Assess the Musculoskeletal system of Tina Jones|2025

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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 Assessment linked to your clients for the day.

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 o 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 OutcomeReferences1 ptsSatisfactoryCorrect APA references.0.5 ptsNeeds ImprovementIncorrect APA references.0 ptsUnsatisfactoryNo APA references.1 pts
Total Points: 10PreviousNext

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soap note Hypertension|2025

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Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Example:

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

Chief complain: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month.

Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

Respiratory:Patient denies shortness of breath, cough or hemoptysis.

Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal:Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

General appearance: The patient is alert and oriented x 3. No acute distress noted.NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT:Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

Cardiovascular:S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

Respiratory:No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

Gastrointestinal:No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no reboundno distention or organomegaly noted on palpation

Musculoskeletal:No pain to palpation. Active and passive ROM within normal limits, no stiffness.

Integumentary:intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed.

Differential diagnosis:

Ø Renal artery stenosis(ICD10 I70.1)

Ø Chronic kidney disease(ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.

These basic laboratory tests are:

· CMP

· Complete blood count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Ø Pharmacological treatment:

The treatment of choice in this case would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

 

Ø Non-Pharmacologic treatment:

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

· Instruction about medication intake compliance.

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.

· No referrals needed at this time.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0

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Focused Exam: Cough Assignment|2025

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Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.

  • Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
  • Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing tReview the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
    Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
    Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

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Managed Care Organizations|2025

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Discuss the differences and similarities between Managed Care Organizations (MCOs) vs. Accountable Care Organizations (ACOs). Given the current health care environment, provide a solid speculation to how MCOs and ACOs may transform to meet the needs of its consumers. Be sure to support your thoughts and analysis with scholarly sources.

*Will also need to respond to 3 classmate’s post, will send that after you turn in assignment.

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Gynecologic Health|2025

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Gynecologic Health

 

 

 

Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :

 

Subjective: What details did the patient provide regarding her personal and medical history?

 

Objective: What observations did you make during the physical assessment?

 

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

 

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters for this patient , as well as a rationale for this treatment and management plan.

 

Very Important:  Reflection notes: What would you do differently in a similar patient evaluation?

 

 

 

Reference

 

Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.

 

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.

 

 

 

Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)

 

Chapter 7, “Care of the Woman with Reproductive Health Problems”

 

“Care of the Woman with Dysmenorrhea” (pp. 366–368)

 

“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)

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Shadow Health Focused exams

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  • Complete the ShadowHealth© Focused Exams – Special Populations: Chest Pain, Cough and Abdominal Pain assignments

After you have achieved at least 80% on the assignment(s) download, save and upload your LabPass document to the dropbox.

Professional Development

  • Write a 500-word APA reflection essay of your experience with the Shadow Health virtual assignment(s). At least two scholarly sources in addition to your textbook should be utilized. Answers to the following questions may be included in your reflective essay:
    • What went well in your assessment?
    • What did not go so well? What will you change for your next assessment?
    • What findings did you uncover?
    • What questions yielded the most information? Why do you think these were effective?
    • What diagnostic tests would you order based on your findings?
    • What differential diagnoses are you currently considering?
    • What patient teaching were you able to complete? What additional patient teaching is needed?
    • Would you prescribe any medications at this point? Why or why not? If so, what?
    • How did your assessment demonstrate sound critical thinking and clinical decision making?

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Shadow Health Reflection: Musculoskeletal and Neurological : Review transcripts attached

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  • Complete the ShadowHealth© Musculoskeletal and Neurological assignments

Professional Development

  • Write a 500-word APA reflection essay of your experience with the Shadow Health virtual assignment(s). At least two scholarly sources in addition to your textbook should be utilized. Answers to the following questions may be included in your reflective essay:
    • What went well in your assessment?
    • What did not go so well? What will you change for your next assessment?
    • What findings did you uncover?
    • What questions yielded the most information? Why do you think these were effective?
    • What diagnostic tests would you order based on your findings?
    • What differential diagnoses are you currently considering?
    • What patient teaching were you able to complete? What additional patient teaching is needed?
    • Would you prescribe any medications at this point? Why or why not? If so, what?
    • How did your assessment demonstrate sound critical thinking and clinical decision making?

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We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper

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