Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health treatment plan
Problem Selection
9 out of 9
Primary Diagnosis
During the follow-up visit with Mrs. Tillman, it’s crucial to conduct a thorough nursing assessment to identify the primary and secondary diagnoses.
This involves a careful process of clinical decision-making where multiple potential nursing diagnoses are considered and prioritized based on the patient’s reported symptoms and physical findings.
Proper nursing diagnosis documentation ensures that all findings and reasoning behind diagnostic decisions are recorded accurately for future care.
Diagnosis: Primary Diagnosis
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- Identified as primary
- Evidences:
- Pain not associated with trauma
- Bilateral tenderness upon palpation
- Difficulty moving limbs due to pain
- Learner Rationale: The patient complains of persistent musculoskeletal pain that is not linked to any recent trauma or injury. This suggests that the primary diagnosis could be a musculoskeletal disorder such as myofascial pain syndrome or another chronic musculoskeletal condition. Further diagnostic testing, such as imaging, may be necessary to confirm the cause of the pain and rule out other conditions.
Score: 5 out of 5
Diagnosis: Secondary Diagnosis
- Primary: Yes
- Evidences:
- Pain not associated with trauma
- Generalized fatigue
- Difficulty completing daily tasks
- Model Rationale: In primary care nursing, it is common to encounter multiple symptoms in a single visit. Here, Mrs. Tillman reports musculoskeletal pain along with an unusual lack of energy, and difficulty performing daily tasks, which points to a possible fatigue diagnosis. The secondary diagnosis of fatigue, potentially stemming from conditions like Chronic Fatigue Syndrome or another fatigue-related disorder, is supported by these symptoms. However, additional diagnostic testing in nursing is necessary to determine the underlying cause. More focused nursing interventions for fatigue could be considered depending on the results of these tests.
Model Rationale for Disease Diagnosis:
It is important to remember that nursing diagnosis documentation is permanent in the patient’s records, and thus, it must be accurate and fully supported by evidence. If the available evidence doesn’t sufficiently support a diagnosis, the nurse should avoid prematurely concluding a definitive diagnosis. In this case, multidisciplinary diagnosis approaches may be used to gather more insights from physical therapists or other healthcare professionals to confirm both the primary and secondary diagnoses.
Additional Diagnosis
Diagnosis: Fatigue
- Evidences:
- Feeling tired
- Unusual lack of energy
- Learner Rationale: The patient complains of a persistent fatigue diagnosis in primary care, which often suggests conditions such as Chronic Fatigue Syndrome. In these cases, it is important to rule out other potential causes, including stress, anxiety, or underlying physical health conditions. Symptoms like feeling tired and having an unusual lack of energy can sometimes overlap with other diagnoses such as musculoskeletal disorders and stress management needs.
Score: 4 out of 4
Diagnostic Testing in Nursing
9 out of 9
Review your answers for the Diagnostic Testing: Labs and Imaging activity. You receive one point for each correct differential diagnosis selected, and one point for each correct diagnostic test linked to a correct differential diagnosis.
At this stage, further diagnostic testing in nursing is required to confirm the diagnoses. This may involve:
- Musculoskeletal pain nursing management: Imaging tests such as X-rays or MRIs to rule out fractures, arthritis, or other musculoskeletal disorders.
- Fatigue diagnosis: Blood tests, such as CBC or thyroid function tests, may help rule out conditions like anemia or hypothyroidism that can contribute to fatigue.
Both diagnoses require a combination of nursing interventions for fatigue, such as promoting rest and managing stress, and nursing care for musculoskeletal disorders, which may include pain management and physical therapy recommendations.
Follow-Up Sick Visit: Shoshanna Tillman Shadow Health Treatment Plan
Treatment Plan: 25 of 25 (100.00%)
Once the primary care nursing assessment has been completed and the diagnoses are identified, a treatment plan development in nursing can begin. It should be based on the evidence-based nursing diagnosis and tailored to Mrs. Tillman’s specific needs. The nursing care plan for musculoskeletal pain will focus on reducing pain, improving mobility, and addressing underlying causes, while the nursing care plan for fatigue may involve strategies to reduce stress, improve sleep hygiene, and provide support for energy conservation techniques.
Problem Selection
9 out of 9
Primary Diagnosis
The primary diagnosis will focus on the musculoskeletal disorder nursing care, especially if the pain is related to an ongoing musculoskeletal issue. Pain relief measures, physical therapy, and possibly medication for musculoskeletal pain nursing management will be considered. This will be followed by regular follow-ups to monitor progress and adjust the plan if needed.
