Undergraduate Student Workbook

Transcription

1 Undergrdute Student Workbook Shdow Helth Spring 2013 Your guide to the Shdow Helth Digitl Clinicl Experience UG.2

2 Welcome! Shdow Helth develops eductionl solutions tht ddress the twin problems fcing our ntionl nd globl helth cre systems mintining qulity-of-cre in the fce of incresing provider shortges. We re reforming the sttus quo of nursing eduction delivery so tht grduting students cn become more competent contributors to the workforce. Specificlly, Shdow Helth wnts to give you n ccurte nd in-depth wy to prctice dignostic resoning, communiction, nd procedurl skills. We do this by focusing on two criticl fctors: Replicting the clinicl experience so tht students cn prctice procedurl skills nytime, nywhere to consistently identify bnorml findings in ptients. Incresing student enggement with question nd nswer experience tht encourges clinicl resoning, communiction, nd criticl thinking. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 2

3 Tble of Contents Welcome... 2 Meet Preceptor Din... 4 Meet Tin Jones... 5 Your Role... 6 System Requirements... 7 DCE: The Pth to Success... 8 LMS Nvigtion... 9 Assessment Orienttion Module Intercting with Tin Jones Module History Module Skills Module HEENT Module Respirtory Module Crdiovsculr Module Gstrointestinl (GI) Module 7... Musculoskeletl Module Neurologicl Module Hir, Skin & Nils Module Dischrge Appendix Fmily Helth History Chrt Contct & Resources All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 3

4 Preceptor Din While nvigting the Digitl Clinicl Experience (DCE), you will be ccompnied nd observed by Preceptor Din. In the Orienttion Module, she will explin how to nvigte the DCE, s well s how to communicte with your digitl stndrdized ptient. Following the Orienttion module, Preceptor Din will lso introduce ech subsequent module, guide you through procedures, nd discuss the nursing process with you in the Hllwy fter you leve Tin Jones room. Hi, my nme is Din nd I m here to support nd guide you towrd the best digitl clinicl experience possible. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 4

5 Tin Jones Tin Jones, your digitl stndrdized ptient, is 28- yer-old womn who hs come to Shdow Generl Hospitl to receive tretment for n infected foot wound, fever nd decresed ppetite. Although digitl ptient, Tin Jones brethes, speks, nd hs complex medicl nd psychosocil history. Preceptor Din hs gthered some generl helth informtion regrding Tin Jones below. Tin Jones hs lso completed Fmily Helth History chrt for you to review (see the completed form in Appendix A). Nme: Tin Jones Age: 28 Sex: Femle Rce: Africn Americn Chief complint: Ms. Jones presented to the emergency deprtment with foot wound, fever nd decresed ppetite. She ws previously evluted in locl ER two weeks go fter fll tht resulted in the swelling of her right nkle nd n brsion on her right foot. Ht: 67 inches Wt: 90 kg BMI: 31 All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 5

6 Your Role Your self directed lerning experience begins when you log into the Shdow Helth web- bsed Lerning Mngement System (LMS) on lptop or desktop computer nytime, nywhere. Through the Shdow Helth LMS, you will tke Tin Jones helth history, perform hed-to-toe physicl ssessment, record shift ssessments, collborte with other helthcre professionls, nd receive feedbck on your performnce. After being introduced to Tin Jones in the Orienttion module, the time you spend with your digitl stndrdized ptient will be divided into series of ten modules. At the end of ech module you will hve the opportunity to prioritize informtion, reflect on nursing concepts, write bout the nursing process in the Hllwy, consider lifespn issues relted to ech module, nd compre your documenttion with model shift ssessment. Ech module will lso offer you instnt evlution results upon submission before you receive feedbck from your instructor. Here re some of the wys you cn interct with Tin Jones: s Ask: Prctice tking ptient history to improve communiction skills, increse empthy nd decrese nxiety with future ptients.! L Exmine: Perform comprehensive physicl exmintions to gin experience identifying norml nd bnorml physicl findings. Assess: Anlyze helth history, physicl exm findings, nd lb results to develop clinicl resoning skills. Topics currently not covered in the Shdow Helth DCE: Genitourinry & Brest Assessments nd Billing & Coding All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 6

7 System Requirements We currently support only Mc nd Windows-bsed lptops nd desktops with these system specifictions: Minimum System Requirements Operting System Windows 7, Windows Vist (SP1), Windows XP (SP3) Mc OSX Snow Leoprd (version ) Processor Windows Intel P4 or AMD Athlon 64 Mc Intel Core Duo (non-intel Mcs re not supported) Memory 2GB RAM Disply 1024 x 768 or higher resolution disply Internet Browser nd Connection Google Chrome internet browser is required. Brodbnd Internet connection of 1.5 Mbps is recommended. Grphics Nvidi or ATI grphics crd, or Intel GMA950 Grphics hrdwre ccelertion requires DirectX 9c or lter grphics crd with minimum 128MB VRAM. Web Plyer The Unity Web Plyer is free Web ppliction tht you must instll in order to use the Shdow Helth digitl clinicl experience. Unity is esy to instll nd will not compromise the performnce or the sfety of your computer. Upon entering module for the first time, your browser will prompt you to downlod the Unity Web Plyer instlltion file. Once the file hs downloded, double-click on it to lunch the instlltion process. If the instlltion is not successful, you my lso downlod the Unity Web Plyer directly from the Unity website: Accessibility Optiml System Experience Operting System Windows 7 Mc OSX Snow Leoprd (version ) or more recent Processor Windows Intel Core i3/i5/i7 Mc Intel Core Duo/i3/i5/i7 Memory 4GB RAM recommended for grphics fetures Disply 1366 x 768 or higher resolution disply Internet Browser nd Connection Google Chrome internet browser is required. High-speed brodbnd Internet connection is required. Grphics Nvidi or ATI/AMD grphics crd cpble of DirectX 10 or lter, with 512MB VRAM. Shdow Helth s digitl clinicl experiences require the use of computer monitor, keybord, nd mouse or touchpd. It is our gol to support lterntive input modlities to improve ccessibility for ll users. However, if you re currently unble to use the DCE due to visul or motor impirment, plese contct the Shdow Helth Lerner Support tem for ssistnce. Tin Jones presents uditory nd visul informtion representtive of humn ptient. To ddress uditory ccessibility, when Tin Jones speks, her speech is presented s both udio nd text, except in instnces where the textul representtion would distinguish physicl findings (e.g. textul descriptions of brething sounds). If you require trnscription of these instnces due to n uditory impirment, plese contct the Shdow Helth Lerner Support tem t Support@ShdowHelth.com. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 7

