Neurological _ Completed _ Shadow Health.pdf - Neurological | Completed | Shadow Health Neurological Results | Turned In Health Assessment F2F Spring

Neurological _ Completed _ Shadow Health.pdf - Neurological...

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Unformatted text preview: 5/9/2019 Neurological | Completed | Shadow Health Neurological Results | Turned In Health Assessment - F2F - Spring 2019, RNSG 1215 Return to Assignment Your Results Overview Reopen Transcript Transcript Subjective Data Collection Lab Pass Started: May 09, 2019 | Patient Exam Time: 40 min All Lines (134) Interview Questions (56) Statements (5) Exam Actions (73) Objective Data Collection Documentation Hello! Self-Reflection Question 05/09/19 10:47 AM CDT Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. What is the situation? Question 05/09/19 10:47 AM CDT It's noon on Tina Jones' second day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a neurological exam on Ms. Jones. You will collect subjective and objective data about her risk for neuropathy, which is higher given her history of falls and diabetes. What are my objectives in this assessment? Question 05/09/19 10:48 AM CDT 1/18 5/9/2019 Neurological | Completed | Shadow Health In your interview with Ms. Jones, you will ask about her neurological system and identify any risk factors so that you can determine any current and potential issues. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. You will also inquire into the health history of Ms. Jones' family with regards to the neurological system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her neurological system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones' neurological system to gather objective data about the system's health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. What else will this exam involve? Question 05/09/19 10:54 AM CDT You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation. How will I be evaluated? Question 05/09/19 10:54 AM CDT In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 50 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically. How does this assignment prepare me for the real world? Question 05/09/19 10:54 AM CDT In this assessment, you will become familiarized with the structure and content of neurological exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient's risk of disease, infection, injury, and complications º and obtain and assess objective data. 2/18 5/9/2019 Neurological | Completed | Shadow Health In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What physical exam findings would indicate the presence of neuropathy? monofilament test, sensation test, quantitative sensory testing Statement 05/09/19 10:56 AM CDT Time to begin. Hi, i'm your nurse Cory; how are you today? Greet 05/09/19 10:57 AM CDT Hey. Can you please state your name and date of birth for me? (Clarified to Can you please confirm your name and birthday for me?.) Question 05/09/19 10:57 AM CDT My name's Tina Jones, and my birthday's February 17th. (Clarified to to confirm my name and date of birth.) i'm sorry to see your still here. Empathize 05/09/19 11:00 AM CDT Thanks. Do you have any numbness? Question 05/09/19 11:00 AM CDT No, I don't think so. Do you have any tingling? Question 05/09/19 11:00 AM CDT I mean. . . my hand will fall asleep sometimes or something, and then it will tingle, like pins and needles, but that's normal I think. Any vision issues? Question 05/09/19 11:00 AM CDT Yeah, actually, I have been noticing my eyes getting kind of blurry lately. any headaches? 