nrse 4520 musculoskeletal.pdf - Musculoskeletal | Completed...

Unformatted text preview: 11/17/2019 Musculoskeletal | Completed | Shadow Health Musculoskeletal 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: 38 min All Lines (155) Interview Questions (57) Statements (2) Exam Actions (96) Objective Data Collection Documentation Hello! Question 11/17/19 11:59 AM 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 11:59 AM EST It's 8 a.m. on Tina Jones' second morning as a patient here at Shadow General Hospital. Ms. Jones has a physical therapy consultation later today. Your role in this simulation is that of healthcare provider who will perform a full musculoskeletal system exam on Ms. Jones so that her therapist can understand Ms. Jones' musculoskeletal health and customize therapy accordingly. What are my objectives in this assessment? Question 11/17/19 12:00 PM EST … 1/17 11/17/2019 Musculoskeletal | Completed | Shadow Health In your interview with Ms. Jones, you will ask about her musculoskeletal system and identify any risk factors or complications. 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 musculoskeletal 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 musculoskeletal system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones' musculoskeletal 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 12:00 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 12:01 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 12:01 PM EST In this assessment, you will become familiarized with the structure and content of musculoskeletal 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. … 2/17 11/17/2019 Musculoskeletal | Completed | Shadow Health In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What precautions should you take with a patient that is a fall risk? You should tell them to only get up when there is someone with them, use bed alarm and have them wear a fall risk band Statement 11/17/19 12:02 PM EST Time to begin. Good morning. my name is Crystal i will be your nurse Greet 11/17/19 12:03 PM EST Hey. Can you tell me your name and date of birth Question 11/17/19 12:03 PM EST My name's Tina Jones, and my birthday's February 17th. Vitals measured On a 0-10 scale, how would you rate your pain right now Exam Action 11/17/19 12:04 PM EST Question 11/17/19 12:05 PM EST I'd give it a 5 or 6 out of 10 right now. do you have any problems with your joints Question 11/17/19 12:05 PM EST No, my joints are fine. do you have any pain in your joints Question 11/17/19 12:06 PM EST My joints don't hurt. Inspected front of neck Exam Action 11/17/19 12:06 PM EST … 3/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Inspected left side of neck Inspected front of neck have you noticed swelling of your joints Exam Action 11/17/19 12:06 PM EST Exam Action 11/17/19 12:06 PM EST Question 11/17/19 12:06 PM EST I've only had swelling recently, in the cut in my foot. But it's gone down since I came in. do you have any muscle pain Question 11/17/19 12:06 PM EST My muscles don't hurt. do you have any muscle weakness Question 11/17/19 12:07 PM EST No, I wouldn't say I feel weak. do you have any bone pain Question 11/17/19 12:07 PM EST My bones aren't hurting me, no. have you had any recent injury or trauma to your bone (No matching questions found.) Question 11/17/19 12:07 PM EST have you had any recent injury or trauma to your bones (Clarified to Have you ever had an injury?.) Question 11/17/19 12:08 PM EST I haven't had anything really serious before. I think my foot right now is the worst injury I've had! (Clarified to if I have had an injury.) are you able to bathe yourself Empathize 11/17/19 12:08 PM EST Thanks. … 4/17 11/17/2019 Musculoskeletal | Completed | Shadow Health are you able to bathe yourself Question 11/17/19 12:08 PM EST I don't need help showering. do you have chronic health issues Question 11/17/19 12:09 PM EST I've had asthma since I was little, and I have sugar diabetes, too. do you take medication for your asthma or diabetes Question 11/17/19 12:10 PM EST I just use my inhaler. does your inhaler help Question 11/17/19 12:10 PM EST Yeah, it helps. Sometimes I take an extra puff -- like 