Musculoskeletal Assessment

This is a Unfolding Case Study

Patient Details:

Print Phase Info

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Case Study History

Name:

James, Karen

Age:

57  Years

Gender:

Female

Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.

You are currently working on Phase 1. You have completed Phase 0 of this scenario.

Patient Details:

Print Phase Info

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Case Study History

Name:

James, Karen

Age:

57  Years

Gender:

Female

Phase

1,

Wednesday

16:00

You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.
 

Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:
 

1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?

 

2). What was the last documented temperature for Karen?

 

3). Does Ms. James use any sensory aides?

 

4) What does she rate her pain?

 

5) What is her MORSE Fall Risk Score?
 

Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?
 

[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]
 

When you are finished with this task, you may click Complete this Phase.

Patient Information

Chief Informant:

Patient

Chief Complaint:

Shortness of breath, productive cough

History of Current Problem:

Patient states she has had 3-week history of influenza. Has now developed a severe cough approximately 3 days ago with shortness of breath. Unable to sleep due to cough, which often causes bronchospasms. Patient also complains of fever, fatigue, and right-sided chest pain. Seen in urgent care 3 days ago and given Z-pack. No improvement in symptoms.

Allergies:

None known

Family History:

Mother died at age of 72 with breast cancer. Father is alive at the age of 79 and has congestive heart failure.

Past Medical History

Previous Illnesses:

Patient has asthma. Also states she gets bronchitis every 1-2 years.

Contagious Diseases:

None

Injuries or Trauma:

None

Surgical History:

Tonsillectomy and adenoidectomy as a child.

Dietary History:

Regular diet. Patient is 5’1″ and 140 pounds. Has recently lost 20 pounds on Weight Watchers diet.

Other:

Social History:

No smoking, no drugs. Uses alcohol in social situations.

Current Medications:

Tylenol 650 mg PO every 4 hours PRN pain or fever
Prozac 20 mg PO every day
Xanax 0.25 mg PO every 8 hours PRN
Xopenex HFA 2 puffs every 6 hours PRN

Review of Systems

Integument:

Denies complaints.

HEENT:

States she had neck soreness related to influenza, with “swollen glands.”

Cardiovascular:

No complaints.

Respiratory:

Complains of shortness of breath, frequent productive cough. States her cough often turns into bronchospasms. Uses inhaler, peppermint tea, lozenges, and Vicks VapoRub.

Gastrointestinal:

Complains of decreased appetite.

Genitourinary:

No complaints.

Musculoskeletal:

Complains of generalized body aches.

Neurologic:

Alert and oriented.

Developmental:

Denies complaints.

Endocrine:

No complaints.

Genitalia:

No complaints.

Lymphatic:

No complaints.

Physical Exam

General:

57-year-old female in mild distress. Appears weak.

Vital Signs:

Temp: 103.2 F, Pulse: 114, Resp: 28, Blood pressure: 154/78 in office this morning

Integument:

Skin clear of rash.

HEENT:

Pupils equal and reactive. Nasal congestion. Neck supple.

Cardiovascular:

S1, S2, no murmur.

Respiratory:

Lungs clear with crepitation in right base.

Gastrointestinal:

Abdomen soft, active bowel sounds.

Genitourinary:

Musculoskeletal:

Moves all extremities well.

Neurologic:

Alert and oriented.

Developmental:

Endocrine:

Genitalia:

Not assessed. Seen by gynecologist recently. Negative pap smear and negative mammogram.

Lymphatic:

No lymph node swelling at this time.

Impressions:

Pneumonia

Plan:

The patient is admitted for IV antibiotics and close observation of respiratory status. Patient will need influenza and pneumonia vaccines.

Provider Signature:

Michael Foster, MD

Day:

Wednesday

Time:

12:45

Chief Complaint:
The patient is a 57-year-old female admitted today for chief complaint of shortness of breath.
 

Patient’s labs were completed in the primary care provider’s office prior to admission and results include the following:
WBC: 20.2 x 109/L
RBC: 4.51 RBC x 106/ul
Hemoglobin: 14.0 g/dL
Hematocrit: 40.2%
Sodium: 139 mEq/L
Potassium: 4.2 mEq/L
Chloride: 105 mEq/L
CO2: 26 mEq/L
Glucose: 91 mg/dL
BUN: 17 mg/dL
Creatinine: 0.5 mg/dL
 

She is also febrile at 102.7.
Nursing will initiate IV antibiotics.

