Digital Clinical Assessment of Tina Jones' Mobility and Injury History, Exams of Nursing

Download Digital Clinical Assessment of Tina Jones' Mobility and Injury History and more Exams Nursing in PDF only on Docsity! 1 MUSCULOSKELETAL RESULTS | TURNED IN Nursing Concepts Shadow Health Assessment 2018, Nur 112 Patient: Tina Jones Digital Clinical Experience Score 100% Student Performance Index 50 out of 51 Subjective Data Collection 23 out of 23 Objective Data Collection 27 out of 28 Time 57 minutes total spent in assignment Hello! Question 2 11/09/18 12:00 AM CST 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 11/09/18 12:03 AM 5 they are not automatically graded by the simulation. How will I be evaluated? 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? 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. 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? K e e p t h e c a l l l i g h t w i t h i n r e a c h , r e m o v e a 6 ll tripping or slipping hazards, make sure the bed isn't too high. Time to begin. Hi, my name is Kara and I will be taking care of you today Question 11/09/18 12:10 AM CST Question 11/09/18 12:13 AM CST 7 Question 11/09/18 12:20 AM CST Greet 11/09/18 12:20 AM CST 10 1:00 AM CST 11 Do you have any joint stiffness? No, I'm not stiff anywhere now. Do you have any back pain? No, I don't usually have back pain. What is your pain level while walking? (Clarified to what is your pain like when you try to walk.) It still hurts a lot to put weight on my foot, but I can do it now without help, at least. (Clarified to what my pain is like when I try to walk.) Are you able to stand? 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. D i d y o u n e e d h e l p s t a n d i n g u p ? ( N o m a t c h i 12 ng questions found.) Did you need assistance standing up? (No matching questions found.) Question 11/09/18 1:00 AM CST Question 11/09/18 1:00 AM CST Question 11/09/18 1:01 AM CST Question 11/09/18 1:01 AM CST Question 11/09/18 15 o matching questions found.) Are you able to perform daily tasks without help? (Clarified to Are you able to perform all of your usual daily activities?.) I couldn't really do much at all the last couple days without help. I'm glad my mom and sister were there to help, and the nurses here, Question 11/09/18 1:02 AM CST Question 11/09/18 1:03 AM CST Question 11/09/18 1:03 AM CST Question 11/09/18 1:04 AM CST Question 11/09/18 16 1:04 AM CST Question 11/09/18 1:05 AM CST 17 too. Now, though, I feel like I can start to do things for myself again. My foot still hurts, but not nearly as bad. (Clarified to if I am able to perform daily activities.) HAve you had any muscle injuries? No, I don't think so. Have you had any joint injuries? No, not really. Any history of fractures? I've never broken a bone or anything like that. Any history of sprains? I c a n ' t r e m e m b e r s p r a i n i n g a n y t h i n g b e f o 20 CST My neck feels normal to me. Do you have a history of falls? Last week was the only time I can really remember falling. Where were you when you fell? I was at home, in our living room, changing that light bulb. Did you get dizzy before you fell? No, I wasn't dizzy. How did you feel before you fell? (Clarified to was your foot hurt before you fell.) E v e r y t h i n g w a s f i n e w i t h m y f o o t b e f o r 21 e I got the scrape. (Clarified to if my foot was hurt before I fell.) Have you had any other injuries recently? (Clarified to Do you have any other injuries?.) Nope. It's kind of amazing, but I didn't hurt my hands, knees, nothing else. Just my foot. (Clarified to if I have other injuries.) Did you scrape your foot when you fell? Question 11/09/18 1:11 AM CST Question 11/09/18 1:11 AM CST Question 11/09/18 1:11 AM CST Question 11/09/18 1:11 AM CST Question 11/09/18 1:12 AM CST 22 Question 11/09/18 1:12 AM 25 Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History • Finding: Asked about joint problems • Finding: Denies joint pain (Available) Pro Tip: Uncovering if Tina has any joint pain is important, as they could be a result of her recent foot injury and could contribute to impaired mobility. Example Question: Do you have joint pain? • Finding: Denies joint swelling (Found) Pro Tip: Uncovering if Tina has any swollen joints is important, as they could be a result of her recent foot injury and could contribute to impaired mobility. Example Question: Do you have swollen joints? • Finding: Asked about mobility • Finding: Denies history of walking problems 26 (Found) 27 Pro Tip: Discovering if Tina has a history of walking problems is imperative because it could show that her mobility issues predate the foot wound. Example Question: Have you ever had problems walking? • Finding: Reports recent foot wound hindered mobility (Available) Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether the pain makes it