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RN Remedial Course - Health Assessment Content - August 2020
Return to Assignment Your Results Overview Lab Pass Transcript Transcript
Started: Oct 15, 2020 | Total Time: 167 min
Subjective Data Collection
All Lines (47) Interview Questions (45) Statements (2) Exam Actions (0) Objective Data Collection
Documentation Question
10/15/20 11:22 PM EDT What brings you in today? Student Survey I'm here for my physical. What is your past medical history? Question
10/15/20 11:23 PM EDT I've never had any health problems. I almost never get like, a cold, and I've never been in the
hospital. I've never even broken a bone. Do you take any medications? Question
10/15/20 11:27 PM EDT No. Or.... I mean, almost never. I take ibuprofen sometimes. Question
10/15/20 11:28 PM EDT Do you take any vitamins? No, I don't take any vitamins. Do you take any prescription medications? Question
10/15/20 11:28 PM EDT No, I don't have any prescriptions. Do you take any herbal supplements? Question
10/15/20 11:28 PM EDT No, I don't take anything herbal. Do you take anything other than ibuprofen? Question
10/15/20 11:29 PM EDT No. I mean, for my cramps, the Advil makes them go away. That's all I need to do. Do you take any other over the counter medications? Question
10/15/20 11:31 PM EDT The only thing I ever take is Advil. How often do you take
ibuprofen? Question
10/15/20 11:31 PM EDT I only take Advil once a month. How many do you take at a time? Question
10/15/20 11:32 PM EDT I take two at a time, like it says on the bottle. And I only take them once or twice, on the first day
of my period. That's the only day I have cramps. When was the last time you took Advil? Question
10/15/20 11:32 PM EDT Two weeks ago. That's the last time I got my period. What is the dosage you use? Question
10/15/20 11:33 PM EDT Um, I don't know how many milligrams... It's not extra-strength or anything. I think it's just kind
of regular Advil.
Question
10/15/20 11:36 PM EDT Do you have any allergies? Yeah, I'm allergic to peanuts. Question
10/15/20 11:37 PM EDT Any medication allergies? No, I'm not allergic to any medications that I know of. Question
10/15/20 11:37 PM EDT Any seasonal allergies? No, I don't get hay fever, or sneezy around flowers or anything. Lucky for my mom, since she
makes me help her in the garden all the time.
Question
10/15/20 11:37 PM EDT Are you allergic to latex? Latex allergy? No, I've never had that. What type of reaction do you get when you eat peanuts? Question
10/15/20 11:38 PM EDT Well, when I've eaten peanuts the inside of my mouth and inside my throat gets pretty itchy. It's
weird. But I don't think I've ever had hives or anything like that. How do you treat it? (Clarified to What do you do to treat the reaction?.) Question
10/15/20 11:38 PM EDT The last time, my mom took me to our doctor and they told me to take Benadryl because it was
a mild reaction. It just went away after a couple of hours. (Clarified to how I treat my reaction.)
