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PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal Conditions

PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal Conditions PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsIn clinical settings, patients often present with musculoskeletal conditions such as chronic back pain. Drugs are typically prescribed to help manage this type of pain for patients. There are many different pain medicines, and each one has benefits and risks. To add to the complexity, each patient may also have a slightly different response to a pain reliever. When over-the-counter medications do not address a patient’s pain, more powerful prescription pain relievers, such as opioids, can be effective but also sometimes have serious side effects. There is also a risk of addiction. More than 70,000 people died in 2017 from drug overdoses, and almost 68% involved a prescription or illicit opioid. Drug overdose deaths continue to increase in the United States (Centers for Disease Control and Prevention, n.d.).For the advanced practice nurse, these statistics highlight the need to effectively screen for, diagnose, and manage opioid use. It is essential to carefully observe and watch for signs of drug abuse during patient evaluations. Because not all musculoskeletal conditions require narcotics, a thorough patient evaluation will help to ensure the development of an appropriate treatment plan with patient safety in mind. PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsORDER A PLAGIARISM-FREE PAPER HEREThis week, you will continue to engage with Meditrek, recording your clinical hours and patient encounters. You will also learn about evaluation and management of musculoskeletal conditions in the reading selections as well as conduct a patient evaluation of a patient from your practicum experience who has a musculoskeletal condition. Based on diagnostic and treatment options you identify for the patient, you will identify a primary diagnosis, as well as a treatment and management plan.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsReferenceCenters for Disease Control and Prevention (n.d.). CDC’s response to the opioid overdose epidemic.https://www.cdc.gov/opioids/Learning ObjectivesStudents will:Describe clinical hours and patient encountersFormulate diagnoses for adult patientsJustify adult patient treatment optionsAdvocate health promotion and patient education strategies across the adult lifespanSynthesize the assessment and diagnosis of health conditions for a clinical patientLearning ResourcesRequired Readings (click to expand/reduce)Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care (4th ed.). Elsevier.Chapter 174, “Shoulder Dislocations” (pp. 1163–1167)Chapter 175, “Ankle and Foot Splinting, Casting, and Taping” (pp. 1168–1175)Chapter 176, “Cast Immobilization and Upper Extremity Splinting” (pp. 1176–1185)Chapter 177, “Knee Braces” (pp. 1186–1192)PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsChapter 178, “Fracture Care” (pp. 1193–1211)Chapter 180, “Joint and Soft Tissue Aspiration and Injection (Arthrocentesis)” (pp. 1221–1239)Chapter 181, “Trigger-Point Injection” (pp. 1240–1244)Chapter 235, “Principles of X-Ray Interpretation” (pp. 1566–1575)Practicum ResourcesHSoft Corporation. (2019). Meditrek: Home. https://edu.meditrek.com/Default.htmlNote: Use this website to log into Meditrek to report your clinical hours and patient encounters.Walden University Field Experience. (2019a). Field experience: College of Nursing. https://academicguides.waldenu.edu/fieldexperience/son/homeWalden University Field Experience. (2019b). Student practicum resources: NP student orientation. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientationWalden University. (2019). MSN nurse practitioner practicum manual. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocumentsDocument: Episodic/Focus Note Template (Word document)Assignment 1: Clinical Hour and Patient LogsPhoto Credit: auremar / Adobe StockClinical HoursFor this course, all practicum activity hours are logged within the Meditrek system. Hours completed must be logged in Meditrek within 48 hours of completion in order to be counted. You may only log hours with preceptors that are approved in Meditrek.Students with catalog years before Spring 2018 must complete a minimum of 144 practicum hours. Students with catalog years beginning Spring 2018 must complete a minimum of 160 practicum hours.