nrse 4520 neuro assessment.pdf - Neurological | Completed |...

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Unformatted text preview: 11/17/2019 Neurological | Completed | Shadow Health Neurological Results | Turned In Health Assessment - NRSE 4520 - October 2019, NRSE_4520_LEC_FALL_2019-20 Return to Assignment Your Results Overview Reopen Transcript Transcript Subjective Data Collection Lab Pass Started: Nov 17, 2019 | Patient Exam Time: 59 min All Lines (173) Interview Questions (104) Statements (6) Exam Actions (63) Objective Data Collection Documentation Hello! New Activity Question 11/17/19 1:04 PM EST 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 11/17/19 1:05 PM EST 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 11/17/19 1:05 PM EST … 1/22 11/17/2019 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 11/17/19 1:09 PM EST 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 11/17/19 1:09 PM EST 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 11/17/19 1:12 PM EST 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. … 2/22 11/17/2019 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? loss of sensation Statement 11/17/19 1:12 PM EST Time to begin. Hello Tina. My name is Crystal I will be your nurse today Greet 11/17/19 1:13 PM EST Hey. can you tell me your name and date of birth Question 11/17/19 1:14 PM EST My name's Tina Jones, and my birthday's February 17th. Checked vitals on a scale 0-10, can you rate your pain for me Exam Action 11/17/19 1:15 PM EST Question 11/17/19 1:15 PM EST It's at about a 6 out of 10 right now. im sorry, lets see what we can do to help lower that pain level Empathize 11/17/19 1:16 PM EST Thanks. what brings you in today Question 11/17/19 1:16 PM EST I've been here for two days, for the cut on my foot. what additional symptoms have your experienced (No matching questions found.) Question 11/17/19 1:21 PM EST … 3/22 11/17/2019 Neurological | Completed | Shadow Health can you describe your pain Question 11/17/19 1:22 PM EST It's just sore now, no throbbing or anything. can you tell me how you hurt your foot Question 11/17/19 1:22 PM EST I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! has your foot been draining any fluids Question 11/17/19 1:23 PM EST There was a lot of pus when I came in, but I think it's cleared up. what color was the pus (Clarified to What color was the drainage?.) Question 11/17/19 1:23 PM EST It's... white or maybe off-white. (Clarified to what color the pus was.) how have you been treating the wound Question 11/17/19 1:23 PM EST I made sure to clean it and keep it bandaged. And I put Neosporin on it. Was the neosporin working (No matching questions found.) Question 11/17/19 1:23 PM EST Was the neosporin effective (No matching questions found.) Question 11/17/19 1:24 PM EST can you walk on your effective foot (Clarified to Can you walk on your hurt foot?.) Question 11/17/19 1:24 PM EST No, I can't. I can't put any weight on it without like, shooting pain. (Clarified to if I can walk on my hurt foot.) do you have any history of headaches Question 11/17/19 1:37 PM EST … 4/22 11/17/2019 Neurological | Completed | Shadow Health Yeah, my head aches sometimes. But it's okay right now. how often do you get headaches Question 11/17/19 1:38 PM EST It's whenever I have to read or study a long time for school, so I probably have them a few times a month on average, I'd say. how severe is the headaches Question 11/17/19 1:38 PM EST The headaches aren't too bad. . . just annoying, not debilitating or anything. do you take any medication for your headaches Question 11/17/19 1:39 PM EST Yeah, I'll take Tylenol if it gets bad enough. does it help (Clarified to Does the pain medication alleviate the pain?.) Question 11/17/19 1:39 PM EST The pain pills were helping, but I don't think