Focused Exam- Abdominal Pain |education and empathy.pdf - Focused Exam Abdominal Pain | Completed | Shadow Health Focused Exam Abdominal Pain Results |

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Unformatted text preview: 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Focused Exam: Abdominal Pain Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Education & Empathy : 4 of 7 (57.1%) Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Self-Reflection During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity. Opportunities marked as Not Encountered are opportunities that were not elicited in the interview Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient 1 Symptoms Followed Up Description: Ms. Park describes the symptoms that have been bothering her. What brought you into the clinic today? Question 01:21 PM CDT I have some pain in my belly. . . and I'm having difficulty going to the bathroom. My daughter was worried about me. When did your pain start? Question 01:29 PM CDT The pain started as a general discomfort, about five days ago, when I started having the. . . difficulties going to the bathroom. Was your pain sudden? Question 01:31 PM CDT 1/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health No, it was gradual. I had some pain and discomfort about. . . five days ago. Then in the past few days it got much worse. I'm sorry to hear you're feeling bad Empathize 01:31 PM CDT Thank you. How often are you having the pain? Question 01:31 PM CDT Oh, it's with me all the time. The bloating, too. But certain things do make it worse. Where does it actually hurt? (Clarified to: Which part of your abdomen hurts?) Question 01:32 PM CDT The pain and discomfort is down low in my belly. (Clarified to: which part of my abdomen hurts) Point of location of pain Question 01:33 PM CDT Well my whole belly is uncomfortable to some degree, but it's mostly in the lower part, that's where the pain is. Down in my lower belly. What makes your pain worse? Question 01:33 PM CDT Moving around certainly doesn't help. Neither does eating. How long is your pain last? Question 01:34 PM CDT The pain is there all the time, but it gets much worse at certain points--when I move around a lot or eat something, especially. What causes your pain? Question 01:41 PM CDT I'm just not sure. I've been having trouble going to the bathroom, but I don't know what is making all this happen. What makes your pain worse? Question 01:41 PM CDT Moving around certainly doesn't help. Neither does eating. 2/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Is your pain sharp? Question 01:42 PM CDT No. I'd say it's crampy and. . . a dull, crampy feeling. Rate your pain on a scale of 0 to 10? Question 01:42 PM CDT Right now. . . 6 out of 10. I'm sorry to hear that you're feeling so bad Empathize 01:43 PM CDT Thank you. What makes it feel better? Question 01:48 PM CDT When I rest and try not to move much, I feel better. But the pain is still there. What have you done to relieve your pain? Question 01:48 PM CDT I've tried taking small sips of warm water, resting. The warm water does nothing. A friend suggested it, but it's nonsense. I'm sorry you feel that way Empathize 01:49 PM CDT Thank you. Is your pain constant? Question 01:50 PM CDT Yes. Certain things can make it a tiny bit better or a tiny bit worse, I suppose. But it's always there. What makes it better? (Clarified to: What makes your pain feel better?) Question 01:50 PM CDT When I rest and try not to move much, I feel better. But the pain is still there. (Clarified to: what relieves the pain) 3/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health What makes your pain worse? Question 01:50 PM CDT Moving around certainly doesn't help. Neither does eating. How is your energy level? Question 01:51 PM CDT Right now? I feel slow, sluggish. I just feel very uncomfortable. Sorry you feel uncomfortable Empathize 01:51 PM CDT Thank you. Are you having constipation? (Clarified to: Are you feeling constipated?) Question 01:53 PM CDT Well, yes. . . other than my. . . digestive upset. . . I haven't moved my bowels for several days. (Clarified to: if I am constipated) When was the last time you had a bowel movement? Question 01:53 PM CDT That was a few days ago. When I had a digestive upset. Diarrhea. Do you have a history of constipation? Question 01:53 PM CDT I don't usually have problems going to the bathroom. . . but this has been going on for. . . about five days now. Other than the digestive upset I had a few days ago. Any treatment for constipation? (Clarified to: How have you treated the constipation?) Question 01:54 PM CDT Well, I haven't experienced constipation before, so I haven't done anything for it. (Clarified to: how I have treated the constipation) Any recent diarrhea? Question 01:55 PM CDT Yes, I did have a bout of diarrhea pretty recently. Describe your diarrhea? Question 01:55 PM CDT 4/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health It was very loose. Watery. Last normal bowel movement? (Clarified to: How are you bowel movements?) Question 01:56 PM CDT My bowel movements are usually. . . what I assume one would call normal. Not too soft, a normal brown color. Fairly regular. (Clarified to: what my stool is like) How often are your bowel movements Question 01:57 PM CDT Before this? Every day. Well, I miss a day now and then, but usually every day. It is important to have a bowel movement everyday Educate 01:57 PM CDT Thank you for explaining that. Recent loss of appetite? (Clarified to: how long have you noticed decrease in appetite) Question 03:59 PM CDT It's been hard to eat since the belly pain got much worse, about two or three days ago. When I do eat--my daughter Jennifer makes sure I have a little something--it only makes me feel worse. (Clarified to: how long I have not had an appetite) I'm sorry to hear that Empathize 03:59 PM CDT Thank you. Model Statement: "I’m sorry you’re having these symptoms. It’s good that you came in today so we can see what is causing your discomfort." 