NR 509 Week 3 Shadow Health Neurological Physical Assessment Assignment.docx

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WK 3 Shadow Health example NR 509 Week 3 Shadow Health Neurological Physical Assessment Assignment NR 509 Week 3 Shadow Health Neurological Physical Assessment Assignment Pre Brief Two days after a minor, low-speed car accident in which Tina was a passenger, she noticed daily bilateral headaches along with neck stiffness. She reports that it hurts to move her neck, and she believes her neck might be swollen. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This case study will allow you the opportunity to examine the patient’s optic nerve via use of the ophthalmoscope as well as assess her visual acuity. You will need to document your findings using appropriate medical terminology. Be sure to assess for foot neuropathy using the monofilament test. Reason for visit: Patient presents complaining of headache. NR 509 Week 3 Shadow Health Neurological Physical Assessment Assignment. 1
WK 3 Shadow Health example . Results: Transcript Results: Subjective Data Collection Results: Objective Data Collection Results: Education & Empathy Results: Documentation / Electronic Health Record Results: Pre – Survey Lifespan Results: Review Questions Results: Self-Reflection NR 509 Week 3 Shadow Health Neurological Physical Assessment Assignment Objective Data Collection: 36.75 of 37 (99.32%) Correct Partially correct Incorrect Missed Confirmed orientation 2
WK 3 Shadow Health example 1 of 1 point To Person (1/3 point) Oriented to person Not oriented to person To Place (1/3 point) Oriented to place Not oriented to place To Time (1/3 point) Oriented to time Not oriented to time Evaluated abstract thinking 1 of 1 point Abstractness (1/2 point) Abstract Concrete Relevance (1/2 point) Relevant Not relevant Evaluated attention span 1 of 1 point Serial 7s Test (1/1 point) Accurate Not accurate Evaluated comprehension 1 of 1 point Observations (1/1 point) Able to follow instructions Unable to follow instructions Evaluated general knowledge 1 of 1 point 3
WK 3 Shadow Health example Accuracy (1/1 point) Accurate Not accurate Evaluated judgment 1 of 1 point Observations (1/1 point) Intact Not intact Evaluated memory 1 of 1 point Remote Memory (1/3 point) Intact Not intact Immediate Memory (1/3 point) Intact Not intact New Learning Ability (1/3 point) Accurate Not accurate Observed vocabulary 1 of 1 point Complexity (1/1 point) Expected complex for patient’s age, education level, and general ability Not expected complexity

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