hard for her to walk would illustrate whether her pain is preventing her from some of the activities that comprise her daily life. Example Question: Has your wound affected your mobility? • Finding: Reports ability to walk on foot has recently improved (Found) Pro Tip: Determining if Tina's mobility has recently improved will provide key information as to the healing process and what further steps are needed. Example Question: Has your mobility changed lately? • Finding: Asked pain rating when walking • Finding: Reports pain as a 7 or 8/10 when walking (Available) Pro Tip: People with severe pain might find that they are limited in their movements. Having Tina rank her pain on a scale will help you judge the severity of the wound and help you determine treatment needs. Example Question: How would you rate your pain when walking? • Finding: Asked about ability to stand 30 Pro Tip: Determining if Tina's workplace is safe will allow you to establish any occupational dangers that could exacerbate her current health issues or pose further risks. Example Question: Is your work dangerous? • Finding: Denies work involving repetitive motion (Available) Pro Tip: Establishing if Tina's job requires repetitive motion, such as picking up boxes, can help you determine if those motions have had an impact on her health or pose potential risks. Example Question: Does your work involve repetitive motion? • Finding: Reports foot wound prevented her from working (Found) Pro Tip: People with severe pain might find that they are unable to perform all of their daily activities. Asking Tina whether she has been able to work in spite of the pain would illustrate whether her pain is preventing her from activities that constitute her daily life. Example Question: Did your wound prevent you from working? • Finding: Asked about activities of daily living • Finding: Denies difficulty transferring from sitting to standing (Found) Pro Tip: As a result of Tina's foot would, there is the risk that certain activities of daily living have been compromised. It is important to identify any difficulties with transferring so her quality of life does not suffer. Example Question: Are you able to go from sitting to standing? • Finding: Denies difficulty bathing 31 (Available) Pro Tip: As a result of Tina's foot would, there is the risk that certain activities of daily living have been compromised. It is important to identify any difficulties with bathing so her quality of life does not suffer. Example Question: Can you bathe yourself? Review of Systems • Finding: Asked about joint stiffness • Finding: Denies joint stiffness (Available) Pro Tip: Because Tina's foot wound has recently impaired mobility, which often leads to joint stiffness, it is important to ask Tina about her joints to ascertain the impact of her wound and what treatment she may require. Example Question: Do you feel stiff anywhere? • Finding: Asked about back pain • Finding: Denies history of back pain (Available) Pro Tip: Back pain can be a serious complaint that compromises a patient's quality of life. It is important to determine Tina has suffered from back pain so you can most effectively treat the issue. Example Question: Have you had back pain before? • Finding: Denies current back pain (Found) Pro Tip: Back pain can be a serious complaint that compromises a patient's quality of life. It is important to determine if Tina is currently suffering from back pain so you can most effectively treat the issue. 32 Example Question: Are you having back pain? • Finding: Asked about muscle injury • Finding: Denies history of muscle injury (Found) Pro Tip: It is important to establish if Tina has a history of muscle injuries because it may contribute to her recent mobility issues. Example Question: Have you ever had a muscle injury? • Finding: Denies current muscle injury (Found) Pro Tip: It is important to establish if Tina has a muscle injury because it might contribute to her recent mobility issues. Example Question: Do you have a muscle injury? • Finding: Asked about joint injury • Finding: Denies past joint injury (Found) Pro Tip: It is important to establish if Tina has a history of joint injuries because it may contribute to her recent mobility issues. Example Question: Have you experienced a joint injury in the past? • Finding: Denies current joint injury (Found) 35 • Finding: Reports normal range of motion (Found) Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether she is limited in her movements would illustrate whether her pain is preventing her from some of the activities that comprise her daily life. Example Question: Do you have full range of motion? • Finding: Asked about muscle problems • Finding: Denies muscle weakness (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle weakness, details the way her individual symptoms and pain manifest. Example