Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ | Exams Nursing | Docsity (2024)

Download Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ and more Exams Nursing in PDF only on Docsity! Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ Musculoskeletal Results | Turned In Nursing Concepts Shadow Health Assessment 2021, 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 11/09/21 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 Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ CST 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? 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? 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, Question 11/09/18 12:05 AM CST Question 11/09/18 12:07 AM CST Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ 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. Did you need help standing up? (No matching 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 1:02 AM CST Question 11/09/18 1:02 AM CST Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ Are you experiencing any sore muscles? My muscles don't really get sore ever. Do your joints around your injury hurt? It hurts my foot a little to move my ankle, but my ankle feels fine. What do you do for a living? I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up. Do you stand often at work? I usually have to be on my feet my whole shift at work, which is why I've had to call in sick since my foot started hurting too much to put weight on. How long were you on your feet at work? (No 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 1:04 AM CST Question 11/09/18 1:05 AM CST Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ 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 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. Any muscle problems? I don't have any problems with my muscles. Do you have any issues with your neck? Question 11/09/18 1:06 AM CST Question 11/09/18 1:08 AM CST Question 11/09/18 1:08 AM CST Question 11/09/18 1:09 AM CST Question 11/09/18 1:09 AM CST Question 11/09/18 1:10 AM Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ 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 (Found) Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ 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 Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ • Finding: Denies trouble standing before foot problems (Found) Pro Tip: Asking Tina if she has a history of standing problems will reveal the severity of her injury and whether her standing problem predated her foot injury. Example Question: Do you have a history of standing problems? • Finding: Reports recent foot wound hindered standing (Found) Pro Tip: Asking Tina if she can stand on her foot will reveal the severity of her injury and whether or not she is able to put weight on her foot. Example Question: Has your wound affected your ability to stand? • Finding: Reports improved ability to stand on injured foot (Found) Pro Tip: Asking Tina if she can stand on her foot will reveal the severity of her injury and whether or not she is able to put weight on her foot. Example Question: Are you able to stand on your foot? • Finding: Asked pain rating when standing • Finding: Reports pain as a 7 or 8/10 when bearing weight on foot (Available) Pro Tip: Asking Tina about the pain if she's standing will reveal the severity of her injury and whether or not standing exacerbates her pain. Example Question: How would you rate your pain on a scale of 1 to 10 when you are standing? Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ (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. Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ 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) Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ Pro Tip: It is important to establish if Tina has a joint injury because it might contribute to her recent mobility issues. Example Question: Do you have a joint injury? • Finding: Asked history of fracture • Finding: Denies history of fractures (Found) Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she's ever broken a bone might reveal relevant concerns she'd previously experienced. Example Question: Have you ever broken a bone? • Finding: Asked history of sprains • Finding: Denies history of sprains (Found) Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she has a history of getting sprains might reveal relevant concerns she'd previously experienced. Example Question: Do you have a history of getting sprains? • Finding: Asked about bone problems • Finding: Denies history of bone problems (Found) Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ (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: Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ 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 Symmetry (1/2 point) Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ • Symmetric • Asymmetric Appearance (1/2 point) • No visible abnormal findings • Swelling • Visible pulsation • Visible mass • Irregular alignment • Discoloration Inspected shoulders 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 Left: Appearance (1/3 point) • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration Inspected arms 1 of 1 point Symmetry (1/3 point) • Symmetric bilaterally • Asymmetric Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ • 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 • Irregular alignment • Discoloration • Atrophy • Hypertrophy Left: Appearance (1/3 point) Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ • 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 Symmetry (1/3 point) • Symmetric bilaterally • Asymmetric Right: Appearance (1/3 point) Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ • No visible abnormal findings • Swelling • Visible mass • Discoloration • Atrophy • Hypertrophy • Genu valgum • Genu varum Left: Appearance (1/3 point) • No visible abnormal findings • Swelling • Visible mass • Discoloration • Atrophy • Hypertrophy • Genu valgum • Genu varum Inspected ankles 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) • No visible abnormal findings • Swelling • Visible mass • Irregular alignment • Discoloration • Joint deformity Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ • 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) • 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 Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ • 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 Rotation (1/4 point) • Expected range of motion bilaterally (approx. 30 degrees) • Reduced rotation to the right Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ • Reduced rotation to the left Tested hip range of motion 1 of 1 point Abduction (1/4 point) • Expected range of motion (approx. 45 degrees) • Reduced hip abduction Adduction (1/4 point) • Expected range of motion (approx. 30 degrees) • Reduced hip adduction Extension (1/4 point) • Expected range of motion (approx. 30 degrees) • Reduced hip extension Flexion (1/4 point) • Expected range of motion (approx. 90 degrees) • Reduced hip flexion Tested knee range of motion 1 of 1 point Right: Extension (1/4 point) • Expected range of motion (approx. 0 to 15 degrees) • Reduced extension Left: Extension (1/4 point) • Expected range of motion (approx. 0 to 15 degrees) • Reduced extension Right: Flexion (1/4 point) • Expected range of motion (approx. 130 degrees) • Reduced flexion Left: Flexion (1/4 point) Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ 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 • 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 Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ 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 • 4 - Active movement against gravity and resistance • 5 - Active movement against full resistance without fatigue (normal) Documentation / Electronic Health Record • Flowsheets • Nursing Progress Notes Shadow Health Musculoskeletal Tina Jones 112.LATEST UPDATED SCORED A+ Vitals Vitals 22:0 00 : 02 : 04 : 06:0 08 : 10:0 12 : 14: 16 : 18 : 20: 22: 00: 02 : 04: 06: 08:0 0 00 00 00 0 00 0 00 00 00 00 00 00 00 00 00 00 0 38.7 39.1 38.6 37.9 37.1 36.7 37 C 36.7 38 38.3 36.2 36.7 37 36.7 36.7 36.7 38 Temp C / C / C / C / C / C / / C / C / C / C / C / C / C / C / C / C / 36.7 (<38° C) 101. 102. 101. 100. 98.8 98.1 98.6 98.1 100. 100. 97.1 98.6 98.6 98.1 98.1 98.1 100. C/ 7 F 4 F 5 F 2 F F F F F 4 F 9 F F F F F F F 4 F BP 138/ 138/ 136/ 138/ 134/ 138/ 136/ 136/ 138/ 136/ 134/ 132/ 132/ 130/ 128/ 128/ 124/ (<120/8 0) 90 88 88 90 88 90 88 88 90 88 88 86 86 86 86 88 86 HR (60- 100) 90 72 68 69 70 68 70 71 69 70 68 69 68 68 69 72 70 RR (12- 20) 18 16 16 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 6Scale Pain Reassess 7 ep ep ep ep ep ment after Interven tion Notes @23 :00 asle ep 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