Exam (elaborations)
NR 509 TINA JONES NEUROLOGICAL DOCUMENTATION SHADOW HEALTH (GRADED A)
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NR 509 TINA JONES NEUROLOGICAL DOCUMENTATION SHADOW HEALTH (GRADED A)
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NR 509 Neurological Documentation Shadow2024
Neurological Physical Assessment Diagnostics
Assignment Results | Turned In None at this visit
Advanced Health Assessment -
Chamberlain, NR509-October-2018 Medication
Return to Assignment Initiate treatment with ibuprofen 800 mg by mouth every
8 hours as needed with food for the next 5 days
Education
Encourage Ms. Jones to continue to monitor symptoms
and report any increase in frequency or severity of her
headaches
Ms. Jones can also use adjunct therapy of topical heat or
ice per comfort TID-QID
Educate on mild stretches for upper back and neck
Referral/Consultation
None at this time
Follow-up Planning
Instruct on when to seek emergent care including the
worst headache of her life, acute changes in
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, NR 509 Neurological Documentation Shadow
2024
Student Documentation Model Documentation
vision, hearing, or consciousness, episodes of nausea or
vomiting associated with headache, or numbness,
If the symtpoms do not resolve tingling, or paralysis of new onset
themselves in the next week, I would Ask Ms. Jones to call the office in two days to discuss
want to perform an MRI to determine symptoms. If no decrease in symptoms, order a
the extent of her head injury. computerized tomography scan or magnetic resonance
imaging
I encouraged the patient to get lots Revisit clinic in 5-7 days for follow up and evaluation
of sleep and rest to allow herself to
heal properly
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