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsEach log entry must be linked with an individual practicum Learning Objective or a graduate Program Objective. You should track your hours in Meditrek as they are completed.Your clinical hour log must include the following:DatesCourseClinical FacultyPreceptorTotal Time (for the day)Notes/Comments (including the objective to which the log entry is aligned)Patient LogThroughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 100 patients by the end of this practicum.The patient log must include the following:DateCourseClinical FacultyPreceptorPatient NumberClient InformationVisit InformationPractice ManagementDiagnosisProcedure (Note: Make sure that, as you perform procedures at your practicum site, you also note those on your printed-out Clinical Skills List.)PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsTreatment Plan and NotesIV MedicationBy Day 7Record your clinical hours and patient encounters in Meditrek.Assignment 2: Episodic Visit: Musculoskeletal Focused NotePhoto Credit: PexelsFor this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third  Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsTo prepare:  Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment.Select a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note:Assignment: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 as well as a rationale for this treatment and management plan.Reflection notes: What would you do differently in a similar patient evaluation? PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsNote: Your Focused Note Assignment must be signed by Day 7 of Week 9.By Day 7Submit your Episodic/Focused Note Assignment.(Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 9.)Submission and Grading InformationTo submit your completed Assignment for review and grading, do the following:Please save your Assignment using the naming convention “WK9Assgn2+last name+first initial.(extension)” as the name.Click the Week 9 Assignment 2 Rubric to review the Grading Criteria for the Assignment.Click the Week 9 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsNext, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn2+last name+first initial.(extension)” and click Open.If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.Click on the Submit button to complete your submission. Rubric Detail Select Grid View or List View to change the rubric’s layout.ContentName: PRAC_6531_Week9_Assignment2_RubricPRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsGrid ViewList ViewExcellentGoodFairPoorOrganization of Write-upPoints Range: 27 (27%) – 30 (30%)All information organized in logical sequence; follows acceptable formatPoints Range: 24 (24%) – 26 (26%)Information generally organized in logical sequence; follows acceptable formatPoints Range: 21 (21%) – 23 (23%)Errors in format; information intermittently organizedPoints Range: 0 (0%) – 20 (20%)Errors in format; information disorganizedThoroughness of HistoryPoints Range: 18 (18%) – 20 (20%)PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal Conditions Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive informationPoints Range: 16 (16%) – 17 (17%)Documents most pertinent history components; includes critical informationPoints Range: 14 (14%) – 15 (15%)Fails to document most pertinent history components; Lacks some critical information or rambling in historyPoints Range: 0 (0%) – 13 (13%)Minimal history; critical information missingThoroughness of Physical ExamPoints Range: 9 (9%) – 10 (10%)Thoroughly documents all pertinent examination components for type of notePoints Range: 8 (8%) – 8 (8%)Documents most pertinent examination componentsPoints Range: 7 (7%) – 7 (7%)Documents some pertinent examination componentsPoints Range: 0 (0%) – 6 (6%)Physical examination cursory; misses several pertinent componentsDiagnostic ReasoningPoints Range: 9 (9%) – 10 (10%)Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic testsPoints Range: 8 (8%) – 8 (8%)Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsPoints Range: 7 (7%) – 7 (7%)Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic testsPoints Range: 0 (0%) – 6 (6%)Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic testsTreatmentPlan/PatientEducationPoints Range: 9 (9%) – 10 (10%)Treatment plan and patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Evidence based decisions. Cost effective treatment. Reflection is thoughtful and in depth.Points Range: 8 (8%) – 8 (8%)Treatment plan and patient education addresses most issues raised by diagnoses. Reflection is thoughtful and in depth.Points Range: 7 (7%) – 7 (7%)Treatment plan and patient education fail to address most issues raised by diagnoses.Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.Points Range: 0 (0%) – 6 (6%)Minimal treatment plan and/or patient education addressedReflection is absent.Written Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.Points Range: 9 (9%) – 10 (10%)Uses correct grammar, spelling, and punctuation with no errors.