American Sentinel N522PE Module 5 Assignment 3
American Sentinel N522PE Module 5 Assignment 3
American Sentinel N522PE Module 5 Assignment 3
American Sentinel N522PE Module Five: Neurological & Musculoskeletal Assessment
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Assignment 3
Assignment Instructions:
For this 4-5 page assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Brian, an adult who is complaining of chest pain. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. American Sentinel N522PE Module 5 Assignment 3
Submission Parameters:
For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s).
- Introduction (including purpose statement)
- Focus of the assessment
- Describe the focus of this particular assessment on the patient complaining of chest pain
- Subjective Component
- Describe the ROS, PMH, and other relevant data in this section.
- Objective Component
- Describe the physical examination findings including techniques of examination
- Documented evidence to support clinical reasoning
- Describe the list of differential diagnoses
- Plan of care
- Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment.
- Conclusion
- References (use primary and/or reliable electronic sources)
In regards to APA format, please use the following as a guide:
- Include a cover page and running head (this is not part of the 4-5 pages limit)
- Include transitions in your paper (i.e. headings or subheadings)
- Use in-text references throughout the paper
- Use double space, 12 point Times New Roman font
- Apply appropriate spelling, grammar, and organization
- Include a reference list (this is not part of the 4-5 pages limit)
- Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)
American Sentinel N522PE Module 5 Assignment 3Rubric
Competency
20
18
16
0
Points Earned
Focus of the Assessment is identified with Special Considerations including Documented Focused Health History
Documentation clearly shows student has completed a focused assessment with identified special considerations including a well-documented focused health history.
Documentation supports the student has completed the focused assessment with minimal identification of special concerns. The focused health history is documented.
Documentation supports the student has completed the focused assessment without identification of special concerns. The focused health history is documented and lacks depth and specificity of weekly topic.
Documentation supports the student attempted to complete the focused assessment without identification of special concerns. The focused health history is briefly documented and lacks depth and specificity of weekly topic.
/20
20
18
16
0
Documented Physical Examination Findings including Techniques of Examination
Documentation clearly shows student has completed the physical examination and accurately describes the techniques of examination for the week.
Documentation supports the student has completed the physical examination and describes the techniques of examination for the week.
Documentation supports student completed some of the physical examination for the focused assessment of the week. Documentation is accurate but lacks depth.
No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability of tasks completed in this week.
/20
20
18
16
0
Documented Evidence to Support Clinical Reasoning with External Course Resources
Discourse clearly shows the student has studied the topic and has given thought to the focused assessed topic and documentation for the week.
Discourse supports the student has studied the topic and has given thought to the focused assessment topic and documentation for the week.
Discourse supports student studied some of the topic for the focused assessment topic this week. Discourse is accurate but lacks depth.
No evidence that that student has read or studied the topic.
Discourse lacks depth. May be presented in a rambling manner.
Content is inaccurate &/or is unclear.
/20
20
18
16
0
Individualized Plan of Care Based Upon Clinical Findings
Accurately presents an individualized plan of care based upon clinical findings.
Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted.
Presents a plan of care that is not individualized based upon the clinical findings.
A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings. American Sentinel N522PE Module 5 Assignment 3
/20
5
4
3
0
Developmentally and Culturally Specific
Accurately documents a developmentally and culturally specific assessment and plan of care for the selected patient.
Documents a developmentally and culturally specific assessment and plan of care.
Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient.
A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings.
/5
5
4
3
0
Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice
Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the focused physical assessment.
Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation.
Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the focused physical assessment or inaccuracies are evidenced in the written assessment.
Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the focused physical assessment.
/5
10
9
8
0
Grammar, Spelling, and Punctuation APA Format
APA Format, grammar, punctuation and spelling is accurate with no errors.
APA Format, grammar, punctuation and spelling is accurate with less than two types of errors.
APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors.
APA Format, grammar, punctuation and spelling is accurate with more than five types of errors.
