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9/18/2019Focused Exam: Pain | Completed | Shadow Health1/8Focused Exam: Pain Results | CompletedGerontologic Nursing - August '19, NRSE 4560Return to AssignmentYour ResultsTurn InTurn InReopenReopenLab PassLab PassIndicates an item that you found.Indicates an item that is available to befound.CategoryScored ItemsExperts selected these topics as essentialcomponents of a strong, thorough interviewwith this patient.Patient DataNot ScoredA combination of open and closed questionswill yield better patient data. The followingdetails are facts of the patient's case.Chief ComplaintEstablished chief complaintReports painReports recent fallReports worry about worsening symptomsOrientationEstablished orientationOriented to personOriented to placeOriented to timeOriented to situationPatient StatusSubjective Data Collection: 55 of 58 (94.8%)OverviewTranscriptSubjective Data CollectionObjective Data CollectionEducation & EmpathyQSEN CompetenciesDocumentationSBARReflectionsHover To Reveal...Hover over the Patient Dataitemsbelow to reveal important information,including Pro Tipsand ExampleQuestions.
9/18/2019Focused Exam: Pain | Completed | Shadow Health2/8Asked about medication administered inERReports receiving oxycontinReports oxycontin has been effectiveAsked about patient comfort and needsDenies needing to use the bathroomHistory of Present IllnessAsked about onset and duration ofsymptomsReports recent episode of severe painstarted this morningReports pain has been gettingprogressively worse in the last few weeksAsked about location of painReports hip painReports knee painAsked about characteristics of painDescribes pain as achingDescribes pain as "deep"Denies shooting or sharp painReports occasional "grating" sensation injointsDenies burning painDenies stinging painAsked about severity of painReports current pain is a 1Reports pain before medication was a 9Asked about non-medication relievingfactors of painReports that rest typically relieves the painReports not using any non-medicationtreatments to treat this morning's painReports occasional use of moist heat astreatment on hipsReports using range of motion exercisesfor kneesReports wearing elastic supports on kneesbilaterallyDenies use of ice as treatmentAsked about aggravating factors of painReports that exercise exacerbates painand stiffnessReports that weight bearing exacerbatespain and stiffnessReports that pain and stiffness are worsein the morningReports that changes in weatherexacerbate pain and stiffnessFollowed up on details of the fallReports falling getting out of bed
9/18/2019Focused Exam: Pain | Completed | Shadow Health