2 Medications Followed Up Description: Ms. Park describes her medication use and attitudes toward taking medication. How often do you take your medication? Question 03:26 PM CDT Yes, that's very important. I never skip a dose. 5/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health How often do you take your medication? Question 03:27 PM CDT Yes, that's very important. I never skip a dose. How many times a day? Question 03:27 PM CDT When do you take your medication? (Clarified to: When do you take your blood pressure medication?) Question 03:27 PM CDT I take it every morning at about 8 a.m., after breakfast. (Clarified to: when I take my blood pressure medication) When was the last time you took your medication? Question 03:27 PM CDT I took my Accupril this morning, at around 8. It is important to take your medication everyday as prescribed Educate 03:28 PM CDT Thank you for explaining that. I'm glad you take your medication as prescribed Empathize 03:28 PM CDT Thank you. Do you take any over-the-counter medications? Question 03:28 PM CDT No. Those over-the-counter medicines. . . Tylenol--they say it's very bad for the stomach. I understand Empathize 03:29 PM CDT Thank you. Model Statement: "I understand not wanting to take many medications. However, some medications can help reduce pain, relieve symptoms, and keep you healthy in the long-run." 3 Diet Followed Up 6/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Description: Ms. Park describes her dietary habits. When was your last meal? Question 03:38 PM CDT I haven't been eating much at all lately. . . the last time I ate was this morning, a little toast. Do you typically eat three meals a day? Question 03:39 PM CDT Usually three, but sometimes I skip breakfast. I don't eat snacks. Breakfast is the most important meal of the day. You should never skip meals Educate 03:39 PM CDT Thank you for explaining that. What do you normally eat for breakfast? Question 03:40 PM CDT For breakfast? I eat fruit, usually a banana. What do you normally eat for lunch? Question 03:40 PM CDT Sometimes I skip lunch if I'm not feeling hungry, but usually I eat something light, like soup. You should never skip a meal. Educate 03:40 PM CDT Thank you for explaining that. What do you normally eat for dinner? Question 03:41 PM CDT Usually fish or chicken--a good protein--with rice and a vegetable. Do you take any fiber supplements? Question 03:42 PM CDT No, I don't take any extra fiber. My diet is very healthy. 7/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health On occasion there may be a need to take an additional fiber. Educate 03:42 PM CDT Thank you for explaining that. How do you get your fiber? Question 03:43 PM CDT I have at least one vegetable each day. Any increase in thirst? Question 03:43 PM CDT I haven't felt noticeably thirsty. I suppose I've been drinking a little less water than usual, just in these last few days. It is important to drink six to eight glasses of water per day. Educate 03:44 PM CDT Thank you for explaining that. Model Statement: "Keeping an eye on your fiber intake is a great start. The USDA recommends that adults eat around 28 grams of fiber per day, which is several servings of fruits, vegetables, and whole grains. Let’s talk about ways for you to get a little more fiber in your diet." 4 Activity Level Not Followed Up Description: Ms. Park describes staying socially active and exercising. Does it affect your daily life? (Clarified to: How has your illness affected your daily life?) Question 01:43 PM CDT Well, I have been slowed down lately. This week I missed both of my fitness classes. I never miss a class. . . and I like to help with the cleaning at home, but my daughter--she worries too much-she wants me to rest. (Clarified to: how illness has affected my daily activities) What makes it feel better? Question 01:48 PM CDT Model Statement: "It sounds like you stay physically and socially active. That’s great!" 8/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health 5 Medical History Not Followed Up Description: Ms. Park describes her past c-section and losing a child at birth. What operations did you have? Question 03:34 PM CDT I've had two. I had my gallbladder out, and I had a C-section. Both in my early 40s. Any complications with your surgery? (Clarified to: Have you had problems after surgery?) Question 03:35 PM CDT No, no complications. (Clarified to: if I have had problems after surgery) Any family history of gastrointestinal disorders? Question 03:36 PM CDT Well, I do remember my father having heartburn on occasion. But I can't think of anyone having anything, other than that. Model Statement: "I’m so sorry to hear about this. It must have been a painful situation for you. Thank you for sharing." 6 Sexual Activity Followed Up Description: Ms. Park describes being sexually active. Are you currently sexually active Question 03:55 PM CDT I have a gentleman friend and, yes... We are intimate. Do you have vaginal intercourse (Clarified to: Do you have vaginal intercourse?) Question 03:55 PM CDT We are sexual, but we don't. . . we have oral sex, but no intercourse. (Clarified to: if I have vaginal sex) Intercourse is a very important part of a relationship. Educate 03:56 PM CDT Thank you for explaining that. 9/10 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Model Statement: "Thank you for sharing this personal information. It will help me determine if any part of your abdominal pain is caused by sexual activity." 7 Family and Support Not Followed Up Description: Ms. Park describes being widowed and living with her daughter. Does it affect your daily life? (Clarified to: How has your illness affected your daily life?) Question 01:43 PM CDT Well, I have been slowed down lately. This week I missed both of my fitness classes. I never miss a class. . . and I like to help with the cleaning at home, but my daughter--she worries too much-she wants me to rest. (Clarified to: how illness has affected my daily activities) What makes it feel better? Question 01:48 PM CDT Model Statement: "I’m sorry that your husband passed away. It sounds like you have a wonderful relationship with your daughter and son. I’m happy to hear that you have a strong support system in your children." Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2018 10/10 ...
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  • Fall '15
  • Sexual intercourse, Defecation, PM CDT

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