Showing 1 to 1 of 1 entries

FirstPrevious1NextLast

Chart Time

Temp

Resp

Pulse

BP

Sat%

Notes

Entry By

Wed 12:45

102.7

22

112

142/77

98

C Diaz, RN

Select Chart Type:       Temperature Respiration Pulse Blood Pressure Oxygen Saturation 

Select and drag to zoom in on a date range

102.7F/39.3C

Patient Card

Order Day/Time

Description

Category

Last Performed

Discontinue

Wed | 13:00

Admit   to medical-surgical

Alerts

Wed | 13:00

Start and maintain IV line

IV

Wed | 13:00

Pulse oximetry every 4 hour(s)

Respiratory

Wed | 13:00

Vital signs every 4 hours

Vital Signs

Wed | 13:00

Up as tolerated

Activity/Mobility

Wed | 14:00

Diagnosis-Respiratory   distress syndrome-ADDED-Disease Process

Patient Teaching

Wed | 13:00

Regular/General   Diet

Diet

Showing 1 to 7 of 7 entries

FirstPrevious1NextLast

PRN

Drug Name

Order Start

Order Stop

Dose

Route

Frequency

Dosage Time

Action

Acetaminophen Tablet –   (Tylenol, Genapap)

Wed   13:00

Tue   23:59

650   mg

Oral

Every   6 Hours PRN

 –   –

Levalbuterol Nebulizer   Solution – (Xopenex Nebulizer Solution)

Chart:

System Assessments Wed 13:00

Entry Time:

Wed 13:00

Entered By:

C Diaz, RN

Cardiovascular Assessment

Pulses

Apical:

Regular

Tissue Perfusion

Peripheral vascular, general:

Warm extremities

Edema

No edema noted

Cardiac Assessment

No cardiac problems noted

Respiratory Assessment

Productive Cough Secretions Assessment

Color:

Green

Amount:

Scant

Cough

Cough strength:

Strong

Cough type:

Productive

Oxygenation

Respiratory/breathing support:

Nebulizer treatment

Lower Right Posterior

Auscultation:

Coarse crackles

Lower Left Posterior

Auscultation:

Diminished

Upper Right Posterior

Wheeze Description:

Expiratory

Auscultation:

Wheeze

Upper Left Posterior

Wheeze Description:

Expiratory

Auscultation:

Wheeze

Productive Cough Secretions Assessment

Consistency:

Thick

Secretion odor:

None

Upper Left Anterior

Auscultation:

Clear

Upper Right Anterior

Auscultation:

Clear

Respiratory Effort

Dyspnea/shortness of breath

Shortness of breath on exertion

Respiratory Pattern

Labored

Neurological Assessment

Level of Consciousness/Orientation

Oriented to person, place, time, and situation

Emotional State

Calm

Cooperative

Central Nervous System Assessment (CNS)

No CNS problems evident

Integumentary Assessment

Integumentary Assessment

No assessment required at this time

Sensory Assessment

Vision Assessment

Wears glasses

Wears contacts

Musculoskeletal Assessment

Range of Motion (ROM)

Moves all extremities with full range of motion

Gastrointestinal Assessment

Abdomen

Abdominal assessment:

Soft to palpation

Gastrointestinal

No gastric problems noted

Intestinal

Date of last bowel movement:

Monday

Continence of bowel:

Continent

Intestinal assessment:

No bowel problems noted

Bowel sounds:

Active x 4 quadrants

Rectum:

No reported rectal problems

Pain Assessment

Do You Have Pain Now?

No

Genitourinary Assessment

Genitourinary Assessment

No assessment required at this time

Psychosocial Assessment

Psychosocial Assessment

No assessment required at this time

Safety Assessment

Orientation

Oriented to time, person, place

Fall Risk

30

Bracelet Check

Hospital ID bracelet

Safety Notes

Low fall risk

Morse Fall Scale

History of Falling

No=0

Secondary Diagnosis

No=0

Ambulatory Aid

None/Bedrest/Nurse Assist=0

IV or IV Access

Yes=20

Gait

Weak=10

Mental Status

Oriented to Own Ability=0

Total Fall Risk Score

Risk Score:

30

Fall Risk Score and Preventative Measures Implemented

Fall Risk Level:

Medium Risk

Fall Risk Measures:

Implement <b> Medium</b>  Risk Fall Prevention Interventions:<br>All items in low prevention plus post fall program sign indicating risk, wrist band identification, ambulate with assistance, do not leave patient unattended in diagnostic or treatment area, make comfort rounds every 2 hours for toileting.

Special Precautions/Isolation Assessment

Standard Precautions

Vision Assessment

Wears glasses

Wears contacts

Musculoskeletal Assessment

You are currently working on Phase 2. You have completed Phase 1 of this scenario.

Patient Details:

Print Phase Info

 | 

Case Study History

Name:

James, Karen

Age:

57  Years

Gender:

Female

Phase

0

Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.

You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.
 

Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:
 

1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?

 

2). What was the last documented temperature for Karen?
3). Does Ms. James use any sensory aides?
4) What does she rate her pain?
5) What is her MORSE Fall Risk Score?
 

Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?
 

[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]
 

When you are finished with this task, you may click Complete this Phase.

Phase

2,

Wednesday

16:20

You enter Ms. James’ room to take her vital signs and obtain the following results:
 

Temperature: 101.5 degrees Fahrenheit, oral…
Pulse: 110, radial…
Respirations: 20…
Blood pressure: 144/68 left arm, sitting…
Oxygen saturation: 99%, finger probe, room air…
 

Document the vital signs in the vital signs tab on the Info Panel on the left (do not document in a misc. note). When compared to the patient’s admission vital signs, how is the patient’s temperature trending? Document your answer in a Miscellaneous Nursing Note.
Under Basic Nursing Care: Choose 5 interventions you will perform at this time to make this client to increase safety. Only 5 as you will need to prioritize your cares. Try to find 5 related to Impaired Mobility.
 

