Transcript Comprehensive Assessment _ Completed _ Shadow Health.pdf

This preview shows page 1 out of 36 pages.

Unformatted text preview: Comprehensive Assessment Results | Turned In Patient Assessment and Health Literacy - January 2019, NUR 325 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Feb 12, 2019 | Patient Exam Time: 464 min All Lines (628) Interview Questions (253) Statements (12) Exam Actions (363) Objective Data Collection Documentation Hello! Plan My Exam Self-Reflection Question 02/12/19 12:39 PM EST Hi. Im Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. What is the situation? Question 02/12/19 12:39 PM EST Six months have passed since Tina Jones was admitted to Shadow General Hospital, and her foot wound has healed. Your role in this simulation is that of a healthcare provider who will perform a comprehensive assessment on Ms. Jones to demonstrate your clinical competency. What are my objectives in this assessment? Question 02/12/19 12:39 PM EST At the beginning of this assignment, you will be asked to identify and organize the steps of your comprehensive exam. Having a clear plan is essential to maximizing efficiency and obtaining a full picture of the patients current health. Then you will collect subjective data from Ms. Jones: inquire into her current health status, body systems, mental health, and psychosocial history. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to understanding her current health status. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones systems to gather objective data about her overall health. Ms. Jones has no new abnormal findings, so after you complete an exam task, you do not need to make selections in the Electronic Health Record, though you may document your findings if you like. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. What else will this exam involve? Question 02/12/19 12:40 PM EST You will complete nursing tasks to protect the patients safety, privacy, and health. While it is not required for this assignment, you can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation. How will I be evaluated? Question 02/12/19 12:40 PM EST In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam requires you only to complete all exam actions. Documentation of the exam is optional, though encouraged, as it can provide you valuable realworld experience. This assignment takes on average between 140 and 170 minutes. You can pause and resume the assignment at any time; your work is always saved automatically. How does this assignment prepare me for the real world? Question 02/12/19 12:41 PM EST In this assessment, you will become familiarized with the structure and content of comprehensive assessments so that with real-life patients, you can: º develop a mental model for sequencing a comprehensive exam º ask effective and comprehensive questions º evaluate the patients risk of disease, infection, injury, and complications º and document data with professional terminology. In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: How does interviewing a healthy patient differ from interviewing a patient with a known health condition? In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: How does interviewing a healthy patient differ from interviewing a patient with a known health condition? A health assessment is individualized to each patient based on any known health conditions, current condition and acuity. Knowing a patient has an existing condition enables the nurse to custom tailor the assessment, adding additional depth to the interview and assessment customized to the given disease state to seek additional information about effective management, symptoms, medication compliance and patient perceptions of disease state while further enabling the identification of knowledge gaps and facilitating the provision of additional education. Statement 02/13/19 11:41 AM EST Time to begin. Hello, I'm Kathleen. I'm your nurse today. Question 02/13/19 12:39 PM EST Hi. Can you please confirm your name and date of birth? Question 02/13/19 12:39 PM EST My name's Tina Jones, and my birthday's February 17th. Hi Tina. How old are you? (Clarified to How old are you?.) Question 02/13/19 12:40 PM EST I'm 28. (Clarified to what is my age.) What brought you into the clinic today? Question 02/13/19 12:40 PM EST I came in because I'm required to have a recent physical exam for the health insurance at my new job. Congrats on the new job. Empathize 02/13/19 12:40 PM EST Thanks. What is your new job? Question 02/13/19 12:41 PM EST Well, I'm starting my new job in two weeks, and I'm