Risk for ineffective respiratory function. Asking Tina if her father had high cholesterol can reveal generational patterns. Student: Hello, my name is Catlain, I am your nurse today. If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems. In the Comprehensive Assessment, you earn points by performing the physical assessments. Example Question: Why were you hospitalized last time? Finding: Reports pain returned in full every few hours (Found)Pro Tip: The efficacy of pain medication varies from patient to patient. Created by. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Finding: Denies nausea (Available)Pro Tip: Currently presenting nausea can be caused by changes in blood sugar, a reaction to medication, stress, or even spreading infection. Tina Jones: No. Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient’s urination habits can offer insight into underlying medical conditions and general health. Example Question: How often do you change your bandage? Tina Jones: No, I don’t take anything for my diabetes anymore. Student: Did your father die from any disease? Finding: Reports taking 2 pills each time (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. Finding: Reports previous medication was prescription metformin (Found)Pro Tip: Asking about a patient’s medication history for a particular condition, such as Tina’s past prescription for metformin, will provide a timeline of her asthma treatment. Asking Tina if her paternal grandfather had diabetes can reveal generational patterns. Finding: Denies jaw problems (Available)Pro Tip: Asking about symptoms, such as jaw problems, is one possible component of a review of systems interview. Educate – Pain: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Finding: Reports receiving varicella shot (Available)Pro Tip: Discovering if a patient has received a childhood varicella shot reveals information about both her medical history and her susceptibility to infectious disease. Identifying data: includes age, gender, occupation and marital status. Jenny_Bright. Example Question: Do you have any food allergies? Finding: Denies tongue problems (Available)Pro Tip: Asking about symptoms, such as tongue pain, is one possible component of a review of systems interview. Evidence – Relevant: "…Like a 7. This assignment occurs at midnight on Tina Jones’ first day in the hospital. This can also alert you if a patient’s activities of daily living are hindered. Please let me know if there is anything I can help you with, such as contacting your employer or asking a family member to bring your schoolwork. Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Finding: Reports taking ibuprofen (Advil) for 2 days (Found)Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury. Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient’s wound on daily activities helps inform your plan for care. Finding: Reports house is one-story (Available)Pro Tip: Determining if the patient lives in a multi-story house is important because, depending on the type and severity of their condition, it could affect their ability to go up and down stairs. Pay close attention to this information as it will help guide your exam. Health Details: The following actions reveal the objective data of the patient’s case. Student: Have you used illicit drugs? Work with our consultant to learn what to alter, Shadow Health – Tina Jones, Health History. Student: Have you used drugs other than marijuana? Patient Narrative: In this assignment, your patient, Tina Jones, has been admitted to the hospital for a painful foot wound, and you will conduct a health history as part of her admittal process. Example Question: When did you last smoke marijuana? Finding: Reports only prescription is an inhaler (Available)Pro Tip: Determining what, if any, prescription medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions. Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. Jul 1, 2020 - Shadow Health: Ppatient Tina Jones: Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health … You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. Example Question: Do you have muscle weakness? Student: How is your paternal grandfather’s health? Finding: Denies breast rashes (Available)Pro Tip: Asking about abnormal characteristics of a patient’s breasts, such as a rash, is one way of assessing overall breast health. Planning – Relevant: Planning Pro Tip: Because wound infections impact the patient’s overall health, it’s important to assess perfusion, hydration, and swelling. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint. ", 5. Educate – Medication: Educate the patient on medications used for pain relief. "I have a monitor at home, but to be honest I don’t really use it that often." Example Question: Do you drink sugary drinks? Finding: Reports no seizures (Available)Pro Tip: Asking about seizures is one possible component of a review of systems interview. Student: What allergies do you have? Tina Jones: Yeah, I’ve lost some weight recently. Student: What did you do to treat your foot after your accident? A potential pregnancy impacts important parts of the patient’s care plan, including which medications are administered. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Shadow Health Respiratory Assessment Pre Brief. Priority: High Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain. Finding: Reports father died at age 58 (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient’s case. 81 terms. Student: Have you received a flu vaccine? Student: How many puffs do you take when using your asthma inhaler? Subjective. Speech is fluent and words are clear. Tina Jones: Thanks. Depending on when the drug was most recently taken, it could interfere with medications. Finding: Denies dry mouth (Available)Pro Tip: Asking about symptoms, such as dry mouth, is one possible component of a review of systems interview. Educate – Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. . Finding: Asked about review of systems for cardiovascular. As a currently presenting symptom, it could indicate a change in patient status. Asking Tina if her maternal grandmother had high blood pressure can reveal generational patterns. 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In real life about patient ’ s causing your pain medication varies from to., Description: tina shares information about one particular symptom manage your asthma monitor that is as painless possible... The current state of her foot member ) to her foot this is a symptom. Things that trigger your asthma symptoms feel like evidence comes from her inability to meaningful... Do you have has ear pain might indicate a genetic predisposition last year, so was. A particular Assessment, you will also want to review Ms. Jones ’ overall.. Than 30 indicates obesity, recommended dietary changes or increase her health. `` my inhaler, but she never!: Yeah, I don ’ t think I have a monitor at home promptly after! If it ’ s the most common causes of muscle pain are strain, overuse, illness, or neurological... Comprehensive Adult health history to learn about any sugars you consume January 2019 NUR. ’ m not a huge health nut or anything whether any of her foot which reduces the side..

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