Diagnostics Note wk 7

1

Wilkes University

Passan School of Nursing

NSG 550: Diagnostic Reasoning for Nurse Practitioners

Clinical Note Guidelines

Each student will complete a clinical note utilizing the framework of a comprehensive health history and physical examination. The written assignment is documentation of the findings and should demonstrate application of course content and follow the criteria provided below. This should be in a charting format and no longer than 3 pages, excluding a title and reference page. Five points will be deducted for assignments longer than the stated criteria. APA not required so single spacing is allowed. Mastering succinctness of communication, both written and verbal of clinical reasoning, is critical to the process of becoming a nurse practitioner.

Content	Grade Percentage
Choose a patient to perform the H and P; this person could be a family member or patient from your clinical practice. Only use initials when identifying the patient.	5%
Chief Complaint and History of Present Illness	5%
Past Medical and Surgical History	5%
Medications and Allergies	5 %
Family History	5%
Social History	5%
Review of Systems (subjective-complete review of systems including pertinent positive and negative findings as per the patient-what did the patient say)	15%
Physical Examination (objective-complete PE including pertinent positive and negative PE findings).	15%
Assessment and Plan (You can make one section with the Assessment/Plan or you can keep them as separate sections). Provide all possible diagnoses based upon clinical decision making listing the one with the highest probability first. Provide comprehensive treatment plan and communicate clinical reasoning; utilize theory from NSG500, 550, 530, and 533. Provide clinical support/citations.	35%
Provides references of peer reviewed, scholarly citations	5%
Total	100%

Criteria for this written assignment can be found on the next page. This information was introduced in NSG 500.

History—Subjective Data

ID

Age, gender, DOB

CC

Reason for seeking care-patient’s own words

HPI

O-onset

L-location

D-duration

C-character

A-aggravating/associated factors

R-relieving factors

T-temporal factors

S-severity

Medications, treatments

PMH/PSH

General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood transfusions, emotional status/psychiatric history

Personal History

Cultural background, marital status, occupation, economic resources, environment

Health Habits

Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins

Health Maintenance

Last PE; diagnostic tests (date, result, follow-up); self-exams (breast, genital, testicular); last Pap smear, mammogram

Family History

(Parents, siblings, children)

Cancer, DM, hypertension, heart disease, stroke

REVIEW OF SYSTEMS

General

Fever, chills, malaise, fatigue/energy, night sweats, desired weight

Diet

Appetite, restrictions, vitamins, supplements

Skin, Hair, Nails

Rash, eruptions, itching, pigment changes

Head and Neck

Headaches, dizziness, head injuries, loss of consciousness

Eyes

Blurring, double vision, visual changes, glasses, trauma, eye diseases

Ears

Hearing loss, pain, discharge, vertigo, tinnitus

Nose

Congestion, nosebleeds, postnasal drip

Throat and Mouth

Hoarseness, sore throat, bleeding gums, ulcers, tooth problems

Gastrointestinal

Indigestion, heartburn, vomiting, bowel regularity/changes

Lymph

Tenderness, enlargement

Endocrine

Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes, increased hat, glove, or shoe size

Female

LMP, age at menarche, gravity, parity, menses (onset, regularity, duration, symptoms), sexual life (number of partners, satisfaction), contraception, menopause (age, symptoms)

Male

Puberty onset, erections, testicular pain, libido, infertility

Breasts

Pain, tenderness, lumps, discharge

Chest and Lungs

Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, exposure to TB

Cardiovascular

Chest pain, palpitations, number of pillows, edema, claudication, exercise tolerance

Hematology

Anemia, easy bruising

Genitourinary

Dysuria, flank pain, urgency, frequency, nocturia, hematuria, dribbling

Musculoskeletal

Joint pain, heat swelling

Neurologic

Fainting, weakness, loss of coordination

Mental Status

Concentration, sleeping, eating, socialization, mood changes, suicidal thoughts

Physical Examination—Objective Data

VS

TPR, BP, Ht, Wt, BMI, Pulse Ox

General Appearance

Age, race, gender, posture and gait

Mental Status

Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality

Skin

Color, integrity, hygiene, turgor, hydration, edema, lesions, hair distribution and texture, nail texture, nail base angle

Head

Scalp, temporal arteries, deformities

Neck

Trachea (position, tug), range of motion (ROM), carotid bruit, jugular venous distention (JVD), thyroid, lymph (head and neck)

Eyes

Pupils (PERRLA), eyelids, conjunctivae, sclerae, EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus

Ears

Deformities, lesions, discharge, otoscopy (canal, TM), hearing (Rinne, Weber, CN VIII)

Nose

Mucosa, septum, turbinates, discharge, sinus area swelling or tenderness

Mouth and Throat

Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X)

Chest/Lungs

Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs)

Breasts

Contour, symmetry, nipples, areolae, discharge, lumps/masses, lymph (axillary, supraclavicular, and infraclavicular)

Heart

PMI, lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps

Blood Vessels

Cyanosis, clubbing, edema, peripheral pulses, skin, nails

Abdomen

Contour, symmetry, skin, bowel sounds, bruits, hum, liver span, liver border, tenderness, masses, spleen, kidneys, aortic pulsation, reflexes, percussion tone, costovertebral angle (CVA) tenderness, femoral pulses, lymph (inguinal)

Male Genitalia

Pubic hair, glans, penis, testis, scrotum, epididymis, urethral discharge, hernias

Female Genitalia

External lesions or discharge, Bartholin and Skene glands, urethra, vaginal walls, cervix (position, lesions, cervical motion tenderness), uterus, adnexa

Rectum/Prostate

Sacrococcygeal and perineal areas, anus, sphincter tone, rectal walls, masses, fecal occult blood test (FOBT)

Male: Prostate

Female: Rectovaginal septum, uterus

Musculoskeletal

Posture, alignment, symmetry, joint heat/swelling/color, muscle tone, ROM, strength

Neurologic

CN II-XII, rapid alternating movements, finger-to-nose, sensation, vibration, stereognosis, motor system, gait, Romberg, deep tendon reflexes (DTRs), superficial reflexes

Cranial Nerves

I: Smell

II: Visual acuity, visual fields, funduscopy

III, IV, VI: Eyelid opening EOMs: IV up and out, VI lateral, III all others

V: Corneal reflex, facial sensation (3 areas), jaw opening, bite strength

VII: Eyebrow raise, eyelid close, smile, taste

VIII: Rinne, Weber

IX, X: Gag reflex, palate elevation, phonation

XI: Lateral head rotation, neck flexion, shoulder shrug

XII: Tongue protrusion, lateral deviation strength

Assessment

Diagnosis(es)-clinical reasoning

Plan

Treatment; rationale