- Information
- AI Chat
Tina Jones Musculoskeletal
Health Assessment Of Individuals Across The Lifespan (NUR 3065L)
University of North Florida
Preview text
Musculoskeletal Results | Turned In
Health Assessment Throughout the Lifespan - Fall 2020, NURS 381
Return to Assignment (/assignments/372987/)
Notice: The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.
Experience Overview
Your Results Lab Pass (/assignment_attempts/8282504/lab_pass
Overview Transcript Subjective Data Collection Objective Data Collection Documentation
####### Patient: Tina Jones
####### Digital Clinical Experience Score
100%
This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
####### Student Performance Index
50 out of 51
####### Proficiency Level: Proficient
Students rated as “proficient” demonstrate entry-level expertis nursing competencies and clinical reasoning skills. In compara nursing programs, the top 25% of students perform at the level proficient nurse.
Beginning Developing Proficient
Subjective Data Collection
####### 23 out of 23
Objective Data Collection
####### 27 out of 28
####### Time
####### 57 minutes total spent in assignment
Interaction with patient
####### 57 minutes
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
© Shadow Health 2012 - 2020 (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (shadowhealth/patents)
®
Suppor t
Musculoskeletal Results | Turned In
Health Assessment Throughout the Lifespan - Fall 2020, NURS 381
Return to Assignment (/assignments/372987/)
Notice: The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.
Subjective Data Collection: 23 of 23 (100%)
Relevant Medical History
Your Results Lab Pass (/assignment_attempts/8282504/lab_pass
Overview Transcript
Subjective Data Collection Objective Data Collection Documentation
Indicates an item that you found. Indicates an item that is available to be found.
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 t patient's case.
Asked about joint problems Denies joint pain Denies joint swelling
Asked about mobility Denies history of walking problems Reports recent foot wound hindered mobility Reports ability to walk on foot has recently improved
Asked pain rating when walking Reports pain as a 7 or 8/10 when walking
Asked about ability to stand Denies trouble standing before foot problems Reports recent foot wound hindered standing Reports improved ability to stand on injured foot
Asked pain rating when standing Reports pain as a 7 or 8/10 when bearing weight on foot
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Suppor t
Asked family history of osteoporosis Denies family history of osteoporosis
Asked family history of joint problems Denies family history of joint problems Denies family history of arthritis
Asked family history of bone cancer Denies family history of bone cancer
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
© Shadow Health 2012 - 2020 (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (shadowhealth/patents)
®
Musculoskeletal Results | Turned In
Health Assessment Throughout the Lifespan - Fall 2020, NURS 381
Return to Assignment (/assignments/372987/)
Notice: The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.
Objective Data Collection: 27 of 28 (96%)
Your Results Lab Pass (/assignment_attempts/8282504/lab_pass
Overview Transcript Subjective Data Collection
Objective Data Collection Documentation
Correct Partially correct
Incorrect Missed
Inspected neck 1 of 1 point
Symmetry (1/2 point) 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
Right: Appearance (1/3 point) No visible abnormal findings Swelling Visible mass Irregular alignment
Suppor t
Left: Appearance (1/3 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) No visible abnormal findings Swelling Visible mass Irregular alignment Discoloration Atrophy Hypertrophy
Inspected knees 1 of 1 point
Symmetry (1/3 point) Symmetric bilaterally Asymmetric
Right: Appearance (1/3 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
Right: Appearance (1/3 point) No visible abnormal findings
Asymmetric 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 0 of 1 point
Symmetry (No point) Symmetric bilaterally Asymmetric
Right: Appearance (No 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
Inspected feet 0 of 1 point
Symmetry (No 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 Hammertoe(s) Mallet toe(s) Claw toe(s)
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 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) 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 3 - Active movement against gravity 4 - Active movement against gravity and resistance 5 - Active movement against full resistance without fatigue (normal)
Tested shoulder 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 elbow 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 wrist 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 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 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) Left (1/2 point)
Musculoskeletal Results | Turned In
Health Assessment Throughout the Lifespan - Fall 2020, NURS 381
Return to Assignment (/assignments/372987/)
Notice: The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.
Documentation / Electronic Health Record
Vitals
Vitals 22:00 00:00 02:00 04:00 06:00 08:
Temp (<38° C) 38 C / 101 F 39 C / 102 F 38 C / 101 F 37 C / 100 F 37 C / 98 F 36 C / 98
BP (<120/80) 138/90 138/88 136/88 138/90 134/
HR (60-100) 90 72 68 69 70
RR (12-20) 18 16 16 18 18
O2 Sat (>94%) 98% 98% 98% 98% 98%
Pain Scale 10 7 asleep asleep 9 6
Pain Reassessment after Intervention
7 @23:00 asleep
5 @07:
Your Results Lab Pass (/assignment_attempts/8282504/lab_pass
Overview Transcript Subjective Data Collection Objective Data Collection
Documentation
Flowsheets Nursing Progress Notes
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
© Shadow Health 2012 - 2020 (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (shadowhealth/patents)
®
Suppor t
Musculoskeletal Results | Turned In
Health Assessment Throughout the Lifespan - Fall 2020, NURS 381
Return to Assignment (/assignments/372987/)
Notice: The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.
Documentation / Electronic Health Record
Notes
####### Student Documentation Model Documentat
Musculoskeletal exam performed on Ms. Jones. Vital: T 36, BP 124/86, HR 70, RR 16, O2 99%, Pain 5-6/10, dorsal surface of right foot. She states foot still hurts, but much better than when she arrived yesterday. Ms. Jones states no joint pain, stiffness, swelling, or limitation. No muscle pain or weakness. No history of bone trauma or deformity. Able to manage all usual ADLs, has been somewhat limited due to pain and wound on right foot. Normally on her feet all day for work, but has been unable for the last few days due to pain of 7-8/10 when weight bearing. States "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." Occupation involves no musculoskeletal risk factors. Exercise pattern is the movement she gets at work. Muscles symmetric. Joints symmetric with the exception of ankles, right ankle swollen. Right foot also swollen with laceration to dorsal surface. No masses, deformity; normal spinal curvature. No tenderness to palpation of joints, no heat, swelling, or masses. Full range of motion with exception of right ankle slightly reduced dorsiflexion and plantar flexion. Movements smooth, no crepitance, no tenderness. Muscle strength: able to maintain flexion against resistance and without tenderness (5/5) with excpetion of right ankle, reduced ability to maintain flexion (4/5).
(No Model Documentatio Provided)
Your Results Lab Pass (/assignment_attempts/8282504/lab_pass
Overview Transcript Subjective Data Collection Objective Data Collection
Documentation
Flowsheets Nursing Progress Notes
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
© Shadow Health 2012 - 2020 (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (shadowhealth/patents)
®
Suppor t
Tina Jones Musculoskeletal
Course: Health Assessment Of Individuals Across The Lifespan (NUR 3065L)
University: University of North Florida
- Discover more from:Health Assessment Of Individuals Across The LifespanNUR 3065LUniversity of North Florida23 Documents
- More from:Health Assessment Of Individuals Across The LifespanNUR 3065LUniversity of North Florida23 Documents
