Health Assessment Student Handbook
Health AssessmentStudent HandbookYour guide to the Shadow Health Digital Clinical Experience UGV.1
Table of ContentsWelcome!. 3Health HistoryInstructions.4-5Self Reflection.6HEENTInstructions. 7RespiratoryInstructions. 8CardiovascularInstructions. ns.11NeurologicalInstructions.12Skin, Hair, & NailsInstructions.13Focused Exam: CoughInstructions.14Focused Exam: Chest PainInstructions.15Focused Exam: Abdominal PainInstructions.16Comprehensive AssessmentInstructions.17Health Assessment Student Handbook Copyright 2017 Shadow Health ShadowHealth.com2
Welcome!Shadow Health understands that you want to learn your core nursing competencies inthe most engaging and effective way possible. The Shadow Health Digital ClinicalExperience (DCE) provides you with a dynamic, immersive experience designed toenrich classroom instruction through the clinical examination of our Digital Standardized Patients. We are committed to providing you with an innovative, intuitive virtualclinical experience that offers comprehensive participation in a safe learning environment.Health Assessment Student Handbook Copyright 2017 Shadow Health ShadowHealth.com3
Health HistoryAs healthcare professionals, the health history helps us compile important information tobetter care for our patients. You should conduct a thorough patient interview to collect all thenecessary information to treat your patient.Patient Narrative: In this assignment, your patient, Tina Jones, has been admitted to thehospital for a painful foot wound, and you will conduct a health history as part of her admittalprocess. This assignment occurs at midnight on Tina Jones’ first day in the hospital. You willinteract with Ms. Jones throughout the course of her hospital stay, so this assignment is especiallyimportant to establish baseline information about your patient.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate90 minutes120 minutes150 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leaveGetting Started:View this tutorial for guidance on getting started with the Health History Assignment.Tips for success:Unlike the Conversation Concept Lab, there are no prompts during your interview, so you shouldprepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what taking a health history entails. There are essential sections of patient informationthat your interview will need to uncover. As you learned in the Conversation Concept Lab, thereare multiple essential questions for each of these topics:q Chief Complaintq History of Present Illnessq Pain Assessmentq Allergiesq Immunizationsq Medicationsq Medical Historyq Surgical Historyq Previous Hospitalizationsq Gynecological Historyq Family History (3 Generations)q Social Historyq Full Review of SystemsUndergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com4
Health HistoryKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedRemember when you are doing these exams that this simulation is designed to help you improveyour health assessment skills. Preparing ahead of time will help to set you up for success.Technical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.In all assignments, remember to complete your Self Reflection:What is Self Reflection?Self reflection enables us to look at our performance - be it on the job, in the classroom, or out onthe field - and critique our practice in a systematic and rigorous way. This process enables us todevelop a greater sense of self awareness and to create a plan to improve on areas of weaknessin our performance. We gain critical insights from this reflection that help us move from novicesto experts in our fields. Self-reflection is proven1 to improve our skills as providers, which leads tobetter patient outcomes.How do I begin?As you reflect on your practice, thinking about things that have gone well will help you tounderstand how you can make this happen more often. Conversely, thinking about things thathaven’t gone so well helps you to think about how things could be different in the future. Hereare some questions to ask yourself:1. What are you reflecting on?a. What assignment did you complete?b. How did you do on the assignment?c. Did you meet your goal and achieve a score you were happy with?2. How were you thinking and feelinga. What were you feeling while completing the assignment?b. How do you feel about your score?3. Evaluatea. What are the highs and lows of your experience?b. Were there any factors that influenced the outcome?4. Analyzea. What could I have done differently?b. What did I do that was successful that I will continue to do?c. What did I do that was unsuccessful that I will discontinue?5. Conclusiona. How do I feel about the overall experience?b. What have I learned about my practice?c. How will this experience change my nursing practice?d. Are there any factors in a real life scenario that may be different than this virtualenvironment that may prevent me from reaching my goal that I can anticipate?1Gustafsson, C., and Fagerberg, I. (2004), Reflection, the way to professional development?Journal of Clinical Nursing, 13: 271–280.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com5