8 D CE The Pth to Success 1 8 Sign-up ShdowHelth.com 2 & Red Workbook Red introductory workbook pges 4 Red Assignment 3 Preview ssigned module in workbook $ i Orienttion Complete Orienttion Module 5 Strt Module 6 Set Personl Gols 7 Ask Questions Strt ssigned h module & Crete personl gols to ccomplish during the module? Interview, educte, nd express empthy for your ptient. Communiction is utomticlly recorded. 10 Assess 9 Anlyze helth history, physicl exm findings, nd lb results to develop clinicl resoning skills? Record Findings Record norml nd bnorml findings 8 Exmine Helth L Exmine the ptient s hed-to-toe helth 11 Enter the Hllwy 12 Consider Lifespn 13 Self-Assess Prioritize nd discuss the ptient s findings with other members of the helth cre tem Assess ptient cre cross the lifespn _ 2! Engge in your own reflective lerning experience 16 Clss Review 15 ^ Discuss clss performnce nd best prctices with your instructor nd peers ( Review Feedbck Review instnt feedbck from the system.nd receive personlized feedbck from fculty 14!? Submit Findings Submit your results to your instructor All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 8

9 LMS Nvigtion Dshbord The Shdow Helth LMS dshbord will disply the modules with their due dtes s ssigned to you by your instructor. Lunch Pge Upon entering module, you will hve the option to select the Strt Ptient Exm button in the upper right corner of the pge. As you progress through nd complete the module, you will see ech individul ttempt listed on the module lunch pge with one of the following sttuses:! Exm In Progress: If you close your browser window during your exm, the ttempt will be sved nd mrked Exm In Progress. You my continue the exm by clicking the Resume Exm button on the module lunch pge. Hllwy In Progress: If you leve module while writing responses to the Shdow Generl tem members in the Hllwy, it will be sved nd mrked s Hllwy In Progress. You my continue the ttempt by clicking the Hllwy In Progress sttus on the module lunch pge. Lifespn In Progress: If you leve module while nswering questions on the Lifespn pge, your progress until tht pge will be sved nd mrked s Lifespn In Progress. You my continue the ttempt by clicking the Lifespn In Progress sttus on the module lunch pge. Self-Assessment In Progress: If you leve module while on the ssessment pge it will be sved nd mrked s Self-Assessment In Progress. You my continue the ttempt by clicking the Self-Assessment In Progress sttus, or to turn in the module ttempt, click the Turn It In button. NOTE: Only one ttempt per module cn be submitted to your instructor for review. Awiting Review: Once module ttempt hs been submitted to your instructor by clicking the Turn It In button on the Self-Assessment pge, it will be mrked s Awiting Review. Reviewed: When your instructor hs completed feedbck on your module submission, you will be notified vi emil. You cn directly ccess your instructor s feedbck long with your results by clicking the submitted ttempt, now mrked Reviewed on the module lunch pge. Completed: Becuse only one ttempt per module cn be submitted to your instructor for review, ny subsequent ttempts will be mrked s Completed fter you hve concluded the module nd clicked the View Results button to see the results pge. These modules re not sent to your instructor for review, but your instructor will hve ccess to the results. TIP: As long s you hve n Internet connection, your progress is utomticlly sved. You my logout t ny time nd resume the module lter. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 9

10 Assessment After completing the exm, collborting with the helth cre tem, nswering lifespn questions, nd ssessing your documenttion, your clinicl competence will be evluted bsed on the informtion you elicited from Tin Jones. In ddition to this instnt feedbck, your instructor will hve the opportunity to review your trnscript, shift ssessment, Hllwy responses, lifespn nswers, nd self-ssessment, nd then provide written feedbck to you through the LMS. Assessment Pges The Module Findings tb will rrnge your results into two ctegories: Urgent nd Essentil. Findings you hve discovered while interviewing nd exmining Tin Jones in the DCE will pper on the ssessment pge in green. Findings you didn t uncover during the module will pper in red. Clicking on ny of these findings will provide you with detiled informtion bout wht you hve found, or hve missed. i i Urgent Urgent findings re those which you must find in order to properly tret Tin Jones. Essentil Findings Essentil findings re importnt s well, but my not pose n immedite thret to your ptient s helth. Instructor Review You my submit only one ttempt per module to your instructor for review. Once you hve clicked the Turn It In button, your instructor will be notified tht your module ttempt hs been submitted. After your instructor hs reviewed your findings, shift ssessment, Hllwy responses, lifespn nswers, self-ssessments, nd submitted feedbck on your performnce, you will be notified vi emil nd your ttempt will be mrked s Reviewed on the module lunch pge. Hllwy You my review your hllwy responses here. Lifespn You my review your responses to the lifespn questions s well s the resoning behind ech correct nswer here. Self-Assessment You my review your completed self-ssessments nd personl gols here. Shift Assessment You my review your shift ssessment nd the model notes here. Trnscript You my view the trnscript of your exm here. Reviewing your trnscript will llow you to further ssess your exmintion, communiction, nd questioning skills. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 10