3/18 5/9/2019 Neurological | Completed | Shadow Health Question 05/09/19 11:01 AM CDT Yeah, my head aches sometimes. But it's okay right now. Is their a pattern? (No matching questions found.) Question 05/09/19 11:01 AM CDT Is their a headache pattern? (No matching questions found.) Question 05/09/19 11:02 AM CDT Is there a headache pattern? Question 05/09/19 11:02 AM CDT Uh, I guess I don't know what you mean. What triggers the headaches? Question 05/09/19 11:02 AM CDT The longer I read or study, the worse my headaches get. I try to take a break and rest when they start, but sometimes I'll have a test or something coming up, and then I'll just have to work through it. what types of headache? Question 05/09/19 11:02 AM CDT It's Type 2. what character are your headaches? Question 05/09/19 11:03 AM CDT It's like a tight, throbbing ache behind my eyes. ant headache treatments? Question 05/09/19 11:03 AM CDT When my headaches get bad, I take some Tylenol and go to sleep. Checked vitals Exam Action 05/09/19 11:03 AM CDT 4/18 5/9/2019 Neurological | Completed | Shadow Health What is your pain level on a scale of 1 to 10? Question 05/09/19 11:05 AM CDT It's at about a 6 out of 10 right now. any dizziness? Question 05/09/19 11:05 AM CDT No, I'm not dizzy. any speech problems/ Question 05/09/19 11:05 AM CDT No. I might stumble over my words sometimes but nothing like that. any trouble swallowing? Question 05/09/19 11:05 AM CDT I swallow fine. any fainting issues? (Clarified to Have you ever fainted?.) Question 05/09/19 11:05 AM CDT I've never fainted, no. (Clarified to if I have ever fainted.) any muscle function issues? Question 05/09/19 11:06 AM CDT I think my muscles are fine. any memory loss? Question 05/09/19 11:06 AM CDT I think my memory's been pretty much the same as it always was--not supergenius level, but pretty good. any behavior changes? Question 05/09/19 11:06 AM CDT My behavior's been normal, I think. 5/18 5/9/2019 Neurological | Completed | Shadow Health any illicit drug use? Question 05/09/19 11:06 AM CDT No. any tobacco use? Question 05/09/19 11:07 AM CDT No. I think it's gross. any alcohol use? Question 05/09/19 11:07 AM CDT I do sometimes, yeah, when I go out with my friends. any history of neurological problems? Question 05/09/19 11:07 AM CDT My brain's always been fine, thankfully. [AUDIO COMING SOON] Do you have a family history of migraines? Question 05/09/19 11:08 AM CDT No one in the family gets migraines that I know of. how are apples and oranges alike? Question 05/09/19 11:09 AM CDT How are they alike? Um.... they're both kinds of fruit. Evaluated abstract thinking: similarities among fruit how are a lake and ocean alike? Exam Action 05/09/19 11:09 AM CDT Question 05/09/19 11:09 AM CDT Uh.... they're both bodies of water. 6/18 5/9/2019 Neurological | Completed | Shadow Health Evaluated abstract thinking: similarities among bodies of water how are a trumpet and flute alike? Exam Action 05/09/19 11:10 AM CDT Question 05/09/19 11:10 AM CDT They...... they're both musical instruments. Evaluated abstract thinking: similarities among instruments count backwards by 7's from 100 please Exam Action 05/09/19 11:10 AM CDT Question 05/09/19 11:10 AM CDT Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2. Evaluated attention with serial sevens read and follow these instructions Exam Action 05/09/19 11:11 AM CDT Question 05/09/19 11:11 AM CDT Ok. Established one-stage comprehension read and follow these instructions Exam Action 05/09/19 11:11 AM CDT Question 05/09/19 11:12 AM CDT Sure. Established two-stage comprehension who was the first president of the united states? Exam Action 05/09/19 11:12 AM CDT Question 05/09/19 11:13 AM CDT That's George Washington. 7/18 5/9/2019 Neurological | Completed | Shadow Health Evaluated knowledge of first president who are the last four presidents of the united states? Exam Action 05/09/19 11:13 AM CDT Question 05/09/19 11:13 AM CDT Well, right now it's Donald Trump. Before him it was Obama. Before *him* we had Bill Clinton and George W. Bush. Evaluated knowledge of last four presidents name five large cities in the united states Exam Action 05/09/19 11:13 AM CDT Question 05/09/19 11:14 AM CDT Let's see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That's five. Evaluated knowledge of five large cities what would you do if you found a stamped and addressed envelope on the sidewalk. Exam Action 05/09/19 11:14 AM CDT Question 05/09/19 11:14 AM CDT What would I do.... Hmm.. Well, I'd try to figure out who dropped the envelope, but if not... Well, I'd probably just drop it in the first mailbox I saw, if there was one nearby. Evaluated judgment repeat and remember