Health HistoryExcerpt from an Excellent SelfReflectionExcerpt from a SatisfactorySelf ReflectionI asked Mrs. Smith about her healthhistory and tried to find more information about her low back pain,cough, and frequent urinary tractinfections. OLDCARTS helped guideme through the 7 dimensions of hercomplaints. I assumed that if I wentthrough OLDCARTS I would captureall of the information, and it seemsthat it really helped me get a veryclear picture of the problem. I askedabout her self-care related to herfrequent urinary tract infections toget a good idea of what educationand care she would need to preventthem. I should have addressed Mrs.Smith’s nutrition plan. This wouldhelp her manage her obesity, whichis probably contributing to her lowback pain. I should have askedMrs. Smith about the possibility ofquitting smoking and about whethershe had ever tried to quit (Stead etal., 2008).Mrs. Smith was a very easypatient to interview. I usedOLDCARTS to interview her, andit worked well. I think I really didwell. I missed a few things abouther diet and personal hygiene,but I won’t forget about thesethings in the future.Excerpt from an Unsatisfactory Self ReflectionI loved this experience!This is an incomplete reflection. A deep reflectionshould explain what aboutthe experience was foundto be meaningful and howit can help one become abetter nurse. Deep reflecWhile the student identified areas tions involve practitionersthat should improve, he or sheexamining and questioningdoes not make a specific andtheir practices and asmeasurable improvement plansumptions.or challenge any of his or herassumptions or practices. The reflection is incomplete with limitedintrospection.When I reviewed my transcript,it became apparent that I kept itpurely medical and rarely askedany social or cultural questions. Iused Jarvis to ask the subjectivequestions but didn’t think muchabout finding much else out. Thishas been really good for me toremember to think of my patientsas people with families and lives aswell as medical problems.Citation: Stead, L. F., Bergson, G.,& Lancaster, T. (2008). Physicianadvice for smoking cessation. Cochrane Database Syst Rev, 2 (2).This reflection describes the experience. It also describes clinicalreasoning and supporting citation.It demonstrates analysis of misseditems. It recognizes assumptionsand failings, and it addresses howthese may be addressed in thefuture.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com6
HEENTThe HEENT exam is an interview and physical exam that is concerned with the head, eyes, ears,nose and throat. It is performed when a patient presents with a problem with the HEENT system.Patient Narrative: In this assignment, your patient, Tina Jones, said that she felt congested.This is an opportunity for you to practice a full HEENT exam on Ms. Jones. This assignment occursat 8 a.m. on Ms. Jones’ second day in the hospital.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leaveGetting Started:View this tutorial for guidance on getting started with the HEENT Assignment.Tips for success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook toremind yourself of what doing an HEENT assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questionsfor each of these topics:q Medical History pertaining to the HEENT systemq Targeted Review of Systems related to the HEENT systemq Family History related to the HEENT systemKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedRemember when you are doing these exams that this simulation is designed to help you improveyour health assessment skills. Preparing ahead of time will help to set you up for success.Technical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com7
RespiratoryThe respiratory exam is an interview and physical assessment that is performed when a patientpresents with a respiratory problem or a history that is suggestive of a pathology of the lungs.Patient Narrative: Because Tina Jones has a history of asthma, you will perform a fullrespiratory exam on her. This assignment occurs at noon on Ms. Jones’ second day in the hospital.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Getting Started:View this tutorial for guidance on getting started with the Respiratory Assignment.Tips for success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook toremind yourself of what doing a respiratory assessment entails. There are essential sections ofpatient information that your interview will need to uncover. There are multiple essential questions for each of these topics:q Medical History pertaining to the respiratory systemq Targeted Review of Systems related to the respiratory systemq Risk factors associated with respiratory diseaseq Family History related to the respiratory systemKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedRemember when you are doing these exams that this simulation is designed to help you improveyour health assessment skills. Preparing ahead of time will help to set you up for success.Technical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com8
