Normal Nur2180 Section Q2 Physical Assessment

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Normal Nur2180 Section Q2 Physical Assessment

You will perform a history of a musculoskeletal problem that your instructor has provided you or one that you have experienced, and perform an assessment of the musculoskeletal system. You will document your subjective and objective findings, note any abnormal findings, and submit this in a Word document to the drop box provided. Your subjective portion of the documentation should briefly describe your “client”. For example, “This client is a 23-year-old white female complaining of a painful, swollen ankle. States that she stepped ‘funny’ off a step two days ago and thinks she heard a ripping sound. She takes no medications and has no allergies. The client reports pain as 5/10 with sharp twinges when trying to walk, resting and ice decreases pain to 2/10 aching. Pain is primarily in the outer aspect of ankle and foot. Has no prior injury to this area. No significant past medical history.” In terms of your objective findings, remember to only record what you have assessed. Do not make a diagnosis or state the cause of a particular finding.You are not coming to any conclusions within your documentation. When your documentation is complete, you will note any findings that were abnormal.

You will submit this documentation as a Word document to the drop box provided.

Musculoskeletal Assignment

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

RUBRIC

Title:

Documentation of problem based assessment of the musculoskeletal system.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of musculoskeletal system. Identify abnormal findings.

Course Competency:

Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.

Instructions:

Content:

  • Use of three sections: Subjective, Objective, and Abnormal Findings
  • Short descriptive paragraph of findings for each section

Format:

  • Standard American English (correct grammar, punctuation, etc.)

Resources:

Chapter 5: SOAP Notes: The subjective and objective portion only

Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_91

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-live

Documentation Grading Rubric- 10 possible points

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Subjective

(4 Pts)

Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.

Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.

Points: 0.5

Points:1

Points: 2

Points: 4

Objective

(4 Pts)

Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.

Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”.Contains all objective information. May have signs of bias or explanation of findings.

Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”.No bias or explanation for findings evident Contains all objective information

Includes all components of assessment for particular system. Detailed information provided.Avoided use of words such as “normal”, “appropriate”, or “good”.No bias or explanation for findings evident. All objective information

Points: 1

Points: 2

Points: 3

Points: 4

Strength and Weakness

(2 Pts)

Lists one strength and one weakness with no description or reason for selection of them. Failure to provide both one strength and weakness will result in zero points for this criteria.

Provides brief description of one strength and one weakness with no reason for identification of the strength and weakness.

Provides description of one strength and one weakness noted on assessment. Gives reason for identification of the strength and weakness.

Detailed description of one strength and one weakness noted during assessment. Detailed reason provided for identifying the strength and weakness.

Points: 0.5

Points: 1

Points: 1.5

Points: 2