Focused Exam_ Pain _ Completed _ Shadow Health subjective.pdf

9/18/2019 Focused Exam: Pain | Completed | Shadow Health
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Focused Exam: Pain Results | Completed
Gerontologic Nursing - August '19, NRSE 4560
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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
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below to reveal important information,
including Pro Tips and Example
Questions .

9/18/2019 Focused Exam: Pain | Completed | Shadow Health
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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

9/18/2019 Focused Exam: Pain | Completed | Shadow Health