NURS 6512 DCE: Assessing the Heart, Lungs and Peripheral Vascular System

NURS 6512 DCE: Assessing the Heart, Lungs and Peripheral Vascular System

Patient Information:

Initials: M.H Age: 60 years Old Sex: Male Race: Caucasian

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CC: “I am having shortness of breath; it’s been getting worse. I just feel tired all the time.”

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HPI: M.H is a 60 years old Caucasian male patient who came to the hospital complaining of shortness of breath which has been worsening over time.

Location:

Onset:

Character:

Associated signs and symptoms:

Timing:

Exacerbating/ relieving factors:

Severity:

Current Medications:

Allergies:

PMHx:

Soc Hx: The patient has been smoking in the past with no success in quitting. Currently, he confirms smoking three cigarettes a day.

Fam Hx:

ROS:

GENERAL: proper posture. No weight loss or weight gain, chills, fever, nausea or vomiting.

HEENT: Eyes: denies visual loss, double vision, blurred vision, or using a visual aid. Ears, Nose, Throat: denies hearing difficulties, sneezing, sore throat or running nose.

SKIN: No rash, mole or itching.

CARDIOVASCULAR: confirms chest pressure and chest discomfort. Irregular heart rate with S1 and S2 sounds and no S3 or S4 sounds. No murmurs.

RESPIRATORY: confirms shortness of breath. Denies congestion or wheezing. Denies being exposed to an infected individual with a contagious respiratory infection in the past.

GASTROINTESTINAL: Denies anorexia, diarrhea, nausea or vomiting. Confirms a slight protuberant of the abdomen.

GENITOURINARY: denies burning on urination, foul urine odor or strange urine color. Confirms normal urine frequency.

NEUROLOGICAL: Denies headache, syncope, dizziness, paralysis, numbness, ataxia, or tingling in the extremities.

MUSCULOSKELETAL: Denies muscle pain. Confirms pain associated with joint movement of the lower extremities.

LYMPHATICS: Confirms edema on the right calf.

PSYCHIATRIC: Denies any history of anxiety or depression.

Physical exam: Physical exam: Vital signs: B/P 148/88, HR 112bpm (Fast and irregular); T 97.9F orally; RR 32; labored; SpO2: 90% room air; Wt.: 210lbs; Hit: 5’7

General: Well oriented and cooperative. Slightly anxious but able to respond appropriately to the questions asked. Seems to have slight respiratory distress.

HEENT: head: atraumatic and normocephalic. Eyes: bilateral with no visual aid. The pupils are round, equal and bilaterally reactive to light. Ears: normal bilateral hearing.

Skin: Cool and diaphoretic. No cervical lymphadenopathy. No rashes

Chest/Lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds on the left lung.

Heart/Peripheral Vascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur. Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally

Abdomen: Bulgy with normoactive bowel sounds auscultated x4 quadrants

Genital/Rectal: The bladder is continent. No rashes around the genitalia.

Musculoskeletal: moderate pain of 5/10 on the RLE calf. Right calf with 2+ edema. Motion is of the normal range. There are no deformities of the joints.

Neuro: Alert and well oriented. Normal body posture. Slightly lethargic but with intact sensation.

Diagnostic results: Evaluation of the patient’s health complication require incorporation of the patient history, physical examination and lab test results. Based on the provided information, further diagnosis can be made with regard to the results of several lab tests. A complete blood count is necessary for ruling out infections or anemia as the root cause of the patient’s symptoms. Urinalysis is required in evaluating proteinuria in association with cardiovascular disease. CMP to check for renal dysfunction or fluid retention. An elevated level of fasting glucose also indicates high risks of heart failure (Papadakis, McPhee, & Bernstein, 2019). Natriuretic peptides should also be tested as they increase significantly in cases associated with heart failure. Lipid profile tests and TSH are relevant in assessing thyroid diseases in relation to heart failure. EKG will reveal arrhythmias, coronary artery disease, myocardial infarction and ischemia as possible causes of cardiac failure. Chest X-ray may reveal pulmonary congestion, hypertrophied cardiac silhouette among other causes of the patient’s symptoms.

Differential Diagnoses

Congestive Heart Failure: This condition is characterized by the buildup of fluids in the feet, legs, ankle, liver, abdomen and veins on the neck region, in addition to fatigue and shortness of breath (Shahbazi, & Asl, 2015). The patient displays symptoms of shortness of breath, and fatigue. Upon physical examination, it was revealed that the patient’s lower extremities were swollen, abdomen distended, irregular heart rate slightly elevated blood pressure, oxygen concentration and respiratory rate. All these symptoms point towards CHF as the primary diagnosis of the patient presenting illness.
Myocardial Infarction: This condition is characterised by fatigue, malaise, chest discomfort, shortness of breath, rapid and irregular heartbeat and cough. Upon physical examination, patients with MI, usually exhibit an increased and irregular heart rate, elevated blood pressure, increased respiratory rate, fever, rales or wheezes may be auscultated, and edematous extremities (Reddy, Khaliq, & Henning, 2015). The patient was positive for most of these sign and symptoms.
Pulmonary Embolism: The main indication for pulmonary embolism is a sudden onset of pleuritic chest pain, hypoxia and shortness of breath. Some patients may, however, lack the apparent symptoms, and instead present with an abrupt, catastrophic hemodynamic collapse or gradually progressive dyspnea (Kan et al., 2015). Due to the variation of the symptoms, pulmonary embolism is usually suspected in individuals with respiratory symptoms which are unexplainable by an alternative diagnosis, just like in the above case scenario.
Pneumonia: Patients with pneumonia usually display symptoms such as fever, dyspnea, pleuritic chest pain, fatigue and cough. Upon physical examination, some of the findings will include tachypnea, bronchial breath sounds, rales noted over the affected lobe, decreased tactile fremitus and dullness on percussion of the chest (Papadakis, McPhee, & Bernstein, 2019). Some of these sign and symptoms were exhibited by M.H making pneumonia a potential differential diagnosis.
Pericardial effusion: This condition usually presents as a result of inflammation of the pericardium following an injury or illness. It is characterized by chest congestion, dyspnea, fatigue, orthopnea, cough and lightheadedness. The patient was positive for most of these symptoms (Papadakis, McPhee, & Bernstein, 2019). Consequently, the physical examination findings of an individual with pericardial effusion include decreased breathing sounds, Ewart sign, tachypnea, tachycardia, pericardial friction rub, pulses paradoxus and hepatojugular reflux.

References

Shahbazi, F., & Asl, B. M. (November 01, 2015). Generalised discriminant analysis for congestive heart failure risk assessment based on long-term heart rate variability. Computer Methods and Programs in Biomedicine, 122, 2, 191-198.

Reddy, K., Khaliq, A., & Henning, R. J. (January 01, 2015). Recent advances in the diagnosis and treatment of acute myocardial infarction. World Journal of Cardiology, 7, 5, 243-276.

Kan, Y., Yuan, L., Meeks, J. K., Li, C., Liu, W., & Yang, J. (May 01, 2015). The accuracy of V/Q SPECT in the diagnosis of pulmonary embolism: a meta-analysis. Acta Radiologica, 56, 5, 565-572.

In Papadakis, M. A., In McPhee, S. J., & In Bernstein, J. (2019). Quick medical diagnosis & treatment 2019. New York, N.Y.: McGraw-Hill Education LLC.

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.
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

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 7 Day 7 deadline.

Submission and Grading Information

By Day 7 of Week 7

Complete your Focused Exam: Chest Pain DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
Review the Week 7 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
Complete the Code of Conduct Acknowledgement.

Grading Criteria

To access your rubric:

Week 7 Assignment 1 DCE Rubric

Submit Your Assignment by Day 7 of Week 7

To submit your Lab Pass:

Week 7 Lab Pass

To participate in this Assignment:

Week 7 Documentation Notes for Assignment 1

To Submit your Student Acknowledgement:

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.

Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System

Cardiovascular disease (CVD) is the largest cause of death worldwide. Accounting for 610,000 deaths annually (CDC, 2017), CVD frequently goes unnoticed until it is too late. Early detection and prevention measures can save the lives of many patients who have CVD. Conducting an assessment of the heart, lungs, and peripheral vascular system is one of the first steps that can be taken to detect CVD and many more conditions that may occur in the thorax or chest area.

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.

Learning Objectives

Students will:

Evaluate abnormal cardiac and respiratory findings
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system
Evaluate chest X-Ray and ECG imaging

Learning Resources

Required Readings (click to expand/reduce)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 14, “Chest and Lungs”This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.

Chapter 15, “Heart”The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.

Chapter 16, “Blood Vessels”This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (specifically focus on pp. 480–481)

Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 8, “Chest Pain”
This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.

Chapter 11, “Cough”
A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough by asking questions and performing a physical exam.

Chapter 14, “Dyspnea”
The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.

Chapter 26, “Palpitations”
This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.

Chapter 33, “Syncope”
This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.

Note: Download the Student Checklists and Key Points to use during your practice cardiac and respiratory examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Chest and lungs: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Chest and lungs: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Heart: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Heart: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., … Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.

This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.

Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane, C. C. (2014). Does physical activity influence the relationship between low back pain and obesity? The Spine Journal, 14(2), 209–216. doi:10.1016/j.spinee.2013.11.010

Shiri, R., Solovieva , S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650. doi:10.1016/j.semarthrit.2012.09.002

McCabe, C., & Wiggins, J. (2010a). Differential diagnosis of respiratory disease part 1. Practice Nurse, 40(1), 35–41.

This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.

McCabe, C., & Wiggins, J. (2010b). Differential diagnosis of respiratory diseases part 2. Practice Nurse, 40(2), 33–41.

The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word document)

Use this template to complete your Assignment 1 for this week.

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 1, “Chest Wall, Pulmonary, and Cardiovascular Systems,” pp. 302–433)Note: Section 2 of this chapter will be addressed in Week 10.This section of Chapter 8 describes the anatomy of the chest wall, pulmonary, and cardiovascular systems. Section 1 also explains how to properly conduct examinations of these areas.

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Advanced Health Assessment and Diagnostic Reasoning

Thoughtful, reasoned questioning leads from initial complaint to diagnosis in these three scenarios.
Note: Close the viewing window after the intro segment and after each diagnosis segment to view the menu. (12m)

Photo Credit:Provided courtesy of the Laureate International Network of Universities.

Assessment of the Heart, Lungs, and Peripheral Vascular System – Week 7 (28m)

SkillStat Learning, Inc. (2019). The 6 second ECG. Retrieved from http://www.skillstat.com/tools/ecg-simulator#/-home

This interactive website allows you to explore common cardiac rhythms. It also offers the Six Second ECG game so you can practice identifying rhythms.

Online media for Seidel’s Guide to Physical Examination

In addition to this week’s media, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 13 and 14 that relate to the assessment of the chest, heart, and lungs. Refer to Week 4 for access instructions on https://evolve.elsevier.com/

Name: Mr. J.M. Age: 38 years Sex: Male

SUBJECTIVE DATA:

Chief Complaint (CC): “I have sporadic chest pain”

NURS 6512 DCE: Assessing the Heart, Lungs and Peripheral Vascular System