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Unit 8 Journal NU552

Date Student Name:

Verbal consent for volunteer participation and video (adults only permitted), obtained by student and demonstrated on video. Yes ☐ No ☐

Complete patient information below.

Directions for Part I: Documentation Only

The patient History is normally completed on a form by the parent first, with the ROS; which is not a part of this journal exercise. It is not shown in this form. See required reading for examples. The provider would review with the parent/ patient.

· Complete the physical assessment documentation per the sports physical journal. Part I is not performed in the video submission but for your learning practice on sports physical documentation.

· Place N in the Normal Column. Place AB in the Abnormal column with a comment if you choose. There does not need to be abnormal findings. If so, you must comment and act on it appropriately in the comment.

· You must add comments in the heart and genitalia sections (as if for a male). This is for your learning. There is no video for this part.

SYSTEM

Patient Name Sex M

HT 5/10 WT 190

T- 98 P-70 R-15 B/P110/7

N

AB

COMMENTS

HEAD

Hair, scalp, masses, injuries

EYES

Proptosis, conjunctivae, sclera, EOMI, pupillary size, reaction to light, peripheral vision,

EARS

Gross hearing/ TMs/ Discharge

NOSE

Septum, mucosa, sinuses

THROAT/MOUTH

Teeth condition, tongue, tonsils, lesions

NECK

Thyroid, vessels, range of motion, adenopathy, masses, voice abnormalities

THORAX/LUNGS

Shape, expansion, deformities, rhonchi, wheezes, rales

HEART

PMI, sounds, thrills, murmurs, gallops,

LYMPHATICS

Cervical, axillary

ABDOMEN

Organ enlargement (liver, spleen, etc.), masses, tenderness, hernias, scars

GENITALIA

Scrotum, testicles, lesions, discharge, hernias

(Female is deferred)

(Some organizations waive this section based on the form required.)

UPPER EXTREMITIES

Range of motion, joint stability, muscle strength, limitations, effusion, ecchymoses, atrophy, deformities, edema, clubbing, pulses, veins, injuries

LOWER EXTREMITIES

Range of motion, joint stability, muscle strength, limitations, effusion, ecchymoses, atrophy, deformities, edema, clubbing, pulses, veins, injuries

BACK

Flexion, extension, scoliosis, kyphosis, excessive lordosis, injuries

NEUROLOGICAL

Cranial nerves, reflexes, motor, gait, balance, sensory

SKIN

Texture, striae, rash, acne

MENTAL STATUS

Affect, hostility, agitation

OBJECTIVE

Directions for Part II: Video

As a full and more intensive approach to these 2 systems, complete the Musculoskeletal and Peripheral Vascular exam with documentation for this specialty exam. Test strength of muscle groups, ROM of joints and limb vascularity.

· Complete the Video for only the MS and PV exam then document.

· Complete the document approval section using the draw feature in Word or bold/type your name.

Musculoskeletal

Peripheral Vascular

Approved Y/ N Provider Signature Date

(Bold or circle Y or N, and sign with draw feature)

________________________________________ __________________

In this assignment based on individual patient needs, you formulated a systematic and defendable approach to nursing practice decisions for a patient sports physical examination.

· When would you not approve or give only pending approval for the sport activities? Provide 2-3 specific examples

Complete two (2) scenarios. Once from each section.

If you completed one of these in the discussion you may use that content for the related scenario and complete a new one from the other section below. Otherwise follow the directions and complete one from each group.

Complete one of these scenarios.

· Consider the chief complaint of knee pain

or

· Consider the chief complaint of shoulder pain

or

· Consider the chief complaint of radiating low back pain

And then one of these scenarios.

· Consider the chief complaint of fever in an 8-month-old.

or

· Consider the chief complaint of acne in a 15-year-old.

or

· Consider the chief complaint of nausea in a pregnant 17-year-old

Demonstrate clinical judgment regarding the chief complaint by including this content:Complete one of the three scenarios:

· What pertinent information collected from the history would impact your assessment?

· What other systems need assessment due to the symptoms of the patient?

· What would be pertinent positives or pertinent negatives found in the exam?

· Include at least three differentials.

· Include which diagnostics you would order based on your differentials and why.

· How might a final diagnosis be determined?

