750 words max. APA must be 100% accurate.

Objectives

• Demonstrate documentation of the musculoskeletal assessment findings
• Develop a plan of care for the musculoskeletal system
• Explain how to conduct a physical assessment of the musculoskeletal system

Assignment Overview

In this assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client.

The rubric used to grade this assignment is attached below the assignment description.

Deliverables

Write a 3-page (750 word) paper using APA 7.0 format style.

Step 1

Review the case scenario.

Cecelia Bley is a 75-year-old Native American female who presents to the urgent care today with complaints of wrist pain and swelling. She has a history of osteoarthritis and has joint pain that primarily affects her hands and knees.

• Onset: You ask Mrs. Bley to tell you when her wrist pain started. She tells you that she was taking a walk yesterday and fell. She put her hands out in front of her as she fell and landed on her knees and wrists. Her right wrist has been more swollen since the fall.
• Location: You ask Mrs. Bley about the location of her pain, and she tells you it is in her right wrist.
• Duration: The pain has occurred since the fall.
• Characteristics: You ask Mrs. Bley to describe her pain. She tells you her wrist feels tender and hurts more than usual when she moves it.
• Aggravating factors: You ask Mrs. Bley to describe what makes the pain worse. She tells you that her wrists are always sore in the morning and moving them throughout the day usually makes them feel better, but today her right wrist hurts all the time, especially when she tries to use it.
• Alleviating factors: You ask Mrs. Bley if anything has helped the pain. She tells you that she took some of her arthritis pain medication, and it helped “a little.” She also put some ice on it, and that decreased the pain.
• Other background information: Mrs. Bley has had osteoarthritis for many years and has found that over the past several years her activities have been significantly limited. She is able to care for herself and her husband, but she has been unable to make jewelry, which has always been her passion. This is very upsetting for her, and she is having a difficult time finding activities that she can comfortably do and that she enjoys.

Mrs. Bley was just seen in the clinic last week for her yearly checkup. At that time, she had a complete history and physical. Her musculoskeletal findings were as follows:

• Joints: Mrs. Bley has limited range of motion in many of her joints, including her hands, wrists, hips, and knees. Her hands were tender to palpation, and her finger joints were swollen and tender.
• Strength: Her muscle strength was 4/5 in all her extremities, and pain was noted in the joints.
• Spine: No abnormal curvatures noted.

Diagnosis and treatment: You suspect her wrist is sprained or broken, and an x-ray take shows a Colles’ fracture. She is placed in a cast. You also note that at her appointment last week, she had an x-ray done to measure bone density. The results are positive for osteoporosis, and you share that information with her. Mrs. Bley is discharged from urgent care with her cast and a prescription for a narcotic pain medication (Vicoden), which she has taken for her arthritis pain. After consultation with her primary care physician, she is also started on Fosamax.

Step 2

Write a 3-page (750 word) paper using APA 7.0 format style and address the information below. As a minimum, the resources used should be the required course textbook and any article you are asked to read should be used as evidence, next level of evidence you might use would be peer reviewed articles, and after that well known web sites for example CDC or the AHA. Avoid blogs or obscure web sites. Never cite/reference Wikipedia.

You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills.

• Write a detailed explanation describing what you would say to the student, explaining the assessment conducted and the findings. Discuss the musculoskeletal assessments you would perform and any additional assessments you would perform. What are other factors related to the probable diagnosis you would be concerned about with this client?
• Explain how you would document your findings in the medical record.
• Develop your plan of care. Identify one to two nursing diagnoses and one to two nursing interventions related to those diagnoses. The interventions should be evidence based. Cite the references used in your plan in correct format.
• Identify what client education should be done for Mrs. Bley, given her background and presenting concerns, including her new diagnosis of osteoporosis. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention.
• Be sure to cite all the sources you used in the completion of this assignment and include a reference list.

*Link to course textbook below:

Cover

Lapum, J. L. & Hughes, M. (2024). Introduction to health assessment for the nursing professional (2024)- Canadian edition. Creative Commons Attribution-NonCommercial 4.0 International License.