Question: Are you experiencing any muscle weakness? • Finding: Denies muscle cramping (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle cramping, details the way her individual symptoms and pain manifest. Example Question: Are you experiencing any muscle cramping? Risk Factors • Finding: Asked fall history • Finding: Reports fall 36 (Found) Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density. Example Question: Have you fallen before? • Finding: Reports fall was one week ago (Found) Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density. Example Question: When was the last time you fell? • Finding: Reports belief that she is not particularly prone to falls (Found) Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina if she is prone to falling could provide you with information about her bone density. Example Question: Are you prone to falling? Relevant Family History • Finding: Asked family history of osteoporosis • Finding: Denies family history of osteoporosis (Found) Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has osteoporosis can indicate a potential predisposition. Example Question: Does anyone in your family have osteoporosis? • Finding: 37 Asked family history of joint problems • Finding: Denies family history of joint problems (Found) Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has had joint problems can indicate a potential predisposition. Example Question: Has anyone in your family had joint problems? • Finding: Denies family history of arthritis (Available) Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has arthritis can indicate a potential predisposition. Example Question: Does arthritis run in your family? • Finding: Asked family history of bone cancer • Finding: Denies family history of bone cancer (Found) Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has a history of bone cancer can indicate a potential predisposition. Example Question: Has anyone in your family had bone cancer? Objective Data Collection: 27 of 28 (96.43%) Inspected neck 1 of 1 point 40 Symmetry (1/3 point) • Symmetric bilaterally • Asymmetric 41 Right: Appearance (1/3 point) • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Atrophy • Hypertrophy Left: Appearance (1/3 point) • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Atrophy • Hypertrophy Inspected elbows 1 of 1 point Symmetry (1/3 point) • Symmetric bilaterally • Asymmetric Right: Appearance (1/3 point) • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Joint deformity Left: Appearance (1/3 point) 42 • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Joint deformity 45 • Discoloration • Joint deformity Left: Appearance (No point) • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Joint deformity Inspected hips 1 of 1 point Appearance (1/1 point) • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Pelvic tilt Inspected thighs 1 of 1 point Symmetry (1/3 point) • Symmetric bilaterally • Asymmetric Right: Appearance (1/3 point) • No visible abnormal findings • Swelling • Visible mass 46 • Irregular alignment • Discoloration • Atrophy • Hypertrophy Left: Appearance (1/3 point) 47 • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Atrophy • Hypertrophy Inspected knees 0.67 of 1 point Symmetry (1/3 point) • Symmetric bilaterally • Asymmetric Right: Appearance (No point) • No visible abnormal findings • Swelling • Visible mass • Genu recurvatum • Discoloration • Joint deformity Left: Appearance (1/3 point) • No visible abnormal findings • Swelling • Visible mass • Genu recurvatum • Discoloration • Joint deformity Inspected lower legs 1 of 1 point 50 • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Joint deformity 51 Inspected feet 1 of 1 point Symmetry (1/5 point) • Symmetric bilaterally • Asymmetric Right: Appearance (1/5 point) • No visible abnormal findings • Swelling • Laceration, lesion, or wound • Visible mass • Irregular alignment • Discoloration • Joint deformity • Hallux valgus • Hammertoe(s) • Mallet toe(s) • Claw toe(s) Right: Arch Shape (1/5 point) • Expected curvature • Pes planus • Pes cavus Left: Appearance (1/5 point) • No visible abnormal findings • Swelling • Laceration, lesion, or wound • Visible mass • Irregular alignment • Discoloration • Joint deformity • Hallux valgus 52 • Hammertoe(s) • Mallet toe(s) • Claw toe(s) Left: Arch Shape (1/5 point) • Expected curvature 55 • Reduced range of motion Tested elbow range of motion 1 of 1 point Right: Flexion And Extension (1/4 point) • Expected range of motion (approx. flexion of 160 degrees and 180 of full extension) • Reduced flexion • Reduced extension Left: Flexion And Extension (1/4 point) • Expected range of motion (approx. flexion of 160 degrees and 180 of full extension) • Reduced flexion • Reduced extension Right: Supination And Pronation (1/4 point) • Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees) • Reduced pronation • Reduced supination Left: Supination And Pronation (1/4 point) • Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees) • Reduced pronation • Reduced supination Tested wrist range of motion 1 of 1 point Right: Ulnar And Radial Deviation (1/6 point) • Expected range of motion (approx. ulnar radiation 55 degrees and radial deviation 90 degrees) 56 • Reduced ulnar deviation • Reduced radial deviation Left: Ulnar And Radial Deviation (1/6 point) • Expected range of motion (approx. ulnar radiation 55 degrees and radial deviation 90 degrees) • Reduced ulnar deviation 57 • Reduced radial deviation Right: Extension (1/6 point) • Expected range of motion (approx. 