really excited about that. I'm going to be an Accounting Clerk at this really nice accounting firm. Are you excited or nervous about your new job? Question 02/13/19 12:41 PM EST I'm so excited about my new job. I think it's going to be a great experience, and I can't wait to learn how to do a bunch of new things. Are you having any health problems right now? Empathize 02/13/19 12:58 PM EST Thanks. Are you having any health issues currently? Question 02/13/19 12:58 PM EST I don't have any new problems--still just the old asthma and diabetes. Can you list all of your current medications? Question 02/13/19 12:58 PM EST I'm taking metformin now, that's every day. And I take Yaz, the birth control pill. And then my inhaler is the same, but that's not every day. What is your dose and frequency of metformin? It's 850 mg. And I take one pill, twice a day. Question 02/13/19 12:59 PM EST Do you monitor your blood sugars? Question 02/13/19 1:00 PM EST Yeah, I check it once a day, in the morning. Can you give me a range of your morning blood sugars? (No matching questions found.) Question 02/13/19 1:00 PM EST What are normal blood sugars for you ? Question 02/13/19 1:00 PM EST My blood sugar's usually around 90. Do you check your blood sugar before eating or drinking? Question 02/13/19 1:01 PM EST Yeah, I check it once a day, in the morning. which inhalers do you use? Question 02/13/19 1:01 PM EST It's an albuterol inhaler. How many puffs do you use, and how frequently do you use it? Question 02/13/19 1:02 PM EST It's usually a couple puffs--sometimes 3 if I need it. The prescription says I can do that. How often do you need your albuterol? Question 02/13/19 1:02 PM EST Never more than twice a week, I'd say. It depends on the week. Sometimes I don't use it at all. What are your triggers for asthma? Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven't had a full asthma attack in years, though. Question 02/13/19 1:02 PM EST How many years has it been since your last full asthma attack? Question 02/13/19 1:03 PM EST I had a small exacerbation yesterday from running up the stairs which only lasted a minute, really--just used my inhaler and I was fine. Do you use other medications for you asthma? Question 02/13/19 1:03 PM EST It's an albuterol inhaler. How long have you been taking the birth control pill Yaz? Question 02/13/19 1:04 PM EST About four months ago. I went to the gynecologist, and she prescribed it. Are you using Yaz for birth control or another reason? (No matching questions found.) Question 02/13/19 1:04 PM EST Do you have any medical conditions besides asthma and diabetes? (Clarified to Do you have medical problems other than your diabetes and asthma?.) Question 02/13/19 1:05 PM EST I found out recently that I had PCOS, too. (Clarified to if I have other medical problems besides diabetes and asthma.) Are you taking Yaz to treat pcos? (No matching questions found.) Question 02/13/19 1:05 PM EST Are you using Yaz as birth control? Question 02/13/19 1:06 PM EST Yeah. The gynecologist said I have PCOS, and I should be on birth control. How often do you take Yaz? Question 02/13/19 1:06 PM EST I take it every morning, with breakfast. Have you noticed any changes since taking Yaz? (No matching questions found.) Question 02/13/19 1:07 PM EST What symptoms do you associate with polycystic ovarian syndrome? Question 02/13/19 1:07 PM EST Yeah. The gynecologist said I have PCOS, and I should be on birth control. Prior to starting Yaz, were your menstrual cycles irregular? (No matching questions found.) Question 02/13/19 1:08 PM EST Are your menstrual cycles regular? Question 02/13/19 1:08 PM EST Now that I'm on the pill I'm getting my period every month. When was your last period? Question 02/13/19 1:08 PM EST Um. . . about two weeks ago. Do you have any problems when you have your period? Question 02/13/19 1:08 PM EST Being on the pill has really helped the problems I was having with my period. Do you have any pain with your period? (Clarified to Do you have pain during your menstrual cycle?.) Question 02/13/19 1:09 PM EST They used to be pretty bad. I would have to take three or four Advil, and use a heating pad and everything. They're much better now. (Clarified to if I have pain during menstruation.) Have you had any unusual hair issues? Question 02/13/19 1:09 PM EST Actually, I think I have a little less body hair than I used to. Have you noticed any hair loss on your head? Nope. Question 02/13/19 1:10 PM EST Are you taking any vitamins? Question 02/13/19 1:10 PM EST I don't take any vitamins. Do you use any over the counter