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsPoints Range: 8 (8%) – 8 (8%)Contains a few (1-2) grammar, spelling, and punctuation errors.Points Range: 7 (7%) – 7 (7%)Contains several (3-4) grammar, spelling, and punctuation errors.Points Range: 0 (0%) – 6 (6%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsWritten Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.Points Range: 9 (9%) – 10 (10%)Contains parenthetical/in-text citations and at least 3 evidenced based references are listed.Points Range: 8 (8%) – 8 (8%)Contains parenthetical/in-text citations and at least 2 evidenced based references are listedPoints Range: 7 (7%) – 7 (7%)Contains parenthetical/in-text citations and at least 1 evidenced based reference is listedPoints Range: 0 (0%) – 6 (6%)Contains no parenthetical/in-text citations and 0 evidenced based references listed. Total Points: 100Name: PRAC_6531_Week9_Assignment2_RubricEpisodic/FocusNote Template PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal Conditions Patient Information:Initials: S.J. Age: 29, Sex: Female. Race:African American.S.CC (chief complaint): “I have severe pain in my lower back and is not going away”.HPI: Ms. Johnson is a 29-year-old African American female in with a complaint of severe back pain that started three days ago, when she twisted it while a adjusting furniture in her apartment. Pain is more to her low back and both buttocks, is aching in nature without radiation. She discomfort is worse on sitting, scale at 8/10, while lying down makes the pain better at a 3/10. She has been taking over the counter Ibuprofen 600mg every 6 hours. Current pain level is 5/10. She reported numbness, muscle fatigue, twitching, ache, and tingling. She came into the clinic today, because the pain/discomfort has persisted and is interfering with her everyday life.Location:Lower backOnset: 3 days agoCharacter: Difficulty in motionAssociated signs and symptoms: Numbness, tingling, muscle fatigue, ache, and twitching.Timing: Sitting for long hoursExacerbating/ relieving factors: Lying flat on the backSeverity: 8/10 pain scaleCurrent Medications:-Zyrtec 10mg 1 tablet orally daily-Albuterol 90mcg 2 puffs every 4 hours– Ibuprofen  600mg orally every 6 hours as needed painAllergies: Penicillin, Cats, and dust. No allergy to food or latex.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsPMHx:Ms. Johnson is up to date with her vaccination. Influenza vaccine: 10/22/2020.She was diagnosed with Asthma at age 4yrs, she was late hospitalization was when she was in high school. She has a history of type 2 diabetes but manages it with diet and exercise.  LMP: 3 weeks ago.Past surgical history: NoneSocial Hx:Ms. Johnson issingle, currently employed as a waiter in a local bar. She lives in her own apartment. She denies cigarette smoking, or drink alcohol. She does not use illicit drugs. She uses seatbelt in car and no phone use while driving. She volunteers at a local woman shelter twice a month. Her support system consists of her family and friends.Family Hx:Ms. Johnson has no family history of congenital diseases or chronic illnesses. Mother has history of hypertension and hypercholesterolemia.  Father has diabetes mellitus and hypertension. Maternal grandmother has hypertension, and glaucoma. Maternal grandfather is deceased, had chronic back pain, hypertension, and BPH. Paternal grandmother has hypertension, hyperlipidemia, and type 2 diabetes, while paternal grandfather has type 2 diabetes, hypertension, and arthritis.ROS:GENERAL:No weight loss, fever, chills, weakness, night sweats or fatigue.HEENT:Eyes:No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:No hearing loss, sneezing, congestion, runny nose, or sore throat.SKIN:No rash, lesion or itching.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsCARDIOVASCULAR:No chest discomfort, No palpitations or edema.RESPIRATORY:Denies chest pain non shortness of breathor sputum production.GASTROINTESTINAL:Complaint of abdominal pain, poor appetite, nausea, diarrhea, and occasional vomiting.GENITOURINARY:No dysuria, frequency, or incontinence.LMP: 3 weeks ago.NEUROLOGICAL:No headache, dizziness, syncope. No change in bowel or bladder control.MUSCULOSKELETAL:Pain in lower back. States she has problem moving.HEMATOLOGIC:No history of anemia, bleeding, or easy bruising.LYMPHATICS:No enlarged nodes. No history of splenectomy.PSYCHIATRIC:Denies history of anxiety, depressionor being suicidal.ENDOCRINOLOGIC:No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.ALLERGIES:History of asthma. Allergy to cats/dust.O.Physical exam:Vital signs: T:98.3 , P:80, R:16,B/P:110/60, PO2:98%, RA, HT: 5’7, WT: 175Ibs, BMI:27.4.General: S.J is alert, oriented x 4. Maintains good eye communication throughout the examination. She appeared well nourished, answers questions appropriately without hesitation.HEENT: Head is normocephalic. Pupils are equal and reactive to light. TM’s intact bilaterally without edema, no tenderness or erythema. Patent and intact external auditory canal. Nares are patent bilaterally, absence of polyps.  