3 instead of 2. how often do you need extra puff (No matching questions found.) Question 11/17/19 12:10 PM EST do you take medication for diabetes Question 11/17/19 12:11 PM EST I haven't taken anything for my diabetes at home in a while. when was the last time you seen your doctor about your diabetes Question 11/17/19 12:11 PM EST I got diagnosed when I was 24, then I saw a doctor for a follow-up maybe six months to a year after that, and I haven't needed to go back since. you should follow up yearly with your primary doctor, espeically regarding diabetes. Diabetes can cause other medical issues such as wound healing delay. Educate 11/17/19 12:12 PM EST Thanks for telling me. … 5/17 11/17/2019 Musculoskeletal | Completed | Shadow Health do you have family history of joint disease Question 11/17/19 12:12 PM EST No, I don't think so. family history of degenerative joint disease Question 11/17/19 12:12 PM EST No, I don't think so. family history or arthritis (Clarified to Has anyone in your family had arthritis?.) Question 11/17/19 12:13 PM EST No, I don't know about that. (Clarified to if anyone in my family has arthritis.) do you have a history of arthritis Question 11/17/19 12:13 PM EST No, I don't have arthritis! I'm a little young for that. . . does obesity run in your family Question 11/17/19 12:13 PM EST No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything. can you change positions without problem Question 11/17/19 12:13 PM EST Yes, I can move around in bed OK. [AUDIO COMING SOON] have you been able to work Question 11/17/19 12:14 PM EST I've had to miss work for sure--I'm on my feet all day for my job, and that obviously wouldn't work with my foot the way it is, if I could even get over there. Inspected right side of neck Exam Action 11/17/19 12:14 PM EST … 6/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Inspected front of neck Exam Action 11/17/19 12:14 PM EST Inspected front of neck Exam Action 11/17/19 12:14 PM EST Inspected left side of neck Exam Action 11/17/19 12:15 PM EST Inspected back of neck Exam Action 11/17/19 12:15 PM EST Inspected right side of neck Exam Action 11/17/19 12:15 PM EST Inspected front of neck Exam Action 11/17/19 12:15 PM EST Inspected shoulders from the front Exam Action 11/17/19 12:15 PM EST Inspected right shoulder Exam Action 11/17/19 12:15 PM EST Inspected upper back Exam Action 11/17/19 12:15 PM EST Inspected left shoulder Exam Action 11/17/19 12:15 PM EST Inspected shoulders from the front Exam Action 11/17/19 12:15 PM EST Inspected left arm Exam Action 11/17/19 12:15 PM EST Inspected right arm Exam Action 11/17/19 12:15 PM EST Inspected right elbow Exam Action 11/17/19 12:15 PM EST … 7/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Inspected left elbow Exam Action 11/17/19 12:15 PM EST Inspected right wrist Exam Action 11/17/19 12:15 PM EST Inspected both wrists Exam Action 11/17/19 12:16 PM EST Inspected left wrist Exam Action 11/17/19 12:16 PM EST Inspected right wrist Exam Action 11/17/19 12:16 PM EST Inspected right hand Exam Action 11/17/19 12:16 PM EST Inspected both hands Exam Action 11/17/19 12:16 PM EST Inspected left hand Exam Action 11/17/19 12:16 PM EST Inspected front of hips Exam Action 11/17/19 12:16 PM EST Inspected left side of hips Exam Action 11/17/19 12:16 PM EST Inspected back of hips Exam Action 11/17/19 12:16 PM EST Inspected right side of hips Exam Action 11/17/19 12:16 PM EST Inspected front of hips Exam Action 11/17/19 12:16 PM EST Inspected front of thighs Exam Action 11/17/19 12:16 PM EST … 8/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Inspected left thigh Exam Action 11/17/19 12:16 PM EST Inspected back of thighs Exam Action 11/17/19 12:17 PM EST Inspected right thigh Exam Action 11/17/19 12:17 PM EST Inspected front of thighs Exam Action 11/17/19 12:17 PM EST Inspected front of knees Exam Action 11/17/19 12:17 PM EST Inspected left knee Exam Action 11/17/19 12:17 PM EST Inspected back of knees Exam Action 11/17/19 12:17 PM EST Inspected right knee Exam Action 11/17/19 12:17 PM EST Inspected front of knees Exam Action 11/17/19 12:17 PM EST Inspected front of legs Exam Action 11/17/19 12:17 PM EST Inspected left leg Exam Action 