I need them anymore. (Clarified to if the pain medication helps.) do you have any allergies Question 11/17/19 1:39 PM EST Yeah, I'm allergic to cats. do you have any allergies to medications Question 11/17/19 1:40 PM EST Yeah, I'm allergic to penicillin. what happens when you take penicillin Question 11/17/19 1:40 PM EST I don't remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. do you smoke … 5/22 11/17/2019 Neurological | Completed | Shadow Health Question 11/17/19 1:40 PM EST No. I think it's gross. Good for you! Smoking can cause so many health problems Empathize 11/17/19 1:40 PM EST Thanks. do you drink Question 11/17/19 1:41 PM EST I do sometimes, yeah, when I go out with my friends. how often do you drink Question 11/17/19 1:41 PM EST No more than once or twice a week, sometimes less. how many drinks do you have Question 11/17/19 1:41 PM EST Never any more than 2 or 3. do you use recreational drugs Question 11/17/19 1:41 PM EST No. any fevers Question 11/17/19 1:41 PM EST I had a fever in the ER, but I haven't really been running one since. do you have any chills Question 11/17/19 1:41 PM EST … 6/22 11/17/2019 Neurological | Completed | Shadow Health I had the chills a couple nights ago when I was running a fever, but not now. do you have fatigue Question 11/17/19 1:42 PM EST I'm not tired now. do you have dizziness Question 11/17/19 1:42 PM EST No, I'm not dizzy. any history of dizziness (Clarified to Have you felt dizzy in the past?.) Question 11/17/19 1:42 PM EST I don't remember feeling particularly dizzy, no. (Clarified to if I have felt dizzy in the past.) do you have any changes in sensation Question 11/17/19 1:42 PM EST I think I feel things normally. do you have numbness Question 11/17/19 1:42 PM EST No, I don't think so. do you have any tingling Question 11/17/19 1:42 PM EST 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. how often does it fall asleep Question 11/17/19 1:43 PM EST I had some trouble sleeping the first night I was here. The pain was killing me, so I couldn't fall asleep. I usually don't have any trouble sleeping. how often does your hand feels like pins and needles … 7/22 11/17/2019 Neurological | Completed | Shadow Health Question 11/17/19 1:43 PM EST I didn't mean that my hand falling asleep was a regular thing. I just came up with a random example. I don't have any, like, weird tingling. [AUDIO COMING SOON] do you have any vision problems Question 11/17/19 1:43 PM EST Yeah, actually, I have been noticing my eyes getting kind of blurry lately. when was the last time you had your eyes checked Question 11/17/19 1:43 PM EST When I was a kid and had check-ups the pediatrician would check my vision. . . and I think maybe someone came a couple times in elementary school to do vision tests. But I haven't had an eye exam since then. when did you notice changes in vision Question 11/17/19 1:44 PM EST I don't know when it started, exactly. Maybe a few months ago? do you have any problems hearing Question 11/17/19 1:44 PM EST No. any muscle weakness Question 11/17/19 1:44 PM EST My muscles don't feel weak ever. how is your mood Question 11/17/19 1:44 PM EST I'm not crazy about being here, honestly, but I'm glad I have someone helping me with my foot. I just hope I feel better soon. Thats our goal is getting you feeling better so you can go home … 8/22 11/17/2019 Neurological | Completed | Shadow Health Empathize 11/17/19 1:45 PM EST Thanks. do you know where you are Question 11/17/19 1:45 PM EST Yeah, I'm at Shadow General Hospital. can you tell me what city you ar in Question 11/17/19 1:45 PM EST I'm from Shadowville. I've lived here my whole life. can you tell me the date Question 11/17/19 1:46 PM EST Um, today's date is . . . [Ms. Jones reports the correct date and year.] how are apples and oranges alike (No matching questions