NR 509 Week 3 Shadow Health Musculoskeletal Assessment

NR 509 Week 3 Shadow Health Musculoskeletal Assessment

Shadow Health Musculoskeletal Assessment Subjective:

HPI:Ms. Jones visits the clinics and presents with back pain, which she states started afflicting her three weeks before. She attributes the back pain to tweaking whilst lifting her friend’s heavy box when the friend was moving. She posits the before the incident, she had lifted several boxes without injuring her back. Further, she states that the purpose of presenting concerns the increased and continued pain, which has impacted her daily living activities.

Social History: Ms. Jones’ job is mostly supervisory, although she does report that she may have to sit or stand for extended periods of time……………. use of tobacco, alcohol, and illicit drugs. She does not exercise.

ROS: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. •

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Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has difficulties with range of motion…… lower back has impacted her comfort while sleeping and sitting in class…….. numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. •

Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.

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NR 509 Week 3 Shadow Health Musculoskeletal Assessment Objective:

ROS: General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination.

Musculoskeletal: Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper extremities with full range of motion of shoulder, elbow, and wrist……………….. upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles.

HPI

According to Bickley (2013) a clear, well organized clinical record is one of the most important adjuncts to patient care and gathering information using open-ended questions, then closed ended questions to prompt specific responses.  This paper provides an overview of clinical reasoning and the nurse’s decision making after providing a complete advanced health history and physical assessment. It will also give insight into the nursing process and how it may enhance clinical thinking, reasoning and judgement in the nursing practice. Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents for complete physical examination and evaluation for right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Ms. Jones is alert and oriented, is seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Chief complaint is headache.

NR 509 Week 3 Shadow Health Musculoskeletal Assessment Rubric

Shadow Health Physical Assessment Rubric
Shadow Health Physical Assessment Rubric
Criteria Ratings Pts

Subjective Data, Organization, Communication, and Summary (DCE Score or transcript)

25.0 pts

Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.

21.0 pts

Average- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.

10.0 pts

Below Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.

0.0 pts

Unsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing.
25.0 pts

Objective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation

20.0 pts

Above Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.

16.0 pts

Average- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).

8.0 pts

Below Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).

0.0 pts

Unsatisfactory- No physical assessment documentation or no treatment plan.
20.0 pts

Self-Reflection

5.0 pts

Above Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.

3.0 pts

Average- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.

2.0 pts

Below Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight

0.0 pts

Unsatisfactory- No reflection posts for the assignment.
5.0 pts
Total Points: 50.0

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