Oropharynx is mildly erythematous. Good dentition with pink gums.NECK: Supple with full range of motion, no JVD or thyroidomegaly.CARDIOVASCULAR:S1, S2, RRR, no heart murmurs, gallops, or rubs.  Regular heart rate and rhythm. Distal and radial pulses equal bilaterally. No pedal edema.LUNGS: Lungs clear on auscultation, symmetric chest with respiration.BREASTS: No masses, lesions, or gynecomastia.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsSKIN: No skin rashes, lesions no cyanosis.GASTOINTESTINAL: Normative bowel sounds, soft and non-tender abdomen.GENITOURINARY: Nourination problemsRECTAL: Good sphincter tone, No bloody stools.MUSCULOSKELETAL: Full weight bearing, ROM full on all extremities.NEUROLOGICAL: S.J is alert and oriented to person, time, place, and situation. Is cooperative, CN 11-X11 is grossly intact. Sensory intact to pinprick.LOWER EXTREMITIES: No edema or tenderness. Equal calves in size bilaterally.Diagnostic results:Complete blood count (CBC):H&H: 10.1 &30.1. Platelets: 23, Prolactin 16 Basic metabolic panel (CMP): To rule out any alteration in the electrolytes. X-ray: To rule out bone spurts or fracture. No report of fracture found. Computed tomography (CT): No tumor or lesions found on report.  A.Differential Diagnoses:Low back muscle strain related to lifting:Muscle strain is an instant injury affecting the tendon, joint or ligament of the body. This strains often occurs due to jarring collisions or movement that involve hard lifting or from extreme weight on the spine. Low back discomfort is often caused by heavy lifting, pushing heavy objects that stretches the spine or lifting heavy lifting from the ground to an overhead space (Suehiro, et al, 2018).PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal Conditions Acute mechanical back pain: Is also known as acute back pain, is the described as back discomfort that lasts less than 4-6 months (Will et al, 2018). The cause usually originates from the spinal nerves, discs, vertebral column, or connective tissues. Acute mechanical back pain is also known as lumbago, psychogenic low back pain, lumbar strain or ligament, lumbar disorder.Herniated disc pain:Also known as slipped discs or ruptured discs, this is a relatively common condition that can occur anywhere along the spine but is most likely to affect the lower back or neck (An, Millard & Anand, 2021). Trauma is the second most common cause of a herniated disc. You can overstress a spinal disc when you twist or lift something heavy. A disc can rupture during high-impact trauma, too, such as a car accident or fall. Herniated disk may cause discomfort, numbness or fatigue in an arm or leg, based on its location.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal ConditionsP.Therapeutic interventions:Continue ibuprofen 600mg by mouth Q 6-8 hours for pain.Acetaminophen 500-1000mg by mouth every 8 hours.Eat balanced diet, rich in iron and fiber.Encourage daily exercise plan.Increase fluid intake. Patient education:Medication and diet compliance education (Kyung-Chul Choi., et al., 2017).Encourage safety in change on body movement, no sudden change in position. Health promotion:Avoid lifting of heavy objects.Follow up appointment in four weeks for re-evaluation of her symptoms.The musculoskeletal examination of Ms. Johnson is considered a success as the questions asked, facts obtained and approached treatment plan points to appropriate treatment and management of low back strain related to lifting (Will, Bury & Miller, 2018). PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal Conditions ReferencesAn, H.S., Millard, E., & Anand, N. (2021). Herniated disc: Symptoms, causes, diagnosis, and treatment. Https://www.spineunvirese.com/conditions/herniated-disc.Kyung-Chul Choi., Jin-Sung Kim, Dong Chan lee. &Choon-Keun park. (2017). Percutaneous endoscopic lumbar discectomy. Minimally invasive technique for multiple episodes of lumbar disc herniation. Https://bmcmuscloskeletdiscrd.biomedcentral.com/articles/10.1186/s12891-017-1697-8Suehiro, T., Ishida, H., Kobara, K.,Osaka, H. & Watanabe, S. (2018). Altered trunk muscle recruitment patterns during lifting in individuals in remission from recurrent low back pain. Journal of electromyography and kinesiology. Https://doi.org/10.1016/j.jelekin.2018.02.008Will, J.S., Bury, D.C. & Miller, J.A. (2018). Mechanical low back pain. American family physician. Https://doi.org/10.5040/9781350984639.PRAC 6531 Week 9 Discussion : Evaluation and Management of Musculoskeletal Conditions

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