Diagnosis: Primary Diagnosis
- Identified as primary
- Evidences:
- Pain not associated with trauma
- Tenderness with palpation
- Bilateral pain
Model Rationale: As stated earlier, the primary diagnosis is musculoskeletal in nature, with pain that isn’t linked to trauma, but could stem from conditions like musculoskeletal disorders. Treatment will involve both diagnostic testing in nursing and nursing interventions for musculoskeletal pain, which may include physical therapy, pain management, and stretching exercises.Additional Diagnosis: Fatigue
- Evidences:
- Lack of energy
- Feeling tired
- Learner Rationale: The secondary diagnosis of fatigue is based on symptoms of extreme tiredness and a lack of energy that Mrs. Tillman reports. This could be due to chronic fatigue syndrome or stress-related factors. The nursing interventions for fatigue may include fatigue and stress management nursing techniques, including lifestyle adjustments, stress management practices, and possibly referrals for further psychiatric or psychological evaluation if needed.
Final Notes
Throughout the entire diagnostic and treatment process, nursing diagnosis documentation is crucial to ensure continuity of care. It is essential to ensure that all assessments, nursing interventions, and diagnostic tests in nursing are properly documented, as this information will guide future interventions and patient management.
Furthermore, the nursing diagnosis process should involve the active collaboration of the entire healthcare team. Multidisciplinary diagnosis approaches are often the best way to ensure that the primary and secondary diagnoses are fully explored, and the patient receives the most comprehensive care.
This expanded treatment plan and diagnostic framework ensures that Shoshanna Tillman’s Shadow Health assessment is thorough, comprehensive, and evidence-based, providing the foundation for quality care.
Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health treatment plan
Primary Diagnosis
Review your answers for the Problem Selection activities. You receive one point for each correct diagnosis, and one point for each correct evidence linked to a correct diagnosis. If there are multiple correct diagnoses, you will also receive a point for correctly selecting which diagnosis is the primary diagnosis.
Nurse Loan Forgiveness by State
| Learner Selection | Model Documentation |
|
Diagnosis: xx Identified as primary Evidences: xx Pain not associated with trauma xx Learner Rationale: The patient complains of xx Score: 5 out of 5 |
Diagnosis: xx Primary: Yes Evidences: xx Pain not associated with trauma Model Rationale: At this point in the diagnostic process, you can only provide Mrs. Tillman with preliminary diagnoses. In order to determine a definitive diagnosis, more diagnostic testing is required. In primary care, it is common to have multiple concerns in one visit. These two diagnoses may be related or are two unrelated situations, nonetheless, each diagnosis requires individual diagnostic investigation. Mrs. Tillman’s primary diagnosis is xx, while her secondary diagnosis is xx. The preliminary diagnosis of xx is supported by the evidence collected in the physical exam and reported by Mrs. Tillman: tenderness with palpation, pain not associated with xx The secondary diagnosis of fatigue is supported by the evidence reported by Mrs. Tillman: an unusual lack of energy, feeling tired, and having difficulty completing tasks due to feeling tired Follow Up Sick Visit: Musculoskeletal Shoshanna Tillman Shadow Health treatment plan. When making a disease diagnosis, it is important to note that disease diagnosis documentation is permanent in the patient’s records and cannot be undone. Therefore, if you do not have the evidence and diagnostic testing to support a disease diagnosis it is best to collect more data before determining a definitive diagnosis, even if the patient’s signs and symptoms point to a likely disease. |
Additional Diagnosis
| Learner Selection | Model Documentation |
|
Diagnosis: xx Evidences: xx Feeling tired Unusual lack of energy Learner Rationale: Patient complains of fatigue, geneal stress, sadness and anxiety. Score: 4 out of 4 |
Diagnosis: xx Evidences: xx Feeling tired Unusual lack of energy Model Rationale: At this point in the diagnostic process, you can only provide Mrs. Tillman with preliminary diagnoses. In order to determine a definitive diagnosis, more diagnostic testing is required. In primary care, it is common to have multiple concerns in one visit. These two diagnoses may be related or are two unrelated situations, nonetheless, each diagnosis requires individual diagnostic investigation. Mrs. Tillman’s primary diagnosis is xx, while her secondary diagnosis is xx. The preliminary diagnosis of xx is supported by the evidence collected in the physical exam and reported by Mrs. Tillman: tenderness with palpation, pain not associated with trauma, and bilateral pain. The secondary diagnosis of xx is supported by the evidence reported by Mrs. Tillman: an unusual lack of energy, feeling tired, and having difficulty completing tasks due to feeling tired. When making a disease diagnosis, it is important to note that disease diagnosis documentation is permanent in the patient’s records and cannot be undone. Therefore, if you do not have the evidence and diagnostic testing to support a disease diagnosis it is best to collect more data before determining a definitive diagnosis, even if the patient’s signs and symptoms point to a likely disease Follow Up Sick Visit: Musculoskeletal Shoshanna Tillman Shadow Health treatment plan. |
Review your answers for the Diagnostic Testing: Labs and Imaging activity. You receive one point for each correct differential diagnosis selected, and one point for each correct diagnostic test linked to a correct differential diagnosis.