burger, tulip, nose, and tea Exam Action 05/09/19 11:15 AM CDT Question 05/09/19 11:15 AM CDT Burger, tulip, nose, and tea. Evaluated immediate memory how did you celebrate your last birthday? Exam Action 05/09/19 11:15 AM CDT Question 05/09/19 11:16 AM CDT 8/18 5/9/2019 Neurological | Completed | Shadow Health Wow. . . it's weird, birthdays were huge for us before Dad died because he would always make a really big deal out of them, like he loved planning these huge celebrations. But the past two birthdays, he hasn't been there, so it's been kind of sad, thinking about what he's missing, and we haven't done huge parties or anything. Last birthday. . . Michael and his fiance came over, and we all had dinner at the house, and I opened presents, and we had a really good cake from this bakery I love. It was nice. Evaluated remote memory repeat the four words from before Exam Action 05/09/19 11:16 AM CDT Question 05/09/19 11:16 AM CDT Burger. . . tulip. . .nose. . . and tea. Evaluated immediate learning Exam Action 05/09/19 11:16 AM CDT Observed patient's general vocabulary Exam Action 05/09/19 11:16 AM CDT Observed patient's general ability to articulate Exam Action 05/09/19 11:18 AM CDT close your eyes and tell me what i trace on your palm Question 05/09/19 11:18 AM CDT Ok. That's an "A." Tested left-hand graphesthesia by letter identification Exam Action 05/09/19 11:18 AM CDT A figure "8." Tested right-hand graphesthesia by number identification Exam Action 05/09/19 11:18 AM CDT close your eyes and tell me if the touch is sharp, dull, or soft 9/18 5/9/2019 Neurological | Completed | Shadow Health Question 05/09/19 11:19 AM CDT Ok. Tested left arm proximal dull sensation Exam Action 05/09/19 11:19 AM CDT Dull. Tested left arm distal dull sensation Exam Action 05/09/19 11:19 AM CDT Dull. Tested right arm proximal dull sensation Exam Action 05/09/19 11:19 AM CDT Dull. Tested right arm distal dull sensation Exam Action 05/09/19 11:19 AM CDT Dull. Tested left arm proximal soft sensation Exam Action 05/09/19 11:19 AM CDT Soft. Tested left arm distal soft sensation Exam Action 05/09/19 11:19 AM CDT Soft. Tested right arm proximal soft sensation Exam Action 05/09/19 11:19 AM CDT Soft. 10/18 5/9/2019 Neurological | Completed | Shadow Health Tested right arm distal soft sensation Exam Action 05/09/19 11:19 AM CDT Soft. Tested left arm proximal sharp sensation Exam Action 05/09/19 11:20 AM CDT Sharp. Tested left arm distal sharp sensation Exam Action 05/09/19 11:20 AM CDT Sharp. Tested right arm proximal sharp sensation Exam Action 05/09/19 11:20 AM CDT Sharp. Tested right arm distal sharp sensation Exam Action 05/09/19 11:20 AM CDT Sharp. close your eyes and tell me if the touch is sharp, dull, or soft Question 05/09/19 11:20 AM CDT Ok. Tested left leg proximal dull sensation Exam Action 05/09/19 11:21 AM CDT Dull. Tested left leg distal dull sensation Exam Action 05/09/19 11:21 AM CDT Dull. 11/18 5/9/2019 Neurological | Completed | Shadow Health Tested right leg proximal dull sensation Exam Action 05/09/19 11:21 AM CDT Dull. Tested right leg distal dull sensation Exam Action 05/09/19 11:21 AM CDT Dull. Tested left leg proximal light sensation Exam Action 05/09/19 11:21 AM CDT Soft. Tested left leg distal light sensation Exam Action 05/09/19 11:21 AM CDT Soft. Tested right leg proximal light sensation Exam Action 05/09/19 11:21 AM CDT Soft. Tested right leg distal light sensation Exam Action 05/09/19 11:21 AM CDT Soft. Tested left leg proximal sharp sensation Exam Action 05/09/19 11:21 AM CDT Sharp. Tested left leg distal sharp sensation Exam Action 05/09/19 11:21 AM CDT 12/18 5/9/2019 Neurological | Completed | Shadow Health Sharp. Tested right leg proximal sharp sensation Exam Action 05/09/19 11:21 AM CDT Sharp. Tested right leg distal sharp sensation Exam Action 05/09/19 11:21 AM CDT Sharp. close your eyes and tell me when you feel the touch Question 05/09/19 11:22 AM CDT Ok, I will. Tested sensation of left heel with monofilament Exam Action 05/09/19 11:22 AM CDT Yes. Tested sensation of left ball of foot under small toe with monofilament Exam Action 05/09/19 11:22 AM CDT Tested