Priority – Low Priority Pro Tip: When caring for a patient diagnosed with asthma, it’s important to be aware of the possibility of emerging respiratory symptoms. 81 terms. ", 2.Impact of injury on daily life Followed Up, Description: Tina brings up her pain and frustration at how being unable to bear weight on her foot impacts her life. Finding: Reports pain (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. I can give you some Advil at this time, and in a few hours, you can have more tramadol. Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem. Finding: Reports past condom use (Available)Pro Tip: Asking about a patient’s past condom use is one possible component of a review of systems interview. Student: Do you know why you lost weight? I know I need sleep, too. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint. Finding: Reports ER administered pain medication (Found)Pro Tip: The differences between prescription and over-the-counter pain medications can be vast and asking about the type of pain medication your patient has been using will help you fully understand her home treatment habits. Priority – High Priority Pro Tip: The patient’s foot wound impairs her walking, which in turn increases her risk for falls while she is an admitted patient. Finding: Reports fever (Available)Pro Tip: Asking about additional symptoms, such as fever, is one possible component of a review of systems interview. Finding: Asked about other foot wound symptoms. This numerical evidence is required to establish obesity. Example Question: What’s the most puffs you ever take? Finding: Reports last penicillin reaction was in childhood (Available)Pro Tip: Determining a patient’s last reaction to penicillin is part of gathering thorough information about her allergy. megan_droste PLUS. Reports no general ear problems, no change in hearing, ear pain, or discharge. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint. x. Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care. Example Question: Does your foot pain affect your work? Educate – Disease Process: Educate the patient on health risks related to obesity. Student: Do you have any problems with your head? Asking Tina if her mother had high cholesterol can reveal generational patterns. Example Question: Have you experienced any type of abuse? Finding: Denies edema (Available)Pro Tip: Asking about edema is one possible component of a review of systems interview. Within the Shadow Health platform, complete the Comprehensive Assessment. Finding: Asked about maternal grandmother’s health. Example Question: Does your mother have health conditions? Example Question: Do you have any lumps in your breasts? Asking Tina whether she’s experienced poor circulation indicates whether she might suffer from underlying cardiac concerns. Tina’s diabetes diagnosis will have a large impact on her body’s healing ability, which should be taken into consideration during your exam. Example Question: At what age were you diagnosed with diabetes? Example Question: What is the pain like when you stand on your foot? The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint. While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patient’s mobility. Finding: Denies current breathing problems (Available)Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns. Finding: Reports cleaning wound twice a day (Available)Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. ( ) Courses, modules, and textbooks for your search: Press Enter to view all search results ( ) Example Question: Are your periods regular? Tina Jones: I don’t know what caused it, I just lost weight. NR 509 Week 1 Assignment: Shadow Health History Assignment entails conducting a comprehensive health history on Tina Jones. Bruising easily can be indicative of anemia or a more serious blood disorder. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. Example Question: Do you have any breast swelling? Tina Jones: Last year when Dad passed, he was only 58. Finding: Reports diabetes (Found)Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. The patient’s response to questions about this topic may uncover additional problems, such as hearing loss, not discovered during the discussion of the patient’s chief complaint. As a currently presenting symptom, it could result in a change to the patient’s care plan. Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient’s most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient’s condition and effectiveness of any treatments. Finding: Denies dry eyes (Available)Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Finding: Asked if the patient received a tetanus immunization. Student: Do you have problems with your mouth? Finding: Denies loss of sensation (Available)Pro Tip: Diabetic patients often experience numbness due to neuropathy, especially in the arms, legs, hands, and feet. "I have a monitor at home, but to be honest I don’t really use it that often." Model Statement: "Staying away from sugar is a great start. Priority – High Priority Pro Tip: Poorly managed diabetes and uncontrolled blood glucose complicate wound healing. Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. If the patient reports a history of gas, it could be a symptom of dietary or gastrointestinal problems. Finding: Denies latex allergy (Available)Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts. Example Question: Does the wound feel warm? Tina Jones: Granny’s doing good. Tina Jones: I mean, it’s all red and swollen, and there’s pus, it feels hot, it hurts like hell… It’s got all that going on. Finding: Reports using inhaler no more than 2 times per week (Available)Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition. Finding: Asked about patient belief system. Example Question: Do you take any over the counter medications? Example Question: Do you have relatives with addiction problems? Student: Have you used drugs other than marijuana? Example Question: Do you wake up at night to urinate? i See more info. Example Question: How old was your father when he died? Example Question: Have you had a runny nose? NR 509 Shadow Health Comprehensive Assessment SOAP NOTE Last document update: ago . Diana Shadow: A health history requires you to ask questions related to Ms. Jones’ past and present health, from her current foot wound to her pre-existing conditions. Tina Jones: …Like a 7. Finding: Denies tingling (Available)Pro Tip: Asking about tingling sensations is one possible component of a review of systems interview. Asking Tina if her maternal grandfather had high blood pressure can reveal generational patterns. Finding: Denies past pregnancies (Available)Pro Tip: A patient’s history of pregnancy can shed light on other health conditions, body systems, or risk factors. Finding: Followed up on home pain medication. Example Question: What’s preventing you from taking your diabetes medication? Example Question: How has the pain changed over time? The patient’s response to these questions may uncover additional problems, such as nerve damage. Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. Finding: Reports taking ibuprofen (Advil) at home (Found)Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury. Planning Pro Tip: To reduce the patient’s pain, assess her current rating. Example Question: How effective is the pain medication? Work with our consultant to learn what to alter, Shadow Health – Tina Jones, Health History. Example Question: Does it hurt when you breathe? Example Question: Did you receive the chicken pox vaccine? Asking Tina if her maternal grandmother had high blood pressure can reveal generational patterns. Student: How many puffs do you take when using your asthma inhaler? Your guide to the Shadow Health ... Health Assessment Student Handbook. Example Question: Have you noticed any changes in your vision? Asking Tina if her maternal grandfather had high cholesterol can reveal generational patterns. Tina Jones: I don’t know. My foot slid off the bottom step and it got all scraped up. 10/27/2020 Abdominal | Completed | Shadow Health … Pay close attention to this information as it will help guide your exam. Finding: Reports maternal grandfather diagnosed with high blood pressure (Available)Pro Tip: Family histories might indicate a genetic predisposition. In Tina’s case, it will help you better understand her asthma and create a timeline. Example Question: How often do you urinate during the day? Finding: Denies swollen glands (Found)Pro Tip: Asking about a patient’s glands in general could include lymph nodes or thyroid glands. Finding: Asked review of systems for reproductive. Finding: Denies frequent sore throat (Available)Pro Tip: Asking if a patient has recurring throat problems is one possible component of a review of systems interview. Subjective. Evidence – Relevant: Evidence Pro Tip: Tina directly reports that she doesn’t exercise, which is the primary evidence for a sedentary lifestyle. Finding: Reports she scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient’s risk factors for injury. comprehensive assessment results turned in health assess spring 2020, 322301 return to assignment your results lab pass subjective data Any recent or abrupt changes could impact the patient’s care plan, such as administering treatment for constipation or diarrhea. but I don’t do that anymore. You also want to identify any potential issues with substance abuse. Shadow Health Final. Finding: Reports that penicillin resulted in hives (Available)Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening. Finding: Reports maternal grandfather diagnosed with high cholesterol (Available)Pro Tip: Family histories might indicate a genetic predisposition. Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment. This will involve gathering Subjective Data, Objective Data,Physical Assessment of various body systems, Differential Diagnosis and creating a Treatment Plan for Tina Jones. Evidence – Relevant: "…Like a 7. Other supporting evidence is her recent injury caused by falling. Finding: Denies lumps (Available)Pro Tip: Asking about abnormal characteristics of a patient’s breasts, such as lumps, is one way of assessing overall breast health. As a currently presenting symptom, it could impact the patient’s care plan. Make sure that the patient feels comfortable asking for your assistance. That sounds like a difficult situation. Intervene – Diet: Provide the patient a diet without concentrated sweets. Finding: Asked about use of pain medication. Tina Jones: 28 year-old female, admitted Example Question: Do you ever notice blood in your urine? Finding: Denies current chest tightness (Available)Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. Example Question: Does your father have health conditions? 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