| Learner Selection Follow Up Sick Visit: Musculoskeletal Shoshanna Tillman Shadow Health treatment plan |
Follow-Up Sick Visit: Musculoskeletal Shoshanna Tillman Shadow Health Treatment Plan
Treatment Plan: 25 of 25 (100.00%)
Problem Selection
9 out of 9
Primary Diagnosis
Review your answers for the Problem Selection activities. You receive one point for each correct diagnosis, and one point for each correct evidence linked to a correct diagnosis. If there are multiple correct diagnoses, you will also receive a point for correctly selecting which diagnosis is the primary diagnosis.
Learner Selection Model Documentation
Diagnosis: Primary Diagnosis
Identified as primary
Evidences:
Pain not associated with trauma
Learner Rationale:
The patient complains of (specific symptoms)
Score: 5 out of 5
Diagnosis: Secondary Diagnosis
Primary: Yes
Evidences:
Pain not associated with trauma
Model Rationale:
At this point in the diagnostic process, you can only provide Mrs. Tillman with preliminary diagnoses. In order to determine a definitive diagnosis, more diagnostic testing is required. In primary care, it is common to have multiple concerns in one visit. These two diagnoses may be related or are two unrelated situations; nonetheless, each diagnosis requires individual diagnostic investigation. Mrs. Tillman’s primary diagnosis is (primary diagnosis), while her secondary diagnosis is (secondary diagnosis). The preliminary diagnosis of (primary diagnosis) is supported by the evidence collected in the physical exam and reported by Mrs. Tillman: tenderness with palpation, pain not associated with trauma, and bilateral pain. The secondary diagnosis of (secondary diagnosis) is supported by the evidence reported by Mrs. Tillman: an unusual lack of energy, feeling tired, and having difficulty completing tasks due to feeling tired. When making a disease diagnosis, it is important to note that disease diagnosis documentation is permanent in the patient’s records and cannot be undone. Therefore, if you do not have the evidence and diagnostic testing to support a disease diagnosis, it is best to collect more data before determining a definitive diagnosis, even if the patient’s signs and symptoms point to a likely disease.
Additional Diagnosis
Learner Selection Model Documentation
Diagnosis: Additional Diagnosis
Evidences:
Feeling tired
Unusual lack of energy
Learner Rationale:
Patient complains of fatigue, general stress, sadness, and anxiety.
Score: 4 out of 4
Diagnosis: Secondary Diagnosis
Evidences:
Feeling tired
Unusual lack of energy
Model Rationale:
At this point in the diagnostic process, you can only provide Mrs. Tillman with preliminary diagnoses. In order to determine a definitive diagnosis, more diagnostic testing is required. In primary care, it is common to have multiple concerns in one visit. These two diagnoses may be related or are two unrelated situations; nonetheless, each diagnosis requires individual diagnostic investigation. Mrs. Tillman’s primary diagnosis is (primary diagnosis), while her secondary diagnosis is (secondary diagnosis).
The preliminary diagnosis of (primary diagnosis) is supported by the evidence collected in the physical exam and reported by Mrs. Tillman: tenderness with palpation, pain not associated with trauma, and bilateral pain. The secondary diagnosis of (secondary diagnosis) is supported by the evidence reported by Mrs. Tillman: an unusual lack of energy, feeling tired, and having difficulty completing tasks due to feeling tired. When making a disease diagnosis, it is important to note that disease diagnosis documentation is permanent in the patient’s records and cannot be undone. Therefore, if you do not have the evidence and diagnostic testing to support a disease diagnosis, it is best to collect more data before determining a definitive diagnosis, even if the patient’s signs and symptoms point to a likely disease.
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