatric Cough Shadow Health for Danny Rivera

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Week 4: SBAR Focused Exam: Cough Results | Turned In – Pediatric Cough Shadow Health for Danny Rivera

NUR 3069C Health Assessment and Communication – May ’18 (Gannon – Jacksonville Only), 3069C

Return to Assignment

Your Results

Lab Pass

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Experience Overview

Patient: Danny Rivera

Student Performance Index

32.95 out of 34

Documentation

SBAR

Proficiency Level: Proficient

Digital Clinical Experience Score – Pediatric Cough Shadow Health for Danny Rivera

96.9%

• Beginning
• Developing
• Proficient

Students rated as “proficient” demonstrate entry-level expertise in nursing competencies and clinical reasoning skills. In comparable nursing programs, the top 25% of students perform at the level of a proficient nurse.

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as

Subjective Data Collection

19 out of 19

Time

Objective Data Collection

13.95 out of 15

documentation or time spent.

72 minutes total spent in assignment

Interaction with patient

72 minutes

Objective Data Collection: 13.95 of 15 (93%) Pediatric Cough Shadow Health for Danny Rivera

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• Correct
• Partially correct
• Incorrect
• Missed

Inspected eyes and orbital area                                1of1point

Orbital Area (1/4 point)

Sclera (1/4 point)

• No visible abnormal findings Ptosis
• Eyelid Lesion
• White Yellow tint Redness

Conjunctiva (1/4 point)

Conjunctival Discharge (1/4 point)

• Moist and pink Dry appearance Redness Swelling
• No discharge
• Clear, watery discharge Purulent discharge

Inspected nasal cavities                            0.75of1point

Color (No point)

Discharge (1/4 point)

• Pink Red Bluish
• No discharge Clear discharge Bloody discharge Purulent discharge

Turbinate Patency (1/4 point)

Observations (1/4 point)

• Patent
• Decreased patency Not patent
• No additional visible abnormal findings Foreign body present
• Polyp
• Septum perforated Septum deviated Lesion

Inspected ears                              0.8of1point

Right: Auditory Canal Color (No point)

Right: Tympanic Membrane Color (No point) Pediatric Cough Shadow Health for Danny Rivera

• Pink Red Pallor
• Pearly gray Red Opaque Yellow
• Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

• No visible abnormal findings Fluid observed
• Visible scars Bulging

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• Perforation
• Retraction

Right: Cone Of Light (1/10 point)

5:00

• Cone of light distorted

Right: Discharge (1/10 point)

Left: Auditory Canal Color (1/10 point)

• No discharge Cerumen
• Clear discharge Bloody discharge Purulent discharge
• Pink Red Pallor

Left: Tympanic Membrane Color (1/10 point)

Left: Tympanic Membrane Appearance (1/10 point)

• Pearly gray Red Opaque Yellow
• Not visible because of cerumen
• No visible abnormal findings Fluid observed
• Visible scars Bulging Perforation Retraction

Left: Cone Of Light (1/10 point)

Left: Discharge (1/10 point)

7:00

• Cone of light distorted
• No discharge Cerumen
• Clear discharge Bloody discharge Purulent discharge

Inspected mouth and throat                              0.4of1point

Oral Mucosa (No point)

Tonsils (No point) Pediatric Cough Shadow Health for Danny Rivera

• Moist and pink Dry appearance Redness
• No visible abnormal findings Swelling
• Redness

Throat Color (1/5 point)

Throat Texture (1/5 point)

• Pink Red
• No abnormal findings Cobblestoning Exudate

Post Nasal Drip (No point)

• No discharge
• Clear discharge
• Purulent discharge

Inspected neck                                1of1 point

Symmetry (1/2 point)

Appearance (1/2 point)

• Symmetric Asymmetric
• No visible abnormal findings Swelling
• Visible pulsation Visible mass Discoloration

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Inspected chest                                1of1 point

Symmetry (1/2 point)

Appearance (1/2 point)

• Symmetric Asymmetric
• No visible abnormal findings Rash
• Barrel chest
• Intercostal retraction while breathing Excessive use of accessory muscles while
• breathing
• Skin growths (freckles or moles)

Auscultated breath sounds                                1of1point

Breath Sounds (1/3 point)

Adventitious Sounds (1/3 point)

• Present in all areas Diminished in some areas Absent in some areas
• No adventitious sounds Wheezing
• Fine crackles Stridor Rhonchi Rales

Location (1/3 point) Pediatric Cough Shadow Health for Danny Rivera

All areas clear

• Adventitious sounds in anterior right upper lobe Adventitious sounds in anterior right middle lobe
• Adventitious sounds in anterior right lower lobe Adventitious sounds in anterior left upper lobe
• Adventitious sounds in anterior left lower lobe Adventitious sounds in posterior right upper lobe
• Adventitious sounds in posterior right lower lobe Adventitious sounds in posterior left upper lobe
• Adventitious sounds in posterior left lower lobe

Auscultated for bronchophony                                1of1point

Bronchophony (1/1 point)

• Positive
• Negative

 

Auscultated heart sounds                                1of1point

Heart Sounds (1/2 point)

Extra Heart Sounds (1/2 point)

• S1 and S2 audible
• S1, S2, and S3 audible S1, S2, and S4 audible
• S1, S2, S3, and S4 audible
• No extra sounds Gallops
• Murmur Friction rub Valve clicks

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Percussed chest wall                                1of1point

Observations (1/2 point)

Location (1/2 point)

• All areas resonant
• Some areas dull, some resonant
• Some areas hyperresonant, some resonant
• No areas of dullness

Dullness

• anterior right upper lobe Dullness
• anterior right middle lobe Dullness
• anterior right lower lobe Dullness
• anterior left upper lobe Dullness
• anterior left lower lobe Dullness
• posterior right upper lobe Dullness
• posterior right lower lobe Dullness
• posterior left upper lobe Dullness
• posterior left lower lobe Pediatric Cough Shadow Health for Danny Rivera

 

Measured diaphragmatic excursion                                1of1point

Range (1/1 point) Pediatric Cough Shadow Health for Danny Rivera

• 3-5 cm
• Greater than 3-5 cm
• Less than 3-5 cm

Palpated sinuses                                1of1point

Frontal (1/2 point)

Maxillary (1/2 point)

• None reported Tenderness reported
• None reported Tenderness reported

Palpated lymph nodes                                1of1point

Head And Neck (1/3 point)

Supraclavicular (1/3 point)

• No palpabe nodes
• Palpable nodes on right side
• Palpable nodes on left side
• No palpable nodes

Axillary (1/3 point) Pediatric Cough Shadow Health for Danny Rivera

• No palpable nodes
• Palpable nodes on right side
• Palpable nodes on left side

Palpated fremitus                                1of1point

Symmetry (1/2 point)

Vibration (1/2 point

• Equal bilaterally
• Unequal bilaterally
• Expected fremitus
• Decreased fremitus

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alpated chest expansion                                                                               1 of 1 point

Symmetry (1/1 point) Pediatric Cough Shadow Health for Danny Rivera