11 Orienttion Module Orienttion Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Lern to effectively communicte with your Digitl Stndrdized Ptient Introduction to the Shdow Tblet Become fmilir with the ction menus Explntion of communiction nd self-ssessment within the Shdow Generl Hllwy Lern to set personl gols Illustrtion of self-ssessment, lifespn, nd reviewing results Time to complete: 55 minutes Suggested resources: Student Workbook; Shdow Tblet Nursing Guide Assignment Overview: In this module, you will become fmilir with the DCE, s well s with the most effective wys to communicte with Tin Jones. Instructions To interct with Tin Jones, you will type questions, sttements, nd instructions s you use tools nd tests to conduct your exmintions. As virtul ptient, Tin Jones hs hd thousnds of converstions with nursing students cross the country, nd she understnds over 35,000 unique questions. However, s you tlk with Tin Jones, you will probbly sk her question tht she s never been sked before. The following steps will help you to successfully overcome potentil communiction chllenges in order to hve the best possible experience. You will begin by logging in nd entering the Orienttion Module. Preceptor Din will guide you through the module step-by-step. o Go to o Login to the system using your usernme nd pssword. o Click on Orienttion Module to review the module s content. o If necessry, instll the Unity Web Plyer. o Click on Strt Ptient Exm to begin the module. Preceptor Din will give you instructions s the progrm lods. STEP 1: DROPDOWN MENU There re multiple resources vilble in the DCE simultion environment. o Scroll over your nme in the upper-right corner. A dropdown menu will pper. This dropdown menu will llow you to edit your profile, contct the lerner support, sign out, or view PDF copy of this Student Workbook. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 11

12 Orienttion STEP 2: PERSONAL GOAL-SETTING An importnt component of your DCE simultion experience is setting personl gols. In every module, before you enter Tin Jones room, you ll set few personl gols to guide your work through the module. You should set your gols bsed on wht you, s nurse-in-trining, would like to focus on. Preceptor Din will give you more specific instructions for gol-setting in the beginning of Module 1. o A box will pper in the doorwy to Tin Jones room. o Type in I wnt to complete ll the tsks in the Orienttion Module nd hit the Submit button. STEP 3: COMMUNICATING WITH TINA JONES After setting your personl gols, you will utomticlly enter Tin Jones room. She ws dmitted to Shdow Generl Hospitl lst night for foot infection. In this simultion, it s 8.m. nd you re beginning your morning rounds nd ssessment. Any time you re with Tin Jones, you cn hve n in-depth dilogue with her bout her helth history, home life, nd more. She contins thousnds of responses to questions tht nurses sk. However, when you interview Tin Jones, you need to follow some rules. Preceptor Din will tke you through series of steps so tht you cn lern to communicte effectively, including how to use the Communiction Menu to mke sttements. Some bsic guidelines for communicting with Tin Jones: u u u u u u u To prctice interpersonl communiction, open the Communiction Menu to Greet, Educte, or Empthize with Tin Jones. The Communiction Menu is in the lower right-hnd corner of the room. To elicit informtion from Tin Jones, or to direct her to perform n ction during n exm, type your question or instruction directly into the converstion br in the lower left-hnd corner of Tin Jones room. You do not hve to select Communiction Menu ction. When you formulte your questions, they should be mediclly relevnt, cler, nd longer thn two words. Sometimes, Tin Jones will sk you for clrifiction. Tin Jones my not recognize question. When this hppens, ssess your question to mke sure it s mediclly relevnt. If it is, try rephrsing it more simply. If Tin Jones still doesn t recognize your question, move on to the next topic of converstion. Your instructor will be ble to review your trnscript to see the questions tht you sked, nd if they were mediclly relevnt. Avoid compound questions tht use the word or, such s, Do you hve ny nuse or dizziness? Insted, sk bout ech topic seprtely: Do you hve ny nuse? nd Are you feeling dizzy? Avoid pronouns, such s it, he, she, her, him, they, nd them. STEP 4: NAVIGATING THE SHADOW HEALTH TABLET Preceptor Din will tech you how to nvigte the Shdow Helth Tblet, which is on the right-hnd side of your screen next to Tin Jones room. You ll use the tblet throughout every module, both s resource nd to document your nursing process. The tblet hs four functions: Nursing Guide, Instructions, Electronic Medicl Record, nd Trnscript. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 12