found.) Question 11/17/19 1:46 PM EST how are apples and oranges alike? (No matching questions found.) Question 11/17/19 1:46 PM EST Can you count backwards from 100 by 7s (No matching questions found.) Question 11/17/19 1:47 PM EST How are apples and oranges alike? Question 11/17/19 1:48 PM EST How are they alike? Um.... they're both kinds of fruit. Evaluated abstract thinking: similarities among fruit how are a lake and an ocean alike Exam Action 11/17/19 1:48 PM EST Question 11/17/19 1:48 PM EST … 9/22 11/17/2019 Neurological | Completed | Shadow Health Uh.... they're both bodies of water. Evaluated abstract thinking: similarities among bodies of water how area trumpet and a flute alike Exam Action 11/17/19 1:48 PM EST Question 11/17/19 1:49 PM EST They...... they're both musical instruments. Evaluated abstract thinking: similarities among instruments excellent! Exam Action 11/17/19 1:49 PM EST Empathize 11/17/19 1:49 PM EST Thanks. count backwards by 7s from 100 Question 11/17/19 1:49 PM EST Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2. read and follow these instructions Question 11/17/19 1:50 PM EST Ok. Established one-stage comprehension read and follow these instructions Exam Action 11/17/19 1:50 PM EST Question 11/17/19 1:50 PM EST Sure. Established two-stage comprehension Exam Action 11/17/19 1:50 PM EST … 10/22 11/17/2019 Neurological | Completed | Shadow Health who was the first president tof the united states Question 11/17/19 1:50 PM EST That's George Washington. Evaluated knowledge of first president who are the last four presidents of the united states Exam Action 11/17/19 1:50 PM EST Question 11/17/19 1:51 PM EST 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 11/17/19 1:51 PM EST Question 11/17/19 1:51 PM EST 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 address envelope on the sidewalk Exam Action 11/17/19 1:51 PM EST Question 11/17/19 1:52 PM EST 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 11/17/19 1:52 PM EST Question 11/17/19 1:52 PM EST Burger, tulip, nose, and tea. Evaluated immediate memory … 11/22 11/17/2019 Neurological | Completed | Shadow Health Exam Action 11/17/19 1:52 PM EST how did you celebrate your last birthday Question 11/17/19 1:53 PM EST 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 11/17/19 1:53 PM EST Question 11/17/19 1:54 PM EST Burger. . . tulip. . .nose. . . and tea. Evaluated immediate learning Exam Action 11/17/19 1:54 PM EST Observed patient's general vocabulary Exam Action 11/17/19 1:54 PM EST what classes are you taking Question 11/17/19 1:54 PM EST I'm taking two classes right now, one on auditing and one on managerial accounting. can you tell me more about school Question 11/17/19 1:54 PM EST School's really great. I've been doing really well and I'm in my last semester, so I'll have my Bachelor's in accounting in just a few months. Observed patient's general ability to articulate Exam Action 11/17/19 1:55 PM EST … 12/22 11/17/2019 Neurological | Completed | Shadow Health close your eyes and tell me what i trace on your palm Question 11/17/19 1:55 PM EST Ok. That's an "A." Tested left-hand graphesthesia by letter identification Exam Action 11/17/19 1:55 PM EST A figure "8." Tested right-hand graphesthesia by number identification close your eyes and tell me if the touch is sharp, dull, or soft Exam Action 11/17/19 1:55 PM EST Question 11/17/19 1:56 PM EST Ok. Tested left arm proximal dull sensation Exam Action 11/17/19 1:56 PM EST Dull. Tested left arm distal dull sensation Exam Action 11/17/19 1:56 PM EST Dull. Tested right arm proximal dull sensation Exam Action 11/17/19 1:56 PM EST Dull. Tested right arm distal dull sensation Exam Action 11/17/19 1:56 PM EST Dull. … 13/22 11/17/2019 Neurological | Completed | Shadow Health close your eyes and tell me if the touch is