NR 509 Assignment Tina Jones Neurological Shadow Health Essay

NR 509 Assignment Tina Jones Neurological Shadow Health Essay

NR 509 Assignment Tina Jones Neurological Shadow Health Essay

Introduction

In this paper, I will discuss a case study of Ms. Tina Jones and provide a detailed history and physical examination findings. I will give a reflection of the tasks undertaken to complete the exam, and discuss the clinical reasoning behind the decisions and tasks. I will also reflect on my strengths and weaknesses identified during the assignment and how I can improve my performance and apply the lessons learnt in my professional practice.

Case Study Overview

Tina presented with complaints of headache and neck stiffness that started two days after she was in a minor accident a week ago. She did not seek emergency care since she felt fine after the accident, but after two days, she developed a bilateral temporal dull ache accompanied by neck ache. The pain was aggravated by head or neck movement, the headache had no triggering factor, but the pain was relieved by rest. She reported that she felt as if her neck might be slightly swollen. She also stated that in the accident, she did not lose consciousness and has had no changes in the level of consciousness since the accident. She reported having a headache daily lasting 1-2 hours and occasionally takes Tylenol 650 mg that brings minor relief. The patient denied having any allergy. Neurological history was positive for frequent past headaches, but she denied having a history of migraine, head trauma, and seizures.

Review of Systems:  A subjective review of systems was done in which the patient denied episodes of fever, chills, fatigue, or changes in energy levels, nausea, vomiting, and night sweats. In the review of the neurological system, she denied hemiparesis, gait disturbance, body weakness, dizziness, light-headedness, syncope, scotoma, numbness or tingling and facial flushing. Review of

psychiatric history had negative findings of depression, increased irritability, problems with concentration or memory or confusion. On eye review, the patient reported occasional blurry vision before the accident but denied changes in vision, unilateral vision disturbance, and sensitivity to light after the accident. Findings on the review of the ear, nose, and throat, were negative for nasal congestion or rhinorrhea, tinnitus, changes in hearing or difficulty in swallowing.

Family history: The patient denied a history of migraines, epilepsy, seizures, Alzheimer’s or Parkinson’s disease in the family.

Objective findings: On general assessment, the patient was pleasant, obese, had no acute distress, but appeared uncomfortable while sitting in the exam chair. She was alert, oriented, and maintained eye contact throughout the interview and examination. The left eye vision was at 20/20 and the right eye vision at 20/40. The left fundoscopic exam revealed sharp disc margins, no hemorrhages while right fundoscopic exam revealed mild retinopathic changes. However, no abnormal findings were identified in the neurological and musculoskeletal system.

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Diagnosis: Acute post-traumatic headache.

Tasks Undertaken to Complete the Exam

1. Review of systems. The neurological system was positive for headaches.
2. Mental status exam: Revealed negative findings of depression, increased irritability, problems with concentration or memory or confusion.
3. Muscle strength, tone and bulk assessment: Findings included, ability to shrug shoulders; full strength against resistance. The neck had a full ROM against resistance.
4. Assessment of reflexes. Gag reflex intact. Equal bilateral upper and lower extremity DTRs and 2+ bilaterally
5. Assessment of Coordination: Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities.
6. Sensory Function: Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia were intact bilaterally.
7. Gait assessment: Steady with continuous, and symmetric steps.

Clinical Reasoning behind Decisions and Tasks

A focused subjective review of systems was conducted to assess symptoms that may have developed before and after the accident and help in coming up with a diagnosis. Besides, the review of systems was to enable me to address and alleviate every symptom and concern in each body system (Jensen, 2018). A mental status exam was performed to assess for signs of mental disorders manifesting in the thought content and thought process that could have been as a result of head injury (Jensen, 2018). Anxiety and depression could indicate long-term concerns following the accident while increased irritability, confusion, and lack of concentration may reveal that she sustained a concussion.