13 Orienttion The Shdow Heth Tblet contins welth of informtion nd guidnce for you s you proceed through module. Here is summry of its prts: u u u u Nursing Guide: Provides informtion bout helth conditions, medictions, instruments, nd more. Instructions: Summrizes wht you should ccomplish in ech module. Electronic Medicl Record, or EMR: Here, you will document your findings nd every tsk you perform with Tin Jones, similr to how you would use n EMR t ny other hospitl. Trnscript: Records everything you sy to Tin Jones nd every ction you perform. You cn consult your trnscript to review wht you ve covered so fr. Also, your instructor cn review your trnscript to see how you conduct your interview nd exmintions. To nvigte the Shdow Helth Tblet o Click on one of the four tbs. o Click on the Bck button (the blue rrow t the bottom) to go to the previous pge. o Click on the Home button (the little house icon on the bottom) to return to the tblet s min menu. More informtion on the Electronic Medicl Record, or EMR The Shdow Generl EMR hs mny prts, similr to n EMR in ny other hospitl. Orders: You ll be ble to review, t ny time, the orders written on dmission so tht you cn ensure the ptient s needs re met. Night Nurse Report: This is the report from the night nurse. The Shdow Heth Tblet History: In your first module you ll tke Tin Jones complete helth nd socil history. You ll record your findings in the History function, nd you ll be ble to view wht you ve documented in the modules tht follow. Mediction Administrtion Record, or MAR: Here, you cn review the medictions which hve been ordered by the provider. Here you cn see wht medictions Tin Jones hs been dministered since she ws dmitted, nd you cn enter the medictions you ll dminister to her in the Skills Module. Flowsheets: You ll fill these out in the Skills Module, nd you cn review your documenttion in the subsequent modules. Flowsheets include vitls, I/Os nd Risk Assessment. Lbs: These re the results of the lbs tken by the emergency deprtment when Tin Jones ws dmitted. You cn ccess this informtion ny time you re in Tin Jones room. Shift Assessment: The Shift Assessment function hs text fields where you cn fill out your findings here. Its formt will chnge depending on the focus of ech module. For exmple, when you give Tin Jones n HEENT exm, the Shift Assessment will hve sections to note your observtions on her hed, ers, eyes, nose, nd throt. Nursing Progress Notes: Record ny dditionl informtion you gther or ny dditionl tsks tht you complete here. For exmple, you could use this section to document the sttus of the ptient s IV nd current comfort level. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 13

14 Orienttion STEP 5: USING ACTION MENUS Preceptor Din will tech you how to exmine nd ssess Tin Jones in the DCE simultion environment. You cn find the ction menus on the left-hnd side of the screen. You ll hve ccess to the tools, tests, nd procedures tht you need in ech module. Nursing Tsks: Tsks relted to ptient sfety, infection control, nd ptient privcy. Privcy: Closes the curtin in Tin Jones room. Ech time you enter, you should use the Privcy button to close the curtin. Infection Control: Just like in ny other hospitl, you must wsh your hnds every time you enter room, every time you perform certin tests, nd every time you re bout to exit room. Remember to close the curtin before you use the Wsh Hnds button. Sfety: Contins tools to mintin Tin Jones sfety. Preceptor Din will instruct you to verify Tin Jones identity by looking t her ptient rmbnd. Procedures: Perform nursing skills including tking vitl signs, wound cre, mediction dministrtion, risk ssessments, nd I/O ssessment. Vitls: Preceptor Din will instruct you to tke Tin Jones pulse. Inspection: Inspect Tin Jones visully nd using instruments such s otoscopes nd ophthlmoscopes. Otoscope: You will use the otoscope to exmine Tin Jones ers. STEP 6: DOCUMENTING YOUR FINDINGS Every time you perform test or procedure with Tin Jones, you must document your findings in the EMR. Preceptor Din will instruct you to prctice documenting in the EMR. Just like in ny hospitl, documenting your ctions is crucil. If you document something you didn t do, or if you do something but fil to document it, there cn be serious legl implictions in your nursing creer. You need to both perform test nd document tht test every time. If you fil to do so, you nd your instructor will see n error messge t the end of the module. STEP 7: ACCESSING NOTIFICATIONS The Shdow Helth Tblet s Nursing Guide will notify you when it cn offer extr informtion or guidnce bout the tool you re using, the topic you re exploring, or the tsk you re performing. Preceptor Din will instruct you in how to check Nursing Guide notifictions. STEP 8: PROCEEDING THROUGH A MODULE Preceptor Din will tech you bout the phses of every module. You cn keep trck of which phse you re in by looking t the top of the screen bove Tin Jones room. The phse tht you re currently in will be highlighted in green. Preceptor Din will sk you to click on the green Leve Room button in the lower right-hnd corner of the screen, underneth the tblet. This will tke you out of Tin Jones room nd into the Hllwy. Once you ve clicked the Leve Room button, you will not be ble to go bck in to Tin Jones room for tht module ttempt. Summry of the phses of module: Clinicl Exm - The first step in the clinicl exm is setting personl gols. You will then complete your interction with Tin Jones within her hospitl room. Hllwy - Your communiction with Tin Jones nurse, Ron, Preceptor Din, nd other Shdow Generl Hospitl stff. Lifespn - A multiple choice ctivity ddressing peditric nd geritric issues relted to ech module; the correct nswers nd resoning for which cn be reviewed immeditely with your other results. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 14

15 Orienttion Self-Assessment - An opportunity to reflect on your ssessment nd documenttion skills s you compre your shift ssessment to model shift ssessment written by n expert. You will lso reflect upon the gols you identified t the strt of the module. Review Results - Upon completion of module, you my review your clinicl findings, trnscript, Hllwy responses, nd self-ssessments. STEP 9: INTERACTING IN THE HALLWAY In every module, you ll meet three people to communicte with fter you leve Tin Jones room. One of these people will lwys be Preceptor Din, nd the other will lwys be Ron, who is Tin Jones nurse on your shift. The third person you meet will be nother stff member of the Shdow Generl Hospitl or one of Tin Jones fmily members. You should type response to ech person. These responses re n opportunity for you to prctice your communiction skills. You cn use your notes in the EMR, s the tblet will be ccessible to you on the right side of your screen. o Click the Next button to move on to the next phse. Once you move on to the next phse, you cn t return to the Hllwy. STEP 10: ANSWERING LIFESPAN QUESTIONS After the Hllwy, you ll enter the Lifespn phse of the module, where you ll nswer two multiple-choice questions exploring how ptient s phse in life ffects the wy you provide cre for them. o Click the Next button to move on to the next phse. STEP 11: COMPLETING YOUR SELF-ASSESSMENT In the Self-Assessment phse, you hve the opportunity to review your own performnce. You cn compre your shift ssessment notes to set of model notes. You will lso ssess nd comment on whether or not you ccomplished your personl gols. Once you hve completed the Self-Assessment, you will click the Turn It In button. This will submit ll of your work to your instructor, including your trnscript, your Hllwy responses, your Lifespn nswers, nd your self-ssessment. o Preceptor Din will instruct you to click the Turn It In button to complete the Orienttion Module. Congrtultions! You ve completed your orienttion. In the following 10 modules, once you complete module you will be ble to review your clinicl findings. Once your instructor hs reviewed your work, you will receive n emil from Shdow Helth to notify you tht you cn log in nd view ny comments from your instructor by opening up the reviewed module from tht module s lunch pge. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 15

