MOCK Validation 2 Example

For teaching/learning purposes: Please watch MOCK Validation 2 video that accompanies these instructions and
sample student documentation (next page). The video gives an example of a patient history and physical exam according
to the instructions below.

See Validation 2 Grading Criteria in syllabus for expectations.

Please watch the correct physical exam techniques for musculoskeletal assessment and assessment of peripheral visual
fields by confrontation.

During the Validation #2 in the Standardized Patient Lab:

NURS 503 CNL Health Assessment STUDENT INSTRUCTIONS

Setting: Emergency room.

Chief complaint/Reason for seeking care: Right wrist and right ankle pain

Student Instructions: Perform a history with a minimum of the following components:

Ask 3 History of Present illness or symptom analysis questions related to the reason for seeking care.
Ask at least 2 allergy or medication questions
Ask at least 3 pertinent Review of System ROS questions
Ask at least 2 environmental/risk factors appropriate for this situation
Obtain vital signs: Temperature, Pulse, respirations, BP, pain, temperature

Perform the following physical exam assessments:

1. Inspect bilateral wrists
2. Assess upper extremity range of motion
3. Assess lower extremity range of motion
4. Assess upper extremity strength
5. Assess lower extremity strength
6. Assess optic nerve: peripheral fields by confrontation
7. Assess spine for scoliosis

Document your Subjective data, Objective data, and 2 complete Nursing Diagnosis statements (due via Blackboard within
24 hours after the physical assessment)
 Validation #2 Graded Documentation Sheets
To be completed following Validation #2 and submitted for grading within 24 hours or by 1700 on 10/22/19 via blackboard.

Biographical X.X. is a 57 year old female (DOB 4/28/62). Appears reliable.

Data
Reason for Visit Arrives with “right wrist and ankle pain”
Allergies X.X. reports allergy to sulfa meds – hives. Denies food or environmental allergies
Current X.X. reports using OTC ibuprofen 200 mg (name unknown) 3 tabs PO TID PRN 2-3 times in the past month for headaches and OTC
Medications Zyrtec-D (dose unknown) 1 tab PO QAM for allergies. X.X. denies using prescription medication. No herbals.
Past Medical X.X. denies history of hypertension, diabetes, heart disease, stroke or cancer. X.X. reports being hospitalized twice as a child for
History bronchitis. X.X. denies any emergency department visits in the last year. X.X. reports having chicken pox, appendicitis, frequent ear
infections and several instances of bronchitis as a child. Childhood vaccinations up to date.
Mental Health X.X. denies history of anxiety or depression or other mental illness.
History
Past Surgical X.X. reports appendectomy in 2000. (or X.X. denies any surgical history)
History
Family History Family history includes father with HTN and MI resulting in death at age 57. Mother alive and well. Siblings alive and well. X.X.
denies family history of diabetes, cancer, stroke, or mental illness.

Social History X.X. denies history of smoking cigarettes, but reports vaping 1-2 e-cigarettes once per week with friends. Drinks 2 alcoholic beers in
the evening once per week socially. Denies illicit drug use. X.X. reports diet consists of eating fast food 2-3 times per week. Currently
living with wife. Works as a full-time cashier in a grocery store, 10-hour shifts.

Environmental X.X. denies history of exposure to excessive UV rays, chemicals, pollutants, or environmental hazards. Lives in a 5 th floor apartment
or Risk Factors with their partner.

Review of Systems Interview and Physical Assessment

VITAL SIGNS P: 80 RR: 12 T: 97.8 BP: 125/85 arm: Left Pain: 0/10 Height: 5’11 Weight: 225 BMI: 31.5
General S: X.X. : Patient reports that her right wrist and right ankle pain started yesterday after she fell tripping over a rug. She reports that she
landed on her right hand and twisted ankle. Reports that immediately after her fall, she could not get up from the floor because of the
pain in her right wrist and right ankle. Reports after resting for 20 minutes, she was able to get up to the couch to rest her wrist and
ankle because her pain improved. Reports that her right wrist and right ankle pain are better today than yesterday; she was able to walk
today. Patient denies hitting her head, numbness or tingling, and lightheadedness. Denies losing consciousness. Reports swelling of her
right wrist and right ankle after her fall that has since resolved.
O: Pt appears to match the description of their reason for seeking care.
Integumentary S - X.X. denies any changes in skin color or nails. No hair loss.
O - Bilateral wrists were free of lesions, rashes, and swelling. Skin was warm, dry, and intact with an even distribution of hair.

HEENOT Deferred
 Neck, including Deferred
lymph nodes
Cardiovascular Deferred
& Peripheral
Vascular
Respiratory Deferred.

Abdomen / GI Deferred
Musculoskeletal S – X.X. states joint or muscle pain on movement, stiffness or weakness.
O - Muscles are symmetrical with adequate tone. Shoulder, elbow, wrist, digits, and ankle joints are symmetrical bilaterally without
visible deformity, swelling, tenderness, or discoloration. AROM full and bilaterally equal in shoulders, elbows, wrists, digits, hips,
knees, and ankles. Positive for generalized tenderness along the lateral wrist upon ulnar deviation against resistance of the right wrist.
Positive for generalized tenderness upon eversion against resistance of the right ankle along the lateral ankle. Spine has full AROM
without lateral deviation.

Neurological S: XX denies any change in sensation to face region, no difficulty swallowing, and no changes in vision or hearing.
O: Visual fields full and equal to examiners. 5/5 strength in upper and lower extremities bilaterally equal.
Genitourinary / Deferred
Breasts
Endocrine Deferred
Hematological Deferred

Nursing Diagnosis Statements

First Priority Nursing Diagnosis Statement:

Acute pain related to recent tripping fall injury as evidenced by patient report of pain level 5/10, clutching right wrist, and reluctance to use
wrist/hand due to pain, slightly less weight-bearing on right foot/ankle with transfer from chair to bed

Second Priority Nursing Diagnosis Statement:

Risk-prone health behavior related to chronic daily tobacco use as evidenced by patient report of smoking 1 ppd for 20 years.