· Address a possible brief management plan

· Apply evidence-based support for your choices; including a clinical guideline for one of your differentials

Unit 8 Journal NU552

Date Student Name:

Verbal consent for volunteer participation and video (adults only permitted), obtained by student and demonstrated on video. Yes ☐ No ☐

Complete patient information below.

Directions for Part I: Documentation Only

The patient History is normally completed on a form by the parent first, with the ROS; which is not a part of this journal exercise. It is not shown in this form. See required reading for examples. The provider would review with the parent/ patient.

· Complete the physical assessment documentation per the sports physical journal. Part I is not performed in the video submission but for your learning practice on sports physical documentation.

· Place N in the Normal Column. Place AB in the Abnormal column with a comment if you choose. There does not need to be abnormal findings. If so, you must comment and act on it appropriately in the comment.

· You must add comments in the heart and genitalia sections (as if for a male). This is for your learning. There is no video for this part.

SYSTEM

Patient Name Sex M

HT 5/10 WT 190

T- 98 P-70 R-15 B/P110/7

N

AB

COMMENTS

HEAD

Hair, scalp, masses, injuries

EYES

Proptosis, conjunctivae, sclera, EOMI, pupillary size, reaction to light, peripheral vision,

EARS

Gross hearing/ TMs/ Discharge

NOSE

Septum, mucosa, sinuses

THROAT/MOUTH

Teeth condition, tongue, tonsils, lesions

NECK

Thyroid, vessels, range of motion, adenopathy, masses, voice abnormalities

THORAX/LUNGS

Shape, expansion, deformities, rhonchi, wheezes, rales

HEART

PMI, sounds, thrills, murmurs, gallops,

LYMPHATICS

Cervical, axillary

ABDOMEN

Organ enlargement (liver, spleen, etc.), masses, tenderness, hernias, scars

GENITALIA

Scrotum, testicles, lesions, discharge, hernias

(Female is deferred)

(Some organizations waive this section based on the form required.)

UPPER EXTREMITIES

Range of motion, joint stability, muscle strength, limitations, effusion, ecchymoses, atrophy, deformities, edema, clubbing, pulses, veins, injuries

LOWER EXTREMITIES

Range of motion, joint stability, muscle strength, limitations, effusion, ecchymoses, atrophy, deformities, edema, clubbing, pulses, veins, injuries

BACK

Flexion, extension, scoliosis, kyphosis, excessive lordosis, injuries

NEUROLOGICAL

Cranial nerves, reflexes, motor, gait, balance, sensory

SKIN

Texture, striae, rash, acne

MENTAL STATUS

Affect, hostility, agitation

OBJECTIVE

Directions for Part II: Video

As a full and more intensive approach to these 2 systems, complete the Musculoskeletal and Peripheral Vascular exam with documentation for this specialty exam. Test strength of muscle groups, ROM of joints and limb vascularity.

· Complete the Video for only the MS and PV exam then document.

· Complete the document approval section using the draw feature in Word or bold/type your name.

Musculoskeletal

Peripheral Vascular

Approved Y/ N Provider Signature Date

(Bold or circle Y or N, and sign with draw feature)

________________________________________ __________________

In this assignment based on individual patient needs, you formulated a systematic and defendable approach to nursing practice decisions for a patient sports physical examination.

· When would you not approve or give only pending approval for the sport activities? Provide 2-3 specific examples

Complete two (2) scenarios. Once from each section.

If you completed one of these in the discussion you may use that content for the related scenario and complete a new one from the other section below. Otherwise follow the directions and complete one from each group.

Complete one of these scenarios.

· Consider the chief complaint of knee pain

or

· Consider the chief complaint of shoulder pain

or

· Consider the chief complaint of radiating low back pain

And then one of these scenarios.

· Consider the chief complaint of fever in an 8-month-old.

or

· Consider the chief complaint of acne in a 15-year-old.

or

· Consider the chief complaint of nausea in a pregnant 17-year-old

Demonstrate clinical judgment regarding the chief complaint by including this content:Complete one of the three scenarios:

· What pertinent information collected from the history would impact your assessment?

· What other systems need assessment due to the symptoms of the patient?

· What would be pertinent positives or pertinent negatives found in the exam?

· Include at least three differentials.

· Include which diagnostics you would order based on your differentials and why.

· How might a final diagnosis be determined?

· Address a possible brief management plan

· Apply evidence-based support for your choices; including a clinical guideline for one of your differentials