When you are finished with these tasks, you may click Complete this Phase.

Please submit your post work to Canvas within 24 hours of the completion of your VCBC Experience.  Please refer to the Experiential Learning Orientation for further questions and a reminder on how to ensure your assignment is properly saved.

Please complete the Concept Notebook (Map) for the concept of Mobility linked to your clients for the day.

This assignment is due within 24 hours of completing your VCBC. Please refer to the Experiential Learning Orientation for further questions and a reminder on how to ensure your assignment is properly saved.

Rubric

205/225 Concept Notebook Rubric205/225 Concept Notebook RubricCriteriaRatingsPtsThis criterion is linked to a Learning OutcomeRelated Concept1 ptsSatisfactoryDocumented at least 2 concepts, related to the client with a detailed explanation of each related concept and how the related concept is impacted by the main concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented at least 1 concept, 1 concept is related to the client, or only minimal explanation of each related concept and how the related concept is impacted by the main concept, or incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no related concept, did not relate the concept to the client, no explanation of each related concept and how the related concept is impacted by the main concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeExemplar1 ptsSatisfactoryDocumented at least 3 Exemplars, related to the client and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2 Exemplars, 1-2 concepts are related to the client, or incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no Exemplars , did not relate the concept to the client and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeAssessment1 ptsSatisfactoryDocumented at least 3 assessments used to find and rule out alterations with the main concept and are all related to the client, a detailed explanation of each assessment and why one would do that assessment relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2 assessments used to find and rule out alterations with the main concept and 1-2 relate to the client, minimal explanation of why one would do that assessment relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no assessments used to find and rule out alterations with the main concept and did not relate to the client, no explanation of why one would do that assessment relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeLab & Diagnostic1 ptsSatisfactoryDocumented at least 3 lab or diagnostic test used to find and rule out alterations with the main concept and all related to the client, a detailed explanation of each lab/test and why one would do that lab/test relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2 lab or diagnostic test used to find and rule out alterations with the main concept, 1-2 relate to the client, minimal explanation of each lab/test and why one would do that lab/test relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no lab or diagnostic test used to find and rule out alterations with the main concept and did not relate to the client, no explanation of each lab/test and why one would do that lab/test relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeInterventions1 ptsSatisfactoryDocumented at least 3 nursing interventions needed to care for clients with alterations to the main concept and all related to the client, a detailed explanation of each intervention and why one would perform the interventions relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2 nursing interventions needed to care for clients with alterations to the main concept, 1-2 relate to the client, minimal explanation of each intervention and why one would perform the interventions relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no nursing interventions needed to care for clients with alterations to the main concept and did not relate to the client, no explanation of each intervention and why one would perform the interventions relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeMedications1 ptsSatisfactoryDocumented at least 3 medications administered to clients to treat or prevent alterations to the main concept and all related to the client, a detailed explanation of each medication and why one would administer the medication relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2medications administered to clients to treat or prevent alterations to the main concept, 1-2 relate to the client, minimal explanation of each medication and why one would administer the medication relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no medications administered to clients to treat or prevent alterations to the main concept and did not relate to the client, no explanation of each medication and why one would administer the medication relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomePotential Complications1 ptsSatisfactoryDocumented at least 2 potential problems that could occur if alterations to the main concept are not addressed/treated and all related to the client, a detailed explanation of each complication and how it could occur relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1 potential problem that could occur if alterations to the main concept are not addressed/treated, 1 concept is related to the client, minimal explanation of each complication and how it could occur relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no potential problems that could occur if alterations to the main concept are not addressed/treated, did not relate the concept to the client, no explanation of each complication and how it could occur relating to the concept, and incorrect APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeCollaborative Care1 ptsSatisfactoryDocumented at least 1 department/ancillary staff that may be needed to treat clients who have or are at risk for alterations with the main concept and is related to the client, a detailed explanation of each how that department/ancillary staff could assist the client relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented at least 1 department/ancillary staff that may be needed to treat clients who have or are at risk for alterations with the main concept and is related to the client, minimal explanation of each how that department/ancillary staff could assist the client relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no department/ancillary staff that may be needed to treat clients who have or are at risk for alterations with the main concept, did not relate the concept to the client, no explanation of each how that department/ancillary staff could assist the client relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeSpelling and Grammar1 ptsSatisfactory0- 2 mistakes in spelling or grammar.0.5 ptsNeeds Improvement3 -4 mistakes in spelling or grammar.0 ptsUnsatisfactory5 or more mistakes in spelling or grammar.1 pts
This criterion is linked to a Learning OutcomeReferencesCorrect APA references.1 ptsSatisfactoryCorrect APA references.0.5 ptsNeeds ImprovementIncorrect APA references.0 ptsUnsatisfactoryNo APA references.1 pts
Total Points: 10PreviousNext