/10
COMMENTS:
TOTAL:
/100
|
Competency |
20 |
18 |
16 |
0 |
Points Earned |
| Focus of the Assessment is identified with Special Considerations including Documented Focused Health History | Documentation clearly shows student has completed a focused assessment with identified special considerations including a well-documented focused health history. American Sentinel N522PE Module 5 Assignment 3 | Documentation supports the student has completed the focused assessment with minimal identification of special concerns. The focused health history is documented. | Documentation supports the student has completed the focused assessment without identification of special concerns. The focused health history is documented and lacks depth and specificity of weekly topic. | Documentation supports the student attempted to complete the focused assessment without identification of special concerns. The focused health history is briefly documented and lacks depth and specificity of weekly topic. | /20 |
|
|
20 |
18 |
16 |
0 |
|
| Documented Physical Examination Findings including Techniques of Examination | Documentation clearly shows student has completed the physical examination and accurately describes the techniques of examination for the week. | Documentation supports the student has completed the physical examination and describes the techniques of examination for the week. | Documentation supports student completed some of the physical examination for the focused assessment of the week. Documentation is accurate but lacks depth. | No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability of tasks completed in this week. | /20 |
|
20 |
18 |
16 |
0 |
||
| Documented Evidence to Support Clinical Reasoning with External Course Resources | Discourse clearly shows the student has studied the topic and has given thought to the focused assessed topic and documentation for the week. | Discourse supports the student has studied the topic and has given thought to the focused assessment topic and documentation for the week. | Discourse supports student studied some of the topic for the focused assessment topic this week. Discourse is accurate but lacks depth. | No evidence that that student has read or studied the topic. Discourse lacks depth. May be presented in a rambling manner. Content is inaccurate &/or is unclear. |
/20 |
|
20 |
18 |
16 |
0 |
||
| Individualized Plan of Care Based Upon Clinical Findings | Accurately presents an individualized plan of care based upon clinical findings. | Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted. | Presents a plan of care that is not individualized based upon the clinical findings. | A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings. American Sentinel N522PE Module 5 Assignment 3 | /20 |
|
5 |
4 |
3 |
0 |
||
| Developmentally and Culturally Specific | Accurately documents a developmentally and culturally specific assessment and plan of care for the selected patient. | Documents a developmentally and culturally specific assessment and plan of care. | Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient. | A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings. | /5 |
|
5 |
4 |
3 |
0 |
||
| Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice | Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the focused physical assessment. | Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation. | Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the focused physical assessment or inaccuracies are evidenced in the written assessment. | Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the focused physical assessment. | /5 |
|
10 |
9 |
8 |
0 |
||
| Grammar, Spelling, and Punctuation APA Format | APA Format, grammar, punctuation and spelling is accurate with no errors. | APA Format, grammar, punctuation and spelling is accurate with less than two types of errors. | APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors. | APA Format, grammar, punctuation and spelling is accurate with more than five types of errors. | /10 |
| COMMENTS: | TOTAL: | /100 | |||
Discussion 5
This week you have studied neurological and musculoskeletal advanced physical assessment. While a diverse set of advanced physical assessment skills where do you place your greatest level of confidence and what areas need more development. What methods do you use to remember assessment of cranial nerves, mental status, or other important clinical assessments of persons with neurological or musculoskeletal problems? Of these areas of advanced physical assessment what psychomotor skill is most challenging for you to accomplish? Why? American Sentinel N522PE Module 5 Assignment 3
Post a concept to the discussion board that you have had difficulty with and note where you are with resolution of these difficulties. Please describe the clinical issue completely, citing your sources so that your classmates can reference the information and provide additional “clinical pearls”. In other words, please include primary sources and/or reliable electronic sources to support your arguments.
Remember to respond to at least two of your peers. Please refer to the Course Syllabus for Discussion Participation Guidelines & Grading Criteria.
Example Discussion Solution and Responses
When it comes to Focus assessment, I found the advanced physical assessment on the musculoskeletal system as having one of the essential components. The system consists of bones, joints, cartilage and muscles It provides the body with movements and supports needed for everyday activities. A functioning musculoskeletal is required for a patient activities of daily living (ADLs) (Nurseceots, 2020).
My greatest confidence is in performing this physical exam as it is just based on inspection, testing strength and range of motion of the patients upper and lower extremities, spine, the hip and joints. Even thought the entire process is time consuming, starting from the, superficial abnormalities could easily be recognized, but it reminds me of fundamentals of nursing and health assessment back in nursing school.