11/17/19 12:17 PM EST Inspected back of legs Exam Action 11/17/19 12:17 PM EST Inspected right leg Exam Action 11/17/19 12:17 PM EST Inspected front of legs Exam Action 11/17/19 12:17 PM EST … 9/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Inspected left ankle Exam Action 11/17/19 12:17 PM EST Inspected both ankles Exam Action 11/17/19 12:17 PM EST Inspected right ankle Exam Action 11/17/19 12:17 PM EST Inspected both ankles Exam Action 11/17/19 12:17 PM EST Inspected left ankle Exam Action 11/17/19 12:17 PM EST Inspected left foot Exam Action 11/17/19 12:18 PM EST Inspected soles of feet: Right: Laceration and swelling, expected curvature. Left: No visible abnormal findings, expected curvature. Exam Action 11/17/19 12:18 PM EST Inspected left foot Exam Action 11/17/19 12:18 PM EST Inspected top of feet Exam Action 11/17/19 12:18 PM EST Tested ROM of neck - extension: Expected Exam Action 11/17/19 12:18 PM EST Tested ROM of neck - flexion: Expected Exam Action 11/17/19 12:21 PM EST Tested ROM of neck - lateral bending: Expected Exam Action 11/17/19 12:22 PM EST Tested ROM of neck - lateral bending: Expected Exam Action 11/17/19 12:22 PM EST Tested ROM of neck - rotation: Expected … 10/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Exam Action 11/17/19 12:22 PM EST any pain Question 11/17/19 12:22 PM EST My foot is still sore, but it's feeling better since I've been here. Tested ROM of shoulders - adduction: Expected Exam Action 11/17/19 12:22 PM EST Tested ROM of shoulders - extension: Expected Exam Action 11/17/19 12:22 PM EST Tested ROM of shoulders - flexion: Expected Exam Action 11/17/19 12:23 PM EST Tested ROM of elbows - flexion and extension: Expected Exam Action 11/17/19 12:23 PM EST Tested ROM of elbows - supination and pronation: Expected Exam Action 11/17/19 12:23 PM EST Tested ROM of wrists - ulnar and radial deviation: Expected Exam Action 11/17/19 12:23 PM EST Tested ROM of wrists - extension: Expected Exam Action 11/17/19 12:23 PM EST Tested ROM of wrists - flexion: Expected Exam Action 11/17/19 12:24 PM EST Tested spinal ROM - extension: Expected Exam Action 11/17/19 12:24 PM EST Tested spinal ROM - flexion: Expected Exam Action 11/17/19 12:24 PM EST Tested spinal ROM - lateral bending: Expected Exam Action 11/17/19 12:24 PM EST … 11/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Tested spinal ROM - rotation to the left: Expected Exam Action 11/17/19 12:25 PM EST Tested spinal ROM - rotation to the right: Expected Exam Action 11/17/19 12:25 PM EST Tested ROM of hips - abduction: Expected Exam Action 11/17/19 12:25 PM EST Tested ROM of hips - adduction: Expected Exam Action 11/17/19 12:25 PM EST Tested ROM of hips - extension: Expected Exam Action 11/17/19 12:25 PM EST Tested ROM of hips - flexion: Expected Exam Action 11/17/19 12:26 PM EST Tested ROM of knees - extension: Expected Exam Action 11/17/19 12:26 PM EST Tested ROM of knees - flexion: Expected Exam Action 11/17/19 12:26 PM EST Tested ROM of ankles - inversion and eversion: Expected Exam Action 11/17/19 12:27 PM EST Tested ROM of ankles - dorsiflexion and plantar flexion: Right, reduced dorsi- and plantar flexion; Left, expected Exam Action 11/17/19 12:27 PM EST Tested neck strength - head down: 5/5 Exam Action 11/17/19 12:28 PM EST Tested neck strength - head turned to the left: 5/5 Exam Action 11/17/19 12:28 PM EST Tested neck strength - head tilted to the left: 5/5 Exam Action 11/17/19 12:28 PM EST Tested neck strength - head turned to the right: 5/5 Exam Action 11/17/19 12:28 PM EST … 12/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Tested neck strength - head tilted to the right: 5/5 Exam Action 11/17/19 12:29 PM EST Tested right and left shoulder strength: 5/5 Exam Action 11/17/19 12:29 PM EST Tested elbow strength during extension: 5/5 Exam Action 11/17/19 12:30 PM EST Tested elbow strength during flexion: 5/5 Exam Action 11/17/19 12:30 PM EST Tested wrist strength during extension - up: 5/5 Exam Action 11/17/19 12:30 PM EST Tested wrist strength during extension - down: 5/5 Exam Action 11/17/19 12:30 PM EST Tested right and left hand strength with grip test: 5/5 Exam Action 11/17/19 12:30 PM EST Tested right and