How do you prevent the allergic reaction? (Clarified to How do you prevent your peanut
allergy?.) Question
10/15/20 11:39 PM EDT Well... I ask what's in things, especially if something's fried, because it could be fried in peanut
oil. And I read ingredients before I buy something if I'm not sure. (Clarified to how I prevent my
peanut allergy.) When did you discover your peanut allergy? Question
10/15/20 11:39 PM EDT Oh, I've had the peanut allergy since I was 4. It started right around when I started kindergarten,
I think. How severe is does the reaction get? (Clarified to How severe is your allergy?.) Question
10/15/20 11:40 PM EDT Not really. Just the itching in my mouth and stuff when I've eaten peanuts, or food made with
peanut oil or whatever. (Clarified to how severe my allergy is.) Do you have any other food allergies? Question
10/15/20 11:40 PM EDT Nope, no other food allergies. Were you ever hospitalized after a peanut allergy reaction? Question
10/15/20 11:41 PM EDT Nah, it's never been that bad. Has your breathing ever changed after a peanut allergy reaction? (No matching questions
found.) Question
10/15/20 11:42 PM EDT Has your breathing ever changed after an exposure? (Clarified to Do you experience any
breathing problems after exposure to peanuts?.) Question
10/15/20 11:42 PM EDT It doesn't really affect my breathing. The reactions are pretty mild. (Clarified to if I have breathing
problems after being exposed to peanuts.) Have you ever used an epi-pen? Question
10/15/20 11:44 PM EDT No, I've never had to. My allergic reactions aren't really the kind that need that. Question
10/15/20 11:45 PM EDT Do you drink alcohol? Nah, I'm not really interested in that. Question
10/15/20 11:45 PM EDT Do you smoke tobacco? No, I mean, not regularly . . . I guess some. Question
10/15/20 11:46 PM EDT What have you smoked? Yeah . . . Well, I have. How many cigarettes do you smoke a day? Question
10/15/20 11:46 PM EDT Really . . . not very many. Question
10/15/20 11:46 PM EDT How often do you smoke? I've had, like, three cigarettes ever. It wasn't a big deal. Question
10/15/20 11:47 PM EDT Do you chew tobacco? Ew! Like chewing tobacco. No. Is there a reason that you smoked a cigarette? (No matching questions found.) Question
10/15/20 11:48 PM EDT Was peer pressure involved in smoking? (No matching questions found.) Question
10/15/20 11:49 PM EDT Why did you decide to smoke a cigarette? Question
10/15/20 11:49 PM EDT When I smoked, I wasn't trying to impress anyone. I mean, maybe I did want to fit in, but mostly
I was just curious. My friends didn't, like, make me do it--I definitely don't want you to think that. Have you smoked a vape pen? Question
10/15/20 11:49 PM EDT No, I haven't tried that. Have you tried any illicit drugs? Question
10/15/20 11:50 PM EDT No. I've never done any drugs, ever. Do you plan on smoking in the future? (Clarified to Do you plan on smoking cigarettes again?.) Question
10/15/20 11:50 PM EDT Definitely not. I've smoked a few times, yeah. But honestly thinking about doing it again makes
me feel sick. (Clarified to if I plan on smoking cigarettes again.) Do you have friends who do drugs? (Clarified to Do your friends ever use drugs?.) Question
10/15/20 11:52 PM EDT No. I don't do drugs, and neither do my friends. (Clarified to if my friends use drugs.) Do your parents drink alcohol? Question
10/15/20 11:54 PM EDT Yeah, both my parents drink sometimes. How often do they drink? (Clarified to How often do your parents drink?.) Question
10/15/20 11:54 PM EDT Not much at all really. They'll have, like, a glass of wine at dinner. (Clarified to how often my
parents drink.) Do any of your friends drink alcohol? Question
10/15/20 11:55 PM EDT No, none of my "friends" drink. Question
10/15/20 11:55 PM EDT Do you smoke cigars? No, last I checked I wasn't an old dude. Do you know the health impacts on smoking? (Clarified to Do you know the risks of smoking?.) Question
10/15/20 11:55 PM EDT I guess I feel kinda embarrassed that I smoked, because I know all the bad stuff it does. Cancer,
emphysema, all of that. It wasn't even enjoyable really. (Clarified to if I know the health risks of
smoking.) Smoking causes cancer, heart disease, stroke, lung diseases, diabetes, and COPD. Educate
10/15/20 11:57 PM EDT Yeah . . . Thanks. Smoking also increases risk for tuberculosis, certain eye diseases, and immune system
problems Educate
10/15/20 11:58 PM EDT Right . . . Yeah, OK. Do you understand the health impacts? (Clarified to Are you aware of the potential health
consequences of smoking cigarettes?.) Question
10/15/20 11:58 PM EDT I know people die from smoking all the time, like millions of people. It causes lung cancer,
emphysema... A whole bunch of other stuff. I mean, by this point everyone must know that.
(Clarified to if I know the health risks of smoking cigarettes.) Comments
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