Documentation Of Problem-Based Assessment Of The Musculoskel ✓ Solved

Documentation of problem based assessment of the musculoskeletal

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.

Instructions: Content: Use of three sections:

• Subjective
• Objective
• Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

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 Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31 (9), 30. Retrieved from

Paper For Above Instructions

In the realm of nursing and healthcare, effective documentation of patient assessments forms the cornerstone of high-quality patient care. This paper aims to provide a structured documentation of a problem-based assessment of the musculoskeletal system. The documentation will be segmented into three sections: Subjective findings, Objective findings, and Actual or potential risk factors based on the assessment.

Subjective Findings

The subjective component of the assessment is based on the information provided by the client concerning their musculoskeletal health. For instance, a 45-year-old female client reported persistent joint pain, particularly in her knees and wrists, which she rated as a 7 on a 10-point pain scale. She described the pain as "aching" and noted that it worsens during cold weather or after prolonged periods of inactivity. Additionally, she expressed feelings of frustration due to her limited mobility, stating, "I can't keep up with my children anymore," reflecting a significant impact of her condition on her quality of life.

The client also reported occasional swelling in her knees, which she attributed to her weekend hiking trips. She stated she had a family history of arthritis, specifically her mother, who had similar joint issues at the same age. Furthermore, she has been experiencing occasional numbness and tingling in her fingers, which she mentioned began recently. These subjective reports are critical as they reflect the client's experience and perspective, which are essential in assessing the overall condition of the musculoskeletal system.

Objective Findings

The objective assessment includes physical examination findings and test results relevant to the musculoskeletal system. Upon clinical examination, the client's range of motion (ROM) was assessed in both the upper and lower extremities. The knees displayed a limited range of motion, with flexion restricted to 90 degrees when compared to the normal range of 135 degrees. There was also notable crepitus during movement, indicating potential degenerative changes within the joint. Meanwhile, her wrist joints were tender upon palpation, with evident swelling suggesting possible inflammation.

Inspection of her fingers revealed mild deformities, specifically a trigger finger where the fingers appeared to catch during flexion. Gait analysis showed a slight limp favoring her right leg, and her posture was slightly altered due to discomfort. Muscle strength testing revealed a reduction in strength (4/5) in both lower limbs, which is indicative of potential musculoskeletal weakness. These findings establish an important baseline for evaluating the client's musculoskeletal health and identifying any abnormalities.

Actual or Potential Risk Factors

Based on the subjective and objective findings, several actual and potential risk factors can be identified. The first actual risk factor is the client's age, as musculoskeletal issues often increase in prevalence with age, particularly for conditions like osteoarthritis. The client's family history of arthritis represents an additional potential genetic risk factor for developing similar conditions.

Moreover, the client’s reported physical inactivity due to pain may lead to further musculoskeletal weakening and functional decline, highlighting the importance of physical activity for maintaining joint health. Another risk factor is her weight status, which if elevated, could exacerbate her joint issues due to increased load on the joints. Addressing these risk factors through educational interventions and lifestyle modifications will be vital in managing the client’s condition effectively.

Conclusion

In conclusion, the assessment of the musculoskeletal system involves a multifaceted approach integrating both subjective reports from the client and objective examination findings. Identifying actual and potential risk factors allows healthcare providers to develop evidenced-based interventions tailored to the client's specific needs. Accurate documentation following the SOAP format not only facilitates an understanding of the patient's condition but also supports the development of effective care plans that address the identified joint issues.

References

• Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book].
• Smith, L. S. (2001). Documentation do’s and don’ts. Nursing, 31(9), 30.
• American Academy of Orthopaedic Surgeons. (2015). Osteoarthritis. Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis
• National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2019). Handout on health: Osteoarthritis. Retrieved from https://www.niams.nih.gov/health-topics/osteoarthritis
• Glyn-Jones, S., Palmer, A. J., Agricola, R., et al. (2015). Osteoarthritis. Lancet, 386(9991), 376-387. doi:10.1016/S0140-6736(14)60881-8
• Fransen, M., McConnell, S., Hernandez-Molina, G., et al. (2015). Exercise for osteoarthritis of the knee: a systematic review. Arthritis Care & Research, 67(12), 1704-1715. doi:10.1002/acr.22692
• Cohen, S. A., & Hochberg, M. C. (2001). Physical activity and osteoarthritis. Arthritis & Rheumatism, 44(1), 165-164.
• Williamson, J., & Wentz, T. (2004). The value of a clinical assessment for osteoarthritis and the importance of timely intervention. Journal of Musculoskeletal Medicine, 21(9), 523-527.
• Hawker, G. A., & Mian, S. (2014). The impact of chronic pain on the functional status of older adults. Aging Clinical and Experimental Research, 26(3), 237-246. doi:10.1007/s40520-014-0129-6