left hip strength: 5/5 Exam Action 11/17/19 12:31 PM EST Tested right and left knee strength: 5/5 Exam Action 11/17/19 12:31 PM EST Tested right and left ankle strength: Right 4/5, Left 5/5 Exam Action 11/17/19 12:32 PM EST do you have any mobility issues Question 11/17/19 12:32 PM EST I can walk on my foot now, but it still hurts a lot. do you have a history of walking problems Question 11/17/19 12:32 PM EST I could walk fine before I hurt my foot. … 13/17 11/17/2019 Musculoskeletal | Completed | Shadow Health can you stand on your own Question 11/17/19 12:33 PM EST Last time I tried to stand normally it really hurt my foot, but at least I was able to stand on it. I'm hoping it'll be better soon. on a scale 0-10, how bad is the pain when you walk on your foot Question 11/17/19 12:33 PM EST It still hurts a lot to walk on. I'd say at least 7, maybe 8. do you have any history of muscle soreness Question 11/17/19 12:33 PM EST My muscles don't really get sore ever. do you have history of ankle issues (Clarified to Have you had problems with your ankle?.) Question 11/17/19 12:33 PM EST My ankles are fine. (Clarified to if I have had ankle problems.) is your work place safe (Clarified to Is your job dangerous?.) Question 11/17/19 12:34 PM EST I never feel like I'm in danger at work. I'm mostly just walking around with a clipboard, anyway. (Clarified to if my job is dangerous.) do you have troubles taking a bath (No matching questions found.) Question 11/17/19 12:34 PM EST have you ever had any difficulty bathing Question 11/17/19 12:35 PM EST I was having trouble doing that stuff before, but my foot's getting better now, so I think I'm fine. do you have any difficulty going from sitting position to a standing position Question 11/17/19 12:35 PM EST I was having trouble doing that stuff before, but my foot's getting better now, so I think I'm fine. do you have any joint stiffness … 14/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Question 11/17/19 12:35 PM EST No, I'm not stiff anywhere now. any back pain Question 11/17/19 12:35 PM EST No, I don't usually have back pain. do you have a history or back pain Question 11/17/19 12:36 PM EST I don't usually have any back pain. Sometimes it aches a little, but nothing bad. do you have a history or muscle injury Question 11/17/19 12:36 PM EST No, I don't think so. do you have any muscle injuries Question 11/17/19 12:36 PM EST No, I don't think so. do have a history of joint injury Question 11/17/19 12:36 PM EST No, not really. do you have a history of sprains Question 11/17/19 12:36 PM EST I can't remember spraining anything before. . . maybe in grade school? I did something to one of my fingers playing tether ball, I think. But nothing since then. do you have a history of bone problems Question 11/17/19 12:37 PM EST … 15/17 11/17/2019 Musculoskeletal | Completed | Shadow Health I don't know of any bone problems in the family. do you have any neck injuries Question 11/17/19 12:37 PM EST No. do you have limited movement Question 11/17/19 12:37 PM EST Well. . . my foot is maybe feeling a little better, but I still wouldn't want to put weight on it or try to walk anywhere just yet. do you have full range of motion of your legs Question 11/17/19 12:37 PM EST It hurts to move my foot, but I can do it. And everything else seems fine. [AUDIO COMING SOON] have you ever fallen Question 11/17/19 12:38 PM EST I didn't fall onto the ground. . . it was like, my foot just slipped as I stepped onto the ladder, but I caught my balance before I could topple over or anything. when did you last fall Question 11/17/19 12:38 PM EST Well, I mean, I sort of fell on the ladder a week ago, but before that I can't remember the last time I fell or hurt myself. do you have a family history of bone cancer Question 11/17/19 12:38 PM EST Oh wow -- no, not that I know of. family history of osteoarthritis Question 11/17/19 12:39 PM EST No one in the family has osteoporosis that I know of. thank you for your time … 16/17 11/17/2019 Musculoskeletal | Completed | Shadow Health Question 11/17/19 12:39 PM EST Alright, thanks. Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2012 - 2019 … 17/17 ...
View Full Document