CardiovascularThe cardiovascular exam is an interview and physical assessment that is performed when a patientpresents with symptoms suggestive of a pathology such as chest pain or high blood pressure.Patient Narrative: Ms. Jones’ attending physician is considering putting her on a medicationfor her blood pressure. Before the doctor prescribes the medication, you’ll need to conduct acardiovascular exam. This assignment occurs at 4 p.m. on Ms. Jones’ second day in the hospital.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Getting Started:View this tutorial for guidance on getting started with the Cardiovascular Assignment.Tips for success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook toremind yourself of what doing a cardiovascular assessment entails. There are essential sectionsof patient information that your interview will need to uncover. There are multiple essentialquestions for each of these topics:q Medical History pertaining to the cardiovascular systemq Targeted Review of Systems related to the cardiovascular systemq Risk factors associated with cardiovascular diseaseq Family History related to the cardiovascular systemKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedRemember when you are doing these exams that this simulation is designed to help you improveyour health assessment skills. Preparing ahead of time will help to set you up for success.Technical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com9
AbdominalThe abdominal exam is an interview and physical assessment to pick up on any gastrointestinalpathology that may be causing symptoms such as abdominal pain, distention, or altered bowel habits.Patient Narrative: Because Ms. Jones has been admitted to Shadow General for almost24 hours, you will conduct a full gastrointestinal exam and check her intake and output. Thisassignment occurs at 8 p.m. on Ms. Jones’ second day in the hospital.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Getting Started:View this tutorial for guidance on getting started with the Abdominal Assignment.Tips for success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook toremind yourself of what doing a abdominal assessment entails. There are essential sections ofpatient information that your interview will need to uncover. There are multiple essential questions for each of these topics:q Medical History pertaining to the abdominal systemq Targeted Review of Systems related to the abdominal systemq Risk factors associated with abdominal diseaseq Family History related to the abdominal systemKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedRemember when you are doing these exams that this simulation is designed to help you improveyour health assessment skills. Preparing ahead of time will help to set you up for success.Technical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com10
MusculoskeletalThe musculoskeletal exam is an interview and physical assessment that assesses the overallfunctionality of the muscles and bones.Patient Narrative: Ms. Jones will be receiving a physical therapy consultation later today. Beforethe physical therapist arrives, you will conduct a full musculoskeletal system to collect subjectiveand objective data. This assignment occurs at 8 a.m. on Ms. Jones’ third day in the hospital.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Getting Started:View this tutorial for guidance on getting started with the Musculoskeletal Assignment.Tips for success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook toremind yourself of what doing a musculoskeletal assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essentialquestions for each of these topics:q Medical History pertaining to the musculoskeletal systemq Targeted Review of Systems related to the musculoskeletal systemq Risk factors associated with musculoskeletal diseaseq Family History related to the musculoskeletal systemKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedRemember when you are doing these exams that this simulation is designed to help you improveyour health assessment skills. Preparing ahead of time will help to set you up for success.Technical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com11
NeurologicalThe neurologic exam is an interview and physical assessment that assesses the nervous system,which includes the brain and spinal cord.Patient Narrative: Because Ms. Jones has a history diabetes, you will conduct a completeneurologic exam to collect subjective and objective data to assess her risk for neuropathy. Thisassignment occurs at noon on Ms. Jones’ third day in the hospital.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Getting Started:View this tutorial for guidance on getting started with the Neurological Assignment.Tips for success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook toremind yourself of what doing a neurologic assessment entails. There are essential sections ofpatient information that your interview will need to uncover. There are multiple essential questions for each of these topics:q Medical History pertaining to the neurological systemq Targeted Review of Systems related to the neurological systemq Risk factors associated with neurological diseaseq Family History related to the neurological systemKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedRemember when you are doing these exams that this simulation is designed to help you improveyour health assessment skills. Preparing ahead of time will help to set you up for success.Technical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com12