70 degrees) • Reduced extension Left: Extension (1/6 point) • Expected range of motion (approx. 70 degrees) • Reduced extension Right: Flexion (1/6 point) • Expected range of motion (approx. 90 degrees) • Reduced flexion Left: Flexion (1/6 point) • Expected range of motion (approx. 90 degrees) • Reduced flexion Tested spine range of motion 1 of 1 point Extension (1/4 point) • Expected range of motion (approx. 30 degrees) • Reduced extension Flexion (1/4 point) • Expected range of motion (approx. 75 - 90 degrees) • Reduced flexion Lateral Bending (1/4 point) • Expected range of motion bilaterally (approx. 35 degrees) • Reduced lateral bending to the right • Reduced lateral bending to the left 60 Right: Flexion (1/4 point) • Expected range of motion (approx. 130 degrees) • Reduced flexion Left: Flexion (1/4 point) 61 • Expected range of motion (approx. 130 degrees) • Reduced flexion Tested ankle range of motion 1 of 1 point Right: Eversion And Inversion (1/4 point) • Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees) • Reduced inversion • Reduced eversion Left: Eversion And Inversion (1/4 point) • Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees) • Reduced inversion • Reduced eversion Right: Dorsiflexion And Plantar Flexion (1/4 point) • Expected range of motion (approx. flexion of 160 degrees and 180 of full extension) • Reduced dorsiflexion • Reduced plantar flexion Left: Dorsiflexion And Plantar Flexion (1/4 point) • Expected range of motion (approx. flexion of 160 degrees and 180 of full extension) • Reduced dorsiflexion • Reduced plantar flexion Tested neck strength 1 of 1 point Strength (1/1 point) • 0 - No muscle contraction • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated 62 • 3 - Active movement against gravity • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Tested shoulder strength 65 Left (1/2 point) • 0 - No muscle contraction • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated • 3 - Active movement against gravity • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Tested hand strength 1 of 1 point Right (1/2 point) • 0 - No muscle contraction • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated • 3 - Active movement against gravity • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Left (1/2 point) • 0 - No muscle contraction • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated • 3 - Active movement against gravity • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Tested hip strength 1 of 1 point Strength (1/1 point) • 0 - No muscle contraction 66 • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated • 3 - Active movement against gravity • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Tested knee strength 67 1 of 1 point Right (1/2 point) • 0 - No muscle contraction • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated • 3 - Active movement against gravity • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Left (1/2 point) • 0 - No muscle contraction • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated • 3 - Active movement against gravity • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Tested ankle strength 1 of 1 point Right (1/2 point) • 0 - No muscle contraction • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated • 3 - Active movement against gravity • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Left (1/2 point) • 0 - No muscle contraction • 1 - Barely detectable contraction • 2 - Active movement with gravity eliminated • 3 - Active movement against gravity 70 12 14 16 18 16 O2 Sat (>94 %) 98 98 98 % % % 98 98 % % 99 98 % % 99% Pain 10 7 asle asle asle asle asle 9 6 Scal e Pai n Reassess 7 ep ep ep ep ep ment after Interven tion Notes @23 :00 asle ep Student Documentation Model Documentation Patient has a laceration and swelling on right foot. Right ankle strength tested 18 18 16 18 16 14 14 16 14 98% 98 % 98% 98 % 98 % 98 % 98 % 98 % 98 % 9 6 8 6 8 6 7 7 8 5 @07 :00 4 @11 :00 71 Student Documentation Model Documentation at 4/5. She mentions pain in foot when moving her ankle. Requires some assistance with ADL's. Patient fell last week which caused injury to right foot. Pain rated at 6/10 @ 08:00.