medications? Question 02/13/19 1:10 PM EST I don't take anything over the counter really. . . except Advil for cramps, but I don't need it that much anymore. Do you take any herbal supplements? Question 02/13/19 1:10 PM EST I don't take any herbal supplements. Have you missed any doses of medication? Question 02/13/19 1:11 PM EST No, I'm pretty careful with my medications. Have you missed any doses of Yaz? (Clarified to Have you missed any days of your birth control pill?.) Question 02/13/19 1:11 PM EST I'm really careful to take it every day. (Clarified to if I have missed days of my birth control pill.) Do you take it at the same time every day? Question 02/13/19 1:11 PM EST I take it every morning, with breakfast. Do you use any inhaled steroids for your asthma? Question 02/13/19 1:12 PM EST Yeah, I have a rescue inhaler. When was your last visit to a healthcare provider? Question 02/13/19 1:13 PM EST Let's see... I had two doctor's appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear. What were the results of your pap smear? Question 02/13/19 1:13 PM EST I think they were all fine. Are you currently sexually active? Question 02/13/19 1:13 PM EST It's been a while, but I actually have a boyfriend now. We haven't had sex yet, but we probably will soon. How do you plan to protect yourself from sexually transmitted infections when you have sex? Question 02/13/19 1:15 PM EST I used condoms. . . some of the time. I was on the pill. It is important to use condoms consistently in any new sexual relationship to protect yourself and your partner. I recommend that each of you are screened for sexually transmitted infections before becoming intimate and again six months into the relationship, and continue condom use until after that six month exam. Educate 02/13/19 1:18 PM EST Thanks for telling me. Please tell me about any hospitalizations you've experienced. (No matching questions found.) Question 02/13/19 1:18 PM EST Will you tell me about any hospitalizations you've experienced? (No matching questions found.) Question 02/13/19 1:18 PM EST Have you been hospitalized? Question 02/13/19 1:19 PM EST Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably sixteen, though. What brought you to the hospital? Question 02/13/19 1:19 PM EST I came in because I'm required to have a recent physical exam for the health insurance at my new job. Why were you hospitalized? Question 02/13/19 1:19 PM EST The last time was when I was admitted for my foot about six months ago. Tell me more about your foot. Question 02/13/19 1:19 PM EST I fell and scraped it, but that was almost six months ago. It's fine now. Was your foot infected? (Clarified to Which foot did you hurt?.) Question 02/13/19 1:20 PM EST It was my right foot, but that was a while back. It's all healed up now. Both my feet are fine. (Clarified to which foot I hurt.) Are you doing daily foot checks to monitor for scrapes, cuts or infections? (No matching questions found.) Question 02/13/19 1:20 PM EST Do you check your feet? Question 02/13/19 1:20 PM EST Um, well I usually wash my feet in the shower every day so I kind of look them over then. Using a handheld mirror helps to see parts of your foot that may be difficult to visualize otherwise. Educate 02/13/19 1:21 PM EST Thanks for telling me. Please tell me about all allergies you have. Question 02/13/19 1:22 PM EST I'm still allergic to cats, but I've been really good about avoiding them. Do you have other allergies? Question 02/13/19 1:22 PM EST Well, besides cats, I'm allergic to penicillin. What happens when you take penicillin? Question 02/13/19 1:23 PM EST I don't remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. What happens when you are exposed to cats? Question 02/13/19 1:23 PM EST I've been trying really hard to stay away from cats, but I have been around them a couple times without meaning to. I still get allergic around them, and my asthma acts up, but not as bad as when I had to come in a while ago. Do you have other symptoms when exposed to cats? (Clarified to Do you experience other symptoms with your shortness of breath?.) Question 02/13/19 1:24 PM EST Just the tightness, like I can't take in air, and the wheezing. (Clarified to if I have other symptoms when I have trouble breathing.) Do you use other medications for allergies? (Clarified to Do you take medication for allergies?.) Question 02/13/19 1:24 PM EST Other than using my rescue inhaler, I don't take anything for allergies. (Clarified to if I take medication for allergies.) Do you experience headaches? Question 02/13/19 1:25 PM EST I haven't had any headaches