In addition, the muscle strength, tone, and bulk were assessed to help me identify signs of muscle abnormalities that could result from a musculoskeletal injury. Assessment of coordination was performed to assist in evaluating the presence of traumatic brain injuries after the accident, which results in loss of coordination (Ganapathy & Bajaj, 2016). A sensory assessment was further performed to assess for nerve injuries as a result of brain injury during the accident. Furthermore, a gait assessment was conducted to facilitate evaluating in muscle or nerve damage (Stone, 2016). Besides, car accidents can cause injuries to muscles and nerve, and this impacts the walking style.

 

Strengths and Weaknesses with Identifying Moments for Empathy

My strengths include the ability to sense patients’ emotional feelings and perceptions when communicating and interacting with them. Besides, I quickly take an interest in their concerns, and I actively involve myself in helping them address their issues. Being empathetic has enabled me to establish a nurse-patient relationship with my patients and connect with them emotionally, and as a result, they freely air their concerns. However, my weakness is being too empathetic, and this results in psychological stress. Besides, I always want to help my patients and their families, even in situations beyond my control. I can improve my ability to recognize my patients’ needs by taking a comprehensive patient spiritual, cultural, and mental assessment of each patient. Furthermore, observing the emotional state of patients during history taking can help me recognize their emotional needs that should be addressed to promote emotional well-being.

Strengths and Weaknesses When Educating the Patient and How I Can Improve My Ability to Educate My Patients More Effectively

My strengths when offering patient education is the fact that I understand the pathophysiology of the disease, and this enabled me to help the patient understand the disease process. Besides, I had vast knowledge on the non-pharmacological measures that the patient can use to relieve her symptoms such as applying topical heat or ice and performing mild stretches for upper and back and neck. However, one weakness that I identified is that I did not assess whether the patient understood how to manage her symptoms by requesting her to state the measures learnt. The other weakness was that I was impatient and in a hurry when educating the patient and the patient may not have fully understood how to manage her symptoms.

I can improve my ability to offer patient education effectively in the future by scheduling ample time for the health education session to ensure patients fully understood how to manage and prevent their symptoms. Furthermore, I will assess patients understanding by asking them to state what they have learnt in the health education session and clarify on issues they may not have understood. I will also enquire from patients if they have questions that need to be defined and respond to them appropriately. Lastly, I will write simple notes for patients and give them health education leaflets that they can read at home to increase their knowledge on how to prevent diseases.

How My Performance Could Be Improved And How I Can Apply “Lessons Learned” Within The Assignment To My Professional Practice.

My performance could be improved by taking a complete subjective history in all the body systems that may not be of focus based on the patient’s complaints. For this case, I should have reviewed the gastrointestinal, cardiovascular, respiratory, and genitourinary system to help identify symptoms that the patient had not mentioned. I can also improve my performance by conducting a thorough and focused physical assessment of each body system. For this case, I should have performed a physical examination of the respiratory, cardiovascular, gastrointestinal, and genitourinary system to help identify any abnormalities.

In this assignment, I have learnt that comprehensive patient history and physical exam should be taken since neurological disorders can affect all body systems. Besides, an assessment should begin assessment as the patient approaches you, and one should assess the mode of dressing, posture, gait, involuntary movements & voice. I can apply the general observation in my nursing practice to enable me to refine the assessment and come up with an accurate diagnosis. I have also learnt that one should take a history of events that preceded the onset of symptoms and the traumatic history to help in addressing the symptoms. I can use this knowledge in the future to take a more detailed patient’s history and come up with an accurate diagnosis.

All pertinent normal and abnormal findings identified;
2.Included professional terminology; 3.Appropriate EBP rationales for interventions and references provided; 4.Subjective and objective documentation includes all relevant body systems;
5.Included three differential diagnoses Treatment plan includes all five components- diagnostics, medication, education, consultation/referral, and follow-up planning
6.Relevant detailed interventions

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed
• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• Student paper example
• Citing Sources
• The Writing Center is a great resource