16 History Module 1 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized interview with Tin Jones 4Perform sfety, privcy, nd infection control tsks 4Observe, perform, nd record pproprite ptient ssessment dt 4Apprise informtion obtined from interview to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones Demonstrte wreness nd proper technique ddressing ptient comfort, ptient privcy, ptient sfety, nd hygienic prctices Personl Gols Time to complete: 1 hour, 15 minutes Suggested resources: None Assignment Overview: In this module you will be conducting ptient history interview with Tin Jones. Tin Jones is cpble of discussing the following topics: Chief Complint (CC) Immuniztions (Imm) History of Present Illness (HPI) Socil History (SH) Medictions (Meds) Sfety Allergies (ALL) Fmily Culture Pst Medicl History (PMH) Spiritul History Surgicl History (Surg) Hospitl Sty nd Comfort Level Instructions: [40] minutes 1. Set personl gols for the topics, procedures, or skills relted to tking ptient history tht you would like to improve. 16 All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook

17 Module 1: History 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet the ptient q Wsh your hnds q Perform two step ptient verifiction process (ID nd verbl confirmtion) 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Obtin complete helth history, inquiring bout the following: q Chief complint q History of present illness q Pst medicl history (including usul source of nd ccess to helthcre, childhood nd dult illnesses, injuries, surgicl procedures, obstetricl history, psychitric problems, hospitliztions, trnsfusions, medictions, nd drug llergies) q Pst fmily medicl history for three genertions q Preventive helth mesures q Socil, fmily, nd occuptionl history (including potentil limittions in the home setting which my require n ltertion in medicl cre to protect the ptient s welfre, psychosocil problems nd concern, diet nd nutrition, tobcco nd lcohol use, living rrngements, religious prctices, eduction, creer, nd mritl sttus) 5. Assure ptient sfety. q Plce non-skid footwer q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 6. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention, nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 17

18 Skills Module 2 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized exmintion of Tin Jones 4Perform tests nd procedures in order, from hed to toe 4Observe, perform, nd record pproprite ptient ssessment dt 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones 4Explin to Tin Jones why you my need to touch sensitive res 4Explin to Tin Jones the purpose of ech test Demonstrte wreness nd proper technique ddressing ptient comfort, ptient privcy, ptient sfety, nd hygienic prctices 4Prctice pproprite infection control mesures 4Demonstrte knowledge nd sfe pproprite dministrtion of phrmcologicl gents Personl Gols Time to complete: 1 hour, 15 minutes Suggested resources: None Assignment Overview: In this module you will prctice nd document your nursing procedures. You will be performing the following skills: Vitl signs Glucose check Mediction dministrtion All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 18

19 Module 2: Skills Instructions: [40] minutes Input/Output Fll risk ssessment Pressure ulcer risk ssessment Venous Thrombosis Event (VTE) Risk ssessment Wound cre Check IV 1. Set personl gols for the nursing topics, procedures, or skills tht you would like to improve. 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet your ptient q Wsh your hnds 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Observe, perform, nd record pproprite ptient documenttion in the EMR. q Vitl signs using the vitl signs monitor 4Temperture 4Blood pressure 4Respirtory rte 4Hert rte nd pulse oximetry q Check glucose 4Put on gloves 4Plce test strip in glucometer 4Clen nd dry the finger 4Use the lncet to stick the finger 4Apply blood to the test strip q Input/Output 4Ask bout liquid intke 4Check IV pump for mount delivered 4Ask bout urine output 4Ask bout stooling 4Ask bout vomiting q Risk ssessments 4Shdow Helth Venous Thrombus Event (VTE) risk ssessment 4Shdow Helth fll risk ssessment 4Shdow Helth pressure ulcer risk ssessment 5. Prctice the steps of mediction dministrtion. q Demonstrte knowledge nd sfe dministrtion of phrmcologicl gents q Confirm ptient identity 4Ask nme nd birthdte 4Check rmbnd 4Check EMR q Ask bout mediction llergies q Only give medictions if needed or scheduled All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 19

20 Module 2: Skills 6. Prctice the steps of wound cre. q Wsh hnds q Wer clen gloves q Dte nd initil tpe for new dressing q Remove old bndge q Mesure wound q Wsh hnds q Open wound cre kit q Wer sterile gloves q Clen wound q Apply new dressing q Wsh hnds 7. Demonstrte wreness of IV sfety. q Check IV pump for proper infusion rte q Check IV bg for dte nd mtching nme q Check IV site for generl ppernce 8. Assure ptient sfety. q Plce non-skid footwer q Plce sequentil compression devices q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 9. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention, nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 20