Skin, Hair, and NailsThe skin, hair, and nails exam is an interview and physical exam that assesses the integumentarysystem. It is performed when a patient presents with a wound or hair loss, among many otherclinical reasons.Patient Narrative: In preparation for Tina Jones’ discharge from Shadow General, you willassess Ms. Jones’ skin, hair and nails for any additional wounds or signs of impaired healing. Thisassignment occurs at 4 p.m. on Ms. Jones third day in the hospital.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leaveGetting Started:View this tutorial for guidance on getting started with the Skin, Hair, and Nails Assignment.Tips for success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook toremind yourself of what doing a skin, hair, and nails assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essentialquestions for each of these topics:q Medical History pertaining to skin, hair, and nailsq Targeted Review of Systems related to skin, hair, and nailsq Family History related to skin, hair, and nailsKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedRemember when you are doing these exams that this simulation is designed to help you improveyour health assessment skills. Preparing ahead of time will help to set you up for success.Technical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com13
Focused Exam: CoughPatient Narrative: Daniel “Danny” Rivera is an 8-year-old boy who is sent to the school nurse’soffice because he has been coughing. You will act as a school nurse to gather data and decide ifDanny is in respiratory distress, and he should be sent home.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Getting Started:View this tutorial for guidance on getting started with the Focused Exam: Cough Assignment.Tips for success:You should prepare prior to meeting Danny Rivera in the nurse’s office. We suggest taking outyour textbook to remind yourself of what doing a focused, complaint oriented respiratory examassessment entails. There are essential sections of patient information that your interview willneed to uncover. There are multiple essential questions for each of these topics:q History of Present Illness (HPI)q Targeted review of systems related to the HPIKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedTechnical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com14
Focused Exam: Chest PainPatient Narrative: The simulation takes place in a hospital, where Mr. Foster, 58, is on his thirdday of recovery after a simple open prostatectomy. He has had an uneventful postoperative courseso far. When the simulation begins, Mr. Foster has started complaining of chest pain.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Getting Started:View this tutorial for guidance on getting started with the Focused Exam: Cough Assignment.Tips for success:You should prepare prior to meeting Brian Foster in his hospital room. We suggest taking outyour textbook to remind yourself of what doing a focused, complaint oriented cardiovascularexam assessment entails. There are essential sections of patient information that your interviewwill need to uncover. There are multiple essential questions for each of these topics:q History of Present Illness (HPI)q Family history related to the cardiovascular systemq Targeted review of systems related to the HPIKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedTechnical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com15
Focused Exam: Abdominal PainPatient Narrative: Mrs. Esther Park is a 78-year-old woman who comes to the emergencydepartment complaining of abdominal pain. She reports that the pain isn’t severe, but that herdaughter was concerned and brought her in. You will have to decide whether or not the situationan emergency and try to determine the underlying cause of Mrs. Park’s discomfort.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate75 minutes90 minutes115 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Getting Started:View this tutorial for guidance on getting started with the Focused Exam: Abdominal Pain.Tips for success:You should prepare prior to meeting Esther Park in her room in the emergency department. Wesuggest taking out your textbook to remind yourself of what doing a focused, complaint oriented abdominal exam assessment entails. There are essential sections of patient information thatyour interview will need to uncover. There are multiple essential questions for each of thesetopics:q History of Present Illness (HPI)q Targeted review of systems related to the HPIKnow all of your qualifying questions for any symptom that may be reported:q Onsetq Locationq Durationq Characteristicsq Aggravating/alleviating factorsq Related symptomsq Treatments triedTechnical Support: Contact Shadow Health with any questions or technical issues beforecontacting your instructor. Support is available at http://support.shadowhealth.com.Undergraduate Student Handbook Spring 2017 Copyright 2017 Shadow Health ShadowHealth.com16
Comprehensive AssessmentPatient Narrative: In this assignment, your patient, Tina Jones presents in your outpatient clinicfor a pre-employment physical. This visit takes place 6 months after her hospitalization and is awell visit.Planning your time:Assignment SettingFirst Turn-inAllow ReopeningFlexible Turn InTime Estimate240 minutes260 minutes280 minutes Review the assignment settings your instructor selected on the assignmentoverview page.Every assignment setting allows you to stop and resume an assignment until you leavethe patient’s room. Your progress is automatically saved every 30 seconds.Tips for success:You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook toremind yourself of what taking a health hi
The respiratory exam is an interview and physical assessment that is performed when a patient presents with a respiratory problem or a history that is suggestive of a pathology of the lungs. Patient Narra
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