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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

NR 509 Assignment Tina Jones Neurological Shadow Health Essay

NR 509 Assignment Tina Jones Neurological Shadow Health Essay

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.

NR 509 Assignment Tina Jones Neurological Shadow Health Essay

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

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