sharp, dull, or soft Question 11/17/19 1:57 PM EST Ok. Tested left leg proximal light sensation Exam Action 11/17/19 1:57 PM EST Soft. Tested left leg distal light sensation Exam Action 11/17/19 1:57 PM EST Soft. Tested right leg proximal light sensation Exam Action 11/17/19 1:57 PM EST Soft. Tested right leg distal light sensation Exam Action 11/17/19 1:57 PM EST Soft. Tested left leg proximal sharp sensation Exam Action 11/17/19 1:57 PM EST Sharp. Tested left leg distal sharp sensation Exam Action 11/17/19 1:57 PM EST Sharp. Tested right leg proximal sharp sensation Exam Action 11/17/19 1:57 PM EST Sharp. … 14/22 11/17/2019 Neurological | Completed | Shadow Health Tested right leg distal sharp sensation Exam Action 11/17/19 1:57 PM EST Sharp. close your eyes and tell me when you feel the touch Question 11/17/19 1:58 PM EST Ok, I will. Tested sensation of right big toe with monofilament Exam Action 11/17/19 1:58 PM EST Tested sensation of right ball of foot with monofilament Exam Action 11/17/19 1:58 PM EST Tested sensation of right heel with monofilament Exam Action 11/17/19 1:58 PM EST Yes. Tested sensation of left heel with monofilament Exam Action 11/17/19 1:58 PM EST Yes. Tested sensation of left ball of foot under small toe with monofilament Exam Action 11/17/19 1:58 PM EST Tested sensation of left ball of foot under big toe with monofilament Exam Action 11/17/19 1:59 PM EST Tested sensation of left big toe with monofilament Exam Action 11/17/19 1:59 PM EST close your eyes and tell e if your finger or toe moves up or down Question 11/17/19 1:59 PM EST … 15/22 11/17/2019 Neurological | Completed | Shadow Health Ok, I will. Up. Tested position sense of finger on left hand Exam Action 11/17/19 1:59 PM EST Down. Tested position sense of finger on right hand Exam Action 11/17/19 2:00 PM EST Down. Tested position sense of toe on left foot Exam Action 11/17/19 2:00 PM EST ...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 11/17/19 2:00 PM EST Question 11/17/19 2:00 PM EST Ok, sure. ...Some kind of coin. Tested left-hand stereognosis with coin Exam Action 11/17/19 2:00 PM EST This is... some wire thing... paperclip? Tested left-hand stereognosis with paper clip Exam Action 11/17/19 2:00 PM EST Um... that feels like a key. … 16/22 11/17/2019 Neurological | Completed | Shadow Health Tested left-hand stereognosis with key Exam Action 11/17/19 2:01 PM EST ...Some kind of coin. Tested right-hand stereognosis with coin Exam Action 11/17/19 2:01 PM EST The paperclip again. Tested right-hand stereognosis with paper clip Exam Action 11/17/19 2:01 PM EST Um... that feels like a key. Tested right-hand stereognosis with key Excellent! Exam Action 11/17/19 2:01 PM EST Empathize 11/17/19 2:01 PM EST Thanks. Tested reflexes of right triceps: 2+ Exam Action 11/17/19 2:02 PM EST Tested reflexes of left triceps: 2+ Exam Action 11/17/19 2:02 PM EST Tested reflexes of right biceps: 2+ Exam Action 11/17/19 2:03 PM EST Tested reflexes of left biceps: 2+ Exam Action 11/17/19 2:03 PM EST Tested reflexes of right brachioradialis: 2+ Exam Action 11/17/19 2:03 PM EST Tested reflexes of left brachioradialis: 2+ Exam Action 11/17/19 2:03 PM EST … 17/22 11/17/2019 Neurological | Completed | Shadow Health Tested reflexes of right patellar tendon: 2+ Exam Action 11/17/19 2:04 PM EST Tested reflexes of left patellar tendon: 2+ Exam Action 11/17/19 2:04 PM EST Tested reflexes of left patellar tendon: 2+ Exam Action 11/17/19 2:04 PM EST Tested reflexes of right achilles tendon: 2+ Exam Action 11/17/19 2:04 PM EST Tested reflexes of left achilles tendon: 2+ Exam Action 11/17/19 2:04 PM EST Tested reflexes of left achilles tendon: 2+ Exam Action 11/17/19 2:05 PM EST close your eyes and touch your fingers to your nose Question 11/17/19 2:0...
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