Focused Exam_ Pain _ Completed _ Shadow Health subjective.pdf - Focused Exam Pain | Completed | Shadow Health Focused Exam Pain Results | Completed

Focused Exam_ Pain _ Completed _ Shadow Health subjective.pdf

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9/18/2019 Focused Exam: Pain | Completed | Shadow Health 1/8 Focused Exam: Pain Results | Completed Gerontologic Nursing - August '19, NRSE 4560 Return to Assignment Your Results Turn In Turn In Reopen Reopen Lab Pass Lab Pass Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports pain Reports recent fall Reports worry about worsening symptoms Orientation Established orientation Oriented to person Oriented to place Oriented to time Oriented to situation Patient Status Subjective Data Collection: 55 of 58 (94.8%) Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy QSEN Competencies Documentation SBAR Reflections Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions .
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9/18/2019 Focused Exam: Pain | Completed | Shadow Health 2/8 Asked about medication administered in ER Reports receiving oxycontin Reports oxycontin has been effective Asked about patient comfort and needs Denies needing to use the bathroom History of Present Illness Asked about onset and duration of symptoms Reports recent episode of severe pain started this morning Reports pain has been getting progressively worse in the last few weeks Asked about location of pain Reports hip pain Reports knee pain Asked about characteristics of pain Describes pain as aching Describes pain as "deep" Denies shooting or sharp pain Reports occasional "grating" sensation in joints Denies burning pain Denies stinging pain Asked about severity of pain Reports current pain is a 1 Reports pain before medication was a 9 Asked about non-medication relieving factors of pain Reports that rest typically relieves the pain Reports not using any non-medication treatments to treat this morning's pain Reports occasional use of moist heat as treatment on hips Reports using range of motion exercises for knees Reports wearing elastic supports on knees bilaterally Denies use of ice as treatment Asked about aggravating factors of pain Reports that exercise exacerbates pain and stiffness Reports that weight bearing exacerbates pain and stiffness Reports that pain and stiffness are worse in the morning Reports that changes in weather exacerbate pain and stiffness Followed up on details of the fall Reports falling getting out of bed
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9/18/2019 Focused Exam: Pain | Completed | Shadow Health
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