21 HEENT Module 3 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized exmintion of Tin Jones 4Perform tests nd procedures in order, from hed to toe 4Observe, perform, nd record pproprite ptient ssessment dt 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones 4Explin to Tin Jones why you my need to touch sensitive res 4Explin to Tin Jones the purpose of ech test Demonstrte wreness nd proper technique ddressing ptient comfort, ptient sfety, nd hygienic prctices Personl Gols Time to complete: 1 hour 15 minutes Suggested resources: None Assignment Overview: This module will llow you to prctice nd document hed nd neck physicl exm techniques. You will be conducting n exm of the following systems: Hed Nose Neck Throt Eyes Lymph nodes Ers All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 21

22 Module 3: HEENT Instructions: [40] minutes 1. Set personl gols for the topics, procedures, or skills relted to the HEENT nd regionl lymphtic systems tht you would like to improve. 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet your ptient q Wsh your hnds 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Perform physicl exmintion of Tin Jones in logicl, orgnized, respectful, nd thorough mnner, giving ttention to Tin Jones generl ppernce, vitl signs, nd pertinent body regions. q Identify common ssessment findings, risk fctors, nd primry preventions strtegies of the HEENT nd regionl lymphtics systems q Identify norml physicl ssessment findings for the HEENT nd regionl lymphtics systems 4Hed exm Inspect fce nd hed Plpte hed Auscultte nd plpte temporl nd crotid rteries 4Eye exm Check visul cuity using Snellen eye chrt Test peripherl vision Test ccommodtion Inspect externl eye Perform funduscopic exm using ophthlmoscope Perform Pupils Eqully Round nd Rective to Light (PERRL) exm 4Er exm Inspect the tympnic membrne using n otoscope 4Nose exm Inspect nose Plpte sinuses 4Throt nd mouth exm Inspect orl mucos Assess gg reflex 4Regionl lymphtics Plpte cervicl/clviculr/xillry lymph nodes q Identify bnorml physicl ssessment findings for the HEENT nd regionl lymphtics systems! NOTE: Although Tin is positioned utomticlly for you within the DCE, you re encourged to think bout how you would position the ptient nd yourself properly for ech prt of the physicl exmintion. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 22

23 Module 3: HEENT 5. Assure ptient sfety. q Plce non-skid footwer q Plce sequentil compression devices q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 6. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor.! TIP: If you encounter difficulties while inspecting, plpting, or performing nother ction on Tin Jones, click on the Return to Menu button, then reopen the tool or test nd try gin. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 23

24 Respirtory Module 4 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized exmintion of Tin Jones 4Perform tests nd procedures in order, from hed to toe 4Observe, perform, nd record pproprite ptient ssessment dt 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones 4Explin to Tin Jones why you my need to touch sensitive res 4Explin to Tin Jones the purpose of ech test Demonstrte wreness nd proper technique ddressing ptient comfort, ptient privcy, ptient sfety, nd hygienic prctices. Personl Gols Time to complete: 1 hour 15 minutes Suggested resources: None Assignment Overview: This module will llow you to prctice complete respirtory exm. In this module, you will be evluting the following: Lungs Chest wll Pulmonry dignostics Instructions: [40] minutes 1. Set personl gols for the topics, procedures, or skills relted to the respirtory exm tht you would like to improve. 24 All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook

25 Module 4: Respirtory 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet your ptient q Wsh your hnds 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Perform physicl exmintion of Tin Jones in logicl, orgnized, respectful, nd thorough mnner, giving ttention to the Tin Jones generl ppernce, vitl signs, nd pertinent body regions. q Identify common ssessment findings, risk fctors, nd primry preventions strtegies of the respirtory system q Identify norml physicl ssessment findings for the respirtory system 4Lung exm 4Inspect nterior nd posterior chest wll 4Plpte nterior nd posterior chest wll 4Percuss nterior nd posterior chest wll 4Auscultte nterior nd posterior chest wll q Identify bnorml physicl ssessment findings for the respirtory system q Interpret pertinent dignostic dt 4Pulse oximetry 4Spirometry 5. Assure ptient sfety. q Plce non-skid footwer q Plce sequentil compression devices q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 6. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor.! TIP: All converstions should now be focused on clinicl ssessment. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 25

26 Crdiovsculr Module 5 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized exmintion of Tin Jones 4Perform tests nd procedures in order, from hed to toe 4Observe, perform, nd record pproprite ptient ssessment dt 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones 4Explin to Tin Jones why you my need to touch sensitive res 4Explin to Tin Jones the purpose of ech test Demonstrte wreness nd proper technique ddressing ptient comfort, ptient privcy, ptient sfety, nd hygienic prctices Personl Gols Time to complete: 1 hour 15 minutes Suggested resources: None Assignment Overview: This module will llow you to prctice crdiovsculr exm. In this module, you will be evluting the following: Crdic sounds Peripherl vsculture Crotid nd temporl rteries Instructions: [40] minutes 1. Set personl gols for the topics, procedures, or skills relted to the crdiovsculr exm tht you would like to improve. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 26

27 Module 5: Crdiovsculr 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet your ptient q Wsh your hnds 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Perform physicl exmintion of Tin Jones in logicl, orgnized, respectful, nd thorough mnner, giving ttention to Tin Jones generl ppernce, vitl signs, nd pertinent body regions. q Identify common ssessment findings, risk fctors nd primry preventions strtegies of crdiovsculr system q Identify norml physicl ssessment findings for the crdiovsculr system 4Crdic exm Auscultte hert sounds Plpte for point of mximl impulse (PMI) 4Peripherl vsculr exm Inspect extremities Plpte peripherl pulses Assess cpillry refill q Identify bnorml physicl ssessment findings for the crdiovsculr system 5. Assure ptient sfety. q Plce non-skid footwer q Plce sequentil compression devices q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 6. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention, nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor.! TIP: All converstions should now be focused on clinicl ssessment. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 27