lately, actually. Do you have any vision problems? Question 02/13/19 1:25 PM EST I don't have problems now that I got these glasses. How long have you been wearing glasses? I went in to the eye doctor about three months ago, and she said I was near sighted and prescribed these glasses. Question 02/13/19 1:25 PM EST Have the glasses improved your ability to see? Question 02/13/19 1:26 PM EST Yeah, they've definitely helped me. What is your weight? Question 02/13/19 1:27 PM EST I've lost a little weight. . . I think I'm at around 185? What was your previous weight? Question 02/13/19 1:27 PM EST I've lost a little weight. . . I think I'm at around 185? How much weight did you lose? Question 02/13/19 1:27 PM EST I've lost about ten pounds in the last four months, I'd say. WEre you trying to lose weight? Question 02/13/19 1:28 PM EST I've lost some weight recently. . . maybe ten pounds. I've been eating better and exercising to stay healthy and keep my diabetes under control, but it makes sense I'd lose some weight, too. Please tell me what you typically eat in a day. Question 02/13/19 1:28 PM EST Well. . . for breakfast, a smoothie made with frozen fruit and yogurt or an egg on wheat toast with yogurt on the side. For lunch, I eat leftovers from dinner the night before, or I'll have a sandwich on wheat bread. Then for dinner, I'll have chicken or fish, usually, with vegetables and brown rice or quinoa on the side. Do you eat snacks? I don't really eat snacks that often anymore, but when I do it's usually carrots or an apple. Has your appetite been good recently? Question 02/13/19 1:29 PM EST Question 02/13/19 1:29 PM EST I was hungrier for a while because of my diabetes, but since I started taking medication for it, my appetite has been pretty normal. How much water drink in a day? Question 02/13/19 1:30 PM EST I'd say I have maybe. . . four or five glasses of water a day. Do you drink soda? Question 02/13/19 1:30 PM EST Yeah, I drink diet Coke. How much diet coke do you drink in a day? Question 02/13/19 1:30 PM EST I drink maybe two diet sodas a day. Do you drink coffee? Question 02/13/19 1:30 PM EST I don't drink coffee. . . it's too bitter. Do you drink tea? Question 02/13/19 1:31 PM EST No. I've never liked tea. Do you use caffeine? Question 02/13/19 1:31 PM EST Yeah, I still drink diet Cokes, but I try not to have too many. Too much caffeine can raise your blood pressure and may make you jittery. Diet Coke has caffeine in it. Try to keep your daily intake of diet coke to 2 or less per day. Thanks for telling me. Educate 02/13/19 1:32 PM EST Do you drink alcohol? Question 02/13/19 1:32 PM EST I do sometimes, yeah, when I go out with my friends. How often do you go out with your friends for drinks? (Clarified to How often do you drink with friends?.) Question 02/13/19 1:32 PM EST Not much. I go out for drinks with friends maybe a couple times a month. (Clarified to how often I drink with friends.) How many drinks do you have when out with friends? Question 02/13/19 1:33 PM EST Like, two or three drinks. If I have more than two or three drinks, I feel like hell the next day, so I stop at three. Do you use any recreational drugs? Question 02/13/19 1:33 PM EST No. Do you use tobacco? Question 02/13/19 1:34 PM EST No, never. Do you vape? Question 02/13/19 1:34 PM EST I would never vape. Tell me about your exercise? I've been exercising more lately, actually. I try to go on a walk for thirty or forty minutes four or five times a week, and Selena and I go swimming at the Y once a week, too. Question 02/13/19 1:34 PM EST Do you experience any difficulties with exercise? (Clarified to Do you have difficulty breathing when exercising?.) Question 02/13/19 1:35 PM EST Sometimes if I walk too fast, my breathing will get tight. So I just take it easy and keep my inhaler on me. (Clarified to if it is hard for me to breathe when I exercise.) Where is your new job? Question 02/13/19 1:36 PM EST I'm going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I'll be helping a more experienced accountant with her clients, and then eventually I'll get more responsibility, and build my own client list. What is the highest level of education you've completed? Question 02/13/19 1:36 PM EST I got my B.A. a little while ago. Congratulation on completing your degree! Empathize 02/13/19 1:37 PM EST Thanks. Tell me about your living situation. Question 02/13/19 1:37 PM EST I've been back at my mom's house, but I'm moving into an apartment closer to my new job. The lease starts in about...
View Full Document

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture