Pa_module 09 card

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Title:

Documentation of problem based assessment of the cardiac system.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of cardiac system. Identify abnormal findings.

Course Competency:

Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.

Instructions:

Content: Use of three sections:

· Subjective

· Objective

· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format:

· Standard American English (correct grammar, punctuation, etc.)

Resources:

Chapter 5: SOAP Notes: The subjective and objective portion only

Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book].

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30.

Documentation Grading Rubric- 10 possible points

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Subjective

(4 Pts)

Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.

Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.

Points: 1

Points: 2

Points: 3

Points: 4

Objective

(4 Pts)

Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.

Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings.

NUR 2180: Health Assessment

Instructor-Observed Skill Demonstration: Cardiorespiratory System

Student Name: ______________________________________

Date: _________________

Points Possible

Points Earned

Comments


Pre-Procedure Steps

Knocks

1

Washes hands

1

Identifies the client with 2 identifiers

1

Provides privacy

1

Explains procedure

1

Identifies any issues that may impact client safety or personal safety

1


General Survey

Assess level of consciousness

2

Assess skin color

2


Thorax

Inspect shape of thorax with comparison of anteroposterior to transverse diameters

5

Assess respiratory rate, rhythm, depth, presence of accessory muscle use or cough

5

Palpate thoracic expansion

5

Palpate for tactile fremitus

5


Lungs

Auscultate breath sounds 8 places on anterior thorax (stethoscope on skin)

10

Auscultate breath sounds 8 places on posterior thorax (stethoscope on skin)

10

Auscultate breath sounds 2 places each in axillary area bilaterally (stethoscope on skin)

10


Carotid Artery

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