28 Gstrointestinl (GI) Module 6 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized exmintion of Tin Jones 4Perform tests nd procedures in order, from hed to toe 4Observe, perform, nd record pproprite ptient ssessment dt 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones 4Explin to Tin Jones why you my need to touch sensitive res 4Explin to Tin Jones the purpose of ech test Demonstrte wreness nd proper technique ddressing ptient comfort, ptient privcy, ptient sfety, nd hygienic prctices Personl Gols Time to complete: 1 hour 15 minutes Suggested resources: None Assignment Overview: This module will llow you to prctice gstrointestinl exm of Tin Jones. In this module, you will be evluting the following: Abdomen Lower bck Instructions: [40] minutes 1. Set personl gols for the topics, procedures, or skills relted to the Gstrointestinl exm tht you would like to improve. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 28

29 Module 6: Gstrointestinl (GI) 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet your ptient q Wsh your hnds 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Perform physicl exmintion of Tin Jones in logicl, orgnized, respectful, nd thorough mnner, giving ttention to Tin Jones generl ppernce, vitl signs, nd pertinent body regions. q Identify common ssessment findings, risk fctors nd primry preventions strtegies of the GI system q Identify norml physicl ssessment findings for the GI system 4Abdominl exm Inspect contour of bdomen Auscultte four qudrnts of the bdomen Plpte four qudrnts of the bdomen Percuss liver, spleen nd four qudrnts of the bdomen 4Lower bck exm Percuss over the costovertebrl ngle (CVA) bilterlly q Identify bnorml physicl ssessment findings for the GI system 5. Assure ptient sfety. q Plce non-skid footwer q Plce sequentil compression devices q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 6. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention, nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor.! TIP: All converstions should now be focused on clinicl ssessment. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 29

30 Musculoskeletl Module 7 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized exmintion of Tin Jones 4Perform tests nd procedures in order, from hed to toe 4Observe, perform, nd record pproprite ptient ssessment dt 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones 4Explin to Tin Jones why you my need to touch sensitive res 4Explin to Tin Jones the purpose of ech test Demonstrte wreness nd proper technique ddressing ptient comfort, ptient privcy, ptient sfety, nd hygienic prctices Personl Gols Time to complete: 1 hour 15 minutes Suggested resources: None Assignment Overview: This module will llow you to prctice musculoskeletl exm of Tin Jones. In this module, you will be evluting the following: Strength Rnge Of Motion (ROM) Instructions: [40] minutes 1. Set personl gols for the topics, procedures, or skills relted to the musculoskeletl exm tht you would like to improve. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 30

31 Module 7: Musculoskeletl 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet your ptient q Wsh your hnds 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Perform physicl exmintion of Tin Jones in logicl, orgnized, respectful, nd thorough mnner, giving ttention to Tin Jones generl ppernce, vitl signs, nd pertinent body regions. q Identify common ssessment findings, risk fctors nd primry preventions strtegies of the musculoskeletl system q Identify norml physicl ssessment findings for the musculoskeletl system 4Musculoskeletl exm Inspect for rnge of motion Plpte for muscle strength 4Lower bck exm Percuss over the costovertebrl ngle (CVA) bilterlly q Identify bnorml physicl ssessment findings for the musculoskeletl system 5. Assure ptient sfety. q Plce non-skid footwer q Plce sequentil compression devices q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 6. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention, nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor.! TIP: All converstions should now be focused on clinicl ssessment. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 31

32 Neurologicl Module 8 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized exmintion of Tin Jones 4Perform tests nd procedures in order, from hed to toe 4Observe, perform, nd record pproprite ptient ssessment dt 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones 4Explin to Tin Jones why you my need to touch sensitive res 4Explin to Tin Jones the purpose of ech test Demonstrte wreness nd proper technique ddressing ptient comfort, ptient privcy, ptient sfety, nd hygienic prctices Personl Gols Time to complete: 1 hour 15 minutes Suggested resources: None Assignment Overview: This module will llow you to prctice neurologicl exm of Tin Jones. In this module, you will be evluting the following: Crnil nerves II-XII Motor function Sensory function Deep tendon reflexes Mentl sttus Instructions: [40] minutes 1. Set personl gols for the topics, procedures, or skills relted to the neurologicl exm tht you would like to improve. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 32

33 Module 8: Neurologicl 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet your ptient q Wsh your hnds 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Perform physicl exmintion of Tin Jones in logicl, orgnized, respectful, nd thorough mnner, giving ttention to Tin Jones generl ppernce, vitl signs, nd pertinent body regions. q Identify common ssessment findings, risk fctors nd primry preventions strtegies of the neurologicl system q Identify norml physicl ssessment findings for the neurologicl system 4Neurologicl exm Crnil nerve exm Motor exm Sensory exm Deep Tendon Reflexes (DTR) 4Mentl sttus tests q Identify bnorml physicl ssessment findings for the neurologicl system 5. Assure ptient sfety. q Plce non-skid footwer q Plce sequentil compression devices q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 6. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention, nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 33