I find the neurological assessment more complex, back breaking, frustrating even back in nursing school, needing more improvement. I learnt that neurologic assessment can take place anywhere not just in the neuro unit or emergency department. Some patients without neurological diagnosis may need some neuro examination. Example: Newborn babies goes through neuro assessment immediately after birth, psychiatric patients gets some neuro assessment, to determine how much of their hallucination or delusional behaviors are caused by mental illness (Kleber, 2020). Pneumonia patients might require neurological assessment because of hypoxia, post-op patients can also develop neuro deficit related to blood loss(Kleber,2020). With all the above-mentioned reasons, I decided to device an easy way to in cooperate neuro assessment into my assessment skills.
Patient LOC is always the most vital part of neuro assessment, because it is an indicative of decline on patient status (Bickeley, 2017). The important of neurological assessment can’t be exaggerated, early detection and intervention of any neurological injury can prevent a lasting damage(Kleber, 2020). Performing a neuro check sends many nurses including myself into having panic attack, but it does not have to be that way. So, I decided to look closer to the twelve cranial nerves to see how I can remember some of them without cramming a bunch of other songs to my already loaded head. For the eye exam, testing extra-ocular movements, to remember the three cranial nerves involved, I named them OAT 3,4 and 6 Oculomotor (Motor), Trochlear (Motor) and Abducens (Motor)
While mental status can be assessed prior or during the interview, the majority of neurological or musculoskeletal issues can be uncovered at the time of the comprehensive focused exam. A Mnemonic that helps me remember my assessments with psych patients are ASEPTIC
A- Appearance/ behaviors, S- speech, E -Emotion (Mood and Affect), P- Perception (Auditory/visual) T- Thought Content (suicidal/Homicidal Ideation) and process I- insight and judgment, C-Cognition (Luo, 2019) American Sentinel N522PE Module 5 Assignment 3
Reference
Kleber, K. (2020). How to Assess an Unconscious Nuero Patient Like a Neuro ICU Nurse Retrieve from: https://www.freshrn.com/how-to-assess-an-unconscious-neuro-patients-like-a-neuro-icu-nurse/
Luo,E.K, ( 2019). What are the 12 cranial nerves? Retrieved from: Medical News Today.
https://. medicalnewstoday/articles/326621
Nurseceots, (2020). 13 Tips for performing a Nursing Health Assessment of the
Musculoskeletal System. Retrieved from:
Performing-a-nursing-health-assesssment-of-the-musculoskeletal-system
530 words
In reply to Ihuoma
Re: Discussion #5 – American Sentinel N522PE Module 5 Assignment 3
10 words
In reply to Dona
Re: Discussion #5
Assessment of cognitive function
Assessment of a patient cognition, requires establishment of the patient attention span first. When a patient is easily distracted, they cannot fully follow the cognitive testing. The evaluation of cognition involves several aspects of cognitive function. Example Orientation time, place and person, attention and concentration, memory, verbal and mathematic abilities, judgment and reasoning (Einstein, 2020).
Orientation: As in Shadow health clinic, I asked Tina Jones (What is your name), What is the time and what building are you (Place)
Memory: Ask the patient to recite 4 objects after 2 to 5 minutes.
As patient about the past (the make of their first car), or to count in 7s starting from 100 and subtracting 7 or how many nickels in $1.55
Attention and Concentration: As a patient to spell a 5 -letter word backward and forward eg WORLD.
Judgment: Ex asking a patient a hypothetical question that requires good judgment. I asked Tina Jones at the clinic, “what she will do, if she found a stamped envelope at the side walk”(Shadow Health, 2020).
Abstract reasoning: Ask a patient to interpret a moderately challenging preverb like” People that live in a glass house should not throw stones”
Reference
Einstein, A. (2020). How to Assess Mental status, Retrieved from: https://www.merckmanuals
.com/professional/neurologic-disorders/neurologic-examination/how-to-asess-mental-
Status
Shadow Health, (2020).Retrieved from: https:// www.shadowhealth.com/patient
230 words
In reply to Ihuoma
Re: Discussion #5 – American Sentinel N522PE Module 5 Assignment 3
10 words American Sentinel N522PE Module 5 Assignment 3
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