sensation of left ball of foot under small toe with monofilament Exam Action 05/09/19 11:22 AM CDT Tested sensation of left ball of foot under big toe with monofilament Exam Action 05/09/19 11:22 AM CDT Tested sensation of left big toe with monofilament Exam Action 05/09/19 11:22 AM CDT Tested sensation of right heel with monofilament Exam Action 05/09/19 11:22 AM CDT Yes. 13/18 5/9/2019 Neurological | Completed | Shadow Health Tested sensation of right ball of foot with monofilament Tested sensation of right big toe with monofilament close your eyes and tell me if your finger or toe moves up or down Exam Action 05/09/19 11:22 AM CDT Exam Action 05/09/19 11:22 AM CDT Question 05/09/19 11:24 AM CDT Ok, I will. Up. Tested position sense of finger on left hand Exam Action 05/09/19 11:24 AM CDT Down. Tested position sense of finger on right hand Exam Action 05/09/19 11:24 AM CDT Down. Tested position sense of toe on left foot Exam Action 05/09/19 11:24 AM CDT ...I think that was up. Tested position sense of toe on right foot close your eyes and tell me what i put in your hand Exam Action 05/09/19 11:24 AM CDT Question 05/09/19 11:25 AM CDT Ok, sure. ...Some kind of coin. Tested left-hand stereognosis with coin 14/18 5/9/2019 Neurological | Completed | Shadow Health Exam Action 05/09/19 11:25 AM CDT This is... some wire thing... paperclip? Tested left-hand stereognosis with paper clip Exam Action 05/09/19 11:25 AM CDT Um... that feels like a key. Tested left-hand stereognosis with key Exam Action 05/09/19 11:26 AM CDT ...Some kind of coin. Tested right-hand stereognosis with coin Exam Action 05/09/19 11:26 AM CDT The paperclip again. Tested right-hand stereognosis with paper clip Exam Action 05/09/19 11:26 AM CDT Um... that feels like a key. Tested right-hand stereognosis with key Exam Action 05/09/19 11:26 AM CDT Tested reflexes of left triceps: 2+ Exam Action 05/09/19 11:26 AM CDT Tested reflexes of right triceps: 2+ Exam Action 05/09/19 11:26 AM CDT Tested reflexes of left biceps: 2+ Exam Action 05/09/19 11:27 AM CDT Tested reflexes of right biceps: 2+ Exam Action 05/09/19 11:27 AM CDT 15/18 5/9/2019 Neurological | Completed | Shadow Health Tested reflexes of left brachioradialis: 2+ Exam Action 05/09/19 11:27 AM CDT Tested reflexes of right brachioradialis: 2+ Exam Action 05/09/19 11:27 AM CDT Tested reflexes of left patellar tendon: 2+ Exam Action 05/09/19 11:28 AM CDT Tested reflexes of left achilles tendon: 2+ Exam Action 05/09/19 11:28 AM CDT close your eyes and touch your fingers to your nose. Question 05/09/19 11:29 AM CDT I can do that. Observed left index finger to nose Exam Action 05/09/19 11:29 AM CDT Observed right index finger to nose Exam Action 05/09/19 11:29 AM CDT run your right foot down your shin Question 05/09/19 11:29 AM CDT Sure. Observed right heel moving to shin run your left foot down your shin Exam Action 05/09/19 11:29 AM CDT Question 05/09/19 11:30 AM CDT Ok. Observed left heel moving to shin Exam Action 05/09/19 11:30 AM CDT place your hands on your knees and turn them over 16/18 5/9/2019 Neurological | Completed | Shadow Health Question 05/09/19 11:30 AM CDT Ok, like this? Observed patient's gait you did great tina Exam Action 05/09/19 11:30 AM CDT Empathize 05/09/19 11:31 AM CDT Thanks. you need to make sure and always keep your wounds clean Educate 05/09/19 11:31 AM CDT Thanks for telling me. also please monitor your blood sugar Educate 05/09/19 11:32 AM CDT Thanks for telling me. you need to always to keep your wounds clean Educate 05/09/19 11:32 AM CDT Thanks for telling me. how is your pain now? Question 05/09/19 11:33 AM CDT It's a lot better now, but it's definitely still hurting. on a scale of 1 to 10 how is your pain now? Question 05/09/19 11:34 AM CDT Ugh... I'd say an 8. I mean, it hurts so much. 17/18 5/9/2019 Neurological | Completed | Shadow Health Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2018 18/18 ...
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  • Spring '17
  • Electronic health record, Left-handedness, Physical examination, Tina Jone Foot Injury Neurolog

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