34 Hir, Skin & Nils Module 9 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Conduct n orgnized exmintion of Tin Jones 4Perform tests nd procedures in order, from hed to toe 4Observe, perform, nd record pproprite ptient documenttion 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs 4Differentite between vritions of norml nd bnorml ssessment findings 4Discuss pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities Prctice effective communiction 4Express considertion for Tin Jones feelings, limittions, nd culturl nd socil bckground 4Use pproprite open- nd closed-ended questions 4Use professionl nd ccessible lnguge tht voids jrgon 4Communicte effectively with members of the helthcre tem 4Demonstrte temwork nd respect towrd members of the helthcre tem Demonstrte professionl nd respectful behvior towrds Tin Jones 4Explin to Tin Jones why you my need to touch sensitive res 4Explin to Tin Jones the purpose of ech test Demonstrte wreness nd proper technique ddressing ptient comfort, ptient privcy, ptient sfety, nd hygienic prctices Personl Gols Time to complete: 1 hour 15 minutes Suggested resources: None Assignment Overview: This module will llow you to prctice skin, hir, nd nils exm of Tin Jones. In this module, you will be evluting the following: Hir Skin Nils Instructions: [40] minutes 1. Set personl gols for the topics, procedures, or skills relted to the skin, hir nd nils exm tht you would like to improve. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 34

35 Module 9: Hir, Skin, & Nils 2. Perform initil ptient encounter tsks. q Provide ptient privcy by closing the curtin q Greet your ptient q Wsh your hnds 3. Prctice reviewing the chrt including flowsheets, medictions, llergies, lbs, orders, history, nd I/O s. 4. Perform physicl exmintion of Tin Jones in logicl, orgnized, respectful, nd thorough mnner, giving ttention to Tin Jones generl ppernce, vitl signs, nd pertinent body regions. q Identify common ssessment findings, risk fctors nd primry preventions strtegies of the integumentry system q Identify norml physicl ssessment findings for the integumentry system 4Skin Inspect skin Assess skin turgor 4Hir Inspect hir 4Lower bck exm Inspect nils Assess cpillry refill q Identify bnorml physicl ssessment findings for the integumentry system 5. Assure ptient sfety. q Plce non-skid footwer q Plce sequentil compression devices q Plce bedside tble nd cll light within rech q Put upper bedrils in the upright position 6. Complete the Shift Assessment to document findings. q Document ny dditionl informtion or observtions in the Nursing Progress Notes [20] minutes 1. Collborte with other members of the helthcre tem nd prctice the nursing process in the Hllwy. 2. Reflect upon helth promotion, disese prevention, nd holistic nursing cre cross the lifespn. [15] minutes 1. Complete self-ssessment of your personl gols nd documenttion. 2. Review nd submit your results to your instructor. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 35

36 Dischrge Module 10 Before You Begin o Open Google Chrome. Close ll other progrms, tbs, nd windows. o Login to the Digitl Clinicl Experience (DCE) t ShdowHelth.com. Gols Review the Dischrge Orders tb 4Apprise informtion obtined from exmintion to determine relevncy ccording to your ptient s needs Develop nd communicte n individulized dischrge pln for Tin Jones prior to her leving the hospitl 4Compose pproprite nursing dignoses tht reflect Tin Jones helth needs nd priorities 4Use professionl nd ccessible lnguge tht voids jrgon 4Demonstrte knowledge of sfe, pproprite dministrtion of phrmcologicl gents Time to complete: 1 hour, 15 minutes Suggested resources: Assignment None Overview: This module will llow you to interpret nd communicte Tin Jones dischrge pln to her. In this module you will be completing the following steps: Review of doctor s dischrge orders Develop nd convey ptient eduction informtion to Tin Jones prior to her dischrge Instructions: [20] minutes 1. Red the instructions provided by Preceptor Din. 2. Review the provider s Dischrge Orders. [40] minutes 3. Click on the Write Ptient Eduction button to continue. 4. Provide guidnce for diet, ctivity, dignosis, medictions, wound cre, nd follow-up. Write your recommendtions s if speking with Tin Jones. Justify the need for the eduction provided. q Diet - Record the informtion you would tech Tin Jones regrding proper diet. Use the suggested cloric intke to encourge reding food lbels. Emphsize tht lifestyle chnges cn improve disese outcomes. q Activity - Provide Tin Jones with the survivl skills needed to mnge nd tke responsibility for her own helth. Include recommendtions for disese prevention nd mngement. q Dignosis - Educte Tin Jones on her condition, mngement, nd potentil environmentl nd lifestyle chnges. q Medictions - Plese note, ll written instructions nd prescriptions should be in lymn s terms. q Wound cre - Educte Tin Jones on the proper technique nd procedure to be used to clen nd mintin her wound. q Follow-up - Communicte primry cre physicin follow up ppointment informtion. q When to return to ER or cll MD - Provide Tin Jones with informtion to identify occsions when she should cll the ER or her primry cre doctor. 5. Click the Turn It In button to provide Tin Jones with dischrge instructions on prescribed tretments, medictions (including food nd/or drug interctions), the nutrition pln, ctivity level, nd scheduled follow-up ppointments. All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 36

37 Appendix Fmily Helth History Ptient Nme: Tin Jones Age Medicl Conditions Living Cuse of deth Cholesterol, blood Biologicl Mother 50 pressure & dibetes Y N Biologicl Fther 62 Cholesterol nd blood pressure Y N Cr ccident Sibling ( M / F ) 14 Asthm Y N Sibling ( M / F ) 25 Y N Sibling ( M / F ) Y N Sibling ( M / F ) Y N M. Grndmother 73 Cholesterol nd blood pressure Y N Stroke M. Grndfther 78 Cholesterol nd blood pressure Y N Hert ttck P. Grndmother 82 blood pressure Y N P. Grndfther 65 Cholesterol, blood pressure nd dibetes Y N Colon cncer Children ( M / F ) Y N Children ( M / F ) Y N All mteril copyright 2012 Shdow Helth Inc. Undergrdute Student Workbook 37