shadow health Comprehensive Health History Assignment – NR 509 Week 1
Shadow health Comprehensive Health History Assignment – NR 509 Week 1
Transcript

Brian Foster Chest Pain Shadow Health Assessment

All Lines (103)Interview Questions (85)Statements (3)Exam Actions (15)

 Height: 170 cm

 Weight: 90 kg

 BMI: 31

 Random blood glucose: 238

 Temperature: 101.1 F

 Blood pressure: 142/82

 Respiratory rate: 19

 O2 sat: 99%

 Heart rate: 86

Hallo M. Tina, my name is pam and i will taking care of you today

Hey.

how are you doing today?

Not so great… My foot really hurts right now.

im sorry to hear that can you tell me more about it

I appreciate you telling me that.

what brings you to the clinic today?

I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me! shadow health Comprehensive Health History Assignment – NR 509 Week 1

tell me about your more about the pain

It’s throbbing and like, sharp if I try to put weight on it.

how long have you been experiencing the pain?

Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.

did you see any doctor?

To be honest, I haven’t been to a doctor for just a check-up in. . . at least two years. But I did see a doctor at the ER about my foot.

were you given any medication? (Clarified to Did the ER prescribe anything?.)

Yes, they wrote me a prescription for some pain pills. (Clarified to if the ER prescribed me any medications.) shadow health Comprehensive Health History Assignment – NR 509 Week 1

what type of pain pills

It’s called tramadol.

how many mg

I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]

how often do you take it

I don’t take anything now, but I used to be on the pill.

how many pills of tramadol do you take

I take two at a time.

how often do you take it

I don’t take anything now, but I used to be on the pill.

on a scale of 1-10 how much is your pain (Clarified to On a scale of 0-10 how would you rate the pain in your right foot?.)

I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my foot pain on a scale.)

have you noticed any drainage

Yeah, there’s definitely pus.

is the pus has any color

Yeah, there’s definitely pus.

are you allergic to any medication

Yeah, I’m allergic to penicillin.

do you have food allergies

Nope, no food allergies that I know of.

do you have any environmental allergies

No, unless cats count.

tell me about the cat allergy

Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. shadow health Comprehensive Health History Assignment – NR 509 Week 1

do you take anything for the allergies

I don’t take anything, unless my inhaler counts.

do you have any other medical conditions

Um, the only things I know I’m diagnosed with are diabetes. And asthma.

do you take anything for diabetes

I don’t take anything for my diabetes anymore.

how do you control your diabetes

I just watch what I eat and try to stay away from sweets.

do you take any asthma medication

I just use my inhaler.

what is the name of your inhaler

It’s just a regular Proventil inhaler.

how many mg

I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]

how many cg is your inhaler (Clarified to How many times did you use your inhaler?.)

Question

03/08/20 3:59 PM PDT

At my cousin’s? I did two puffs, and then I had to do another one a little later. . . that’s been happening sometimes lately. (Clarified to how many times I used my inhaler.)

do you have any medical history
shadow health Comprehensive Health History Assignment – NR 509 Week 1

Yeah. . . I have asthma and diabetes.

does your family have any medical history

My mom has some issues, and I think some of my grandparents did, too.

what kind of issues does you mother have

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

any other medical history in the family (Clarified to What health problems run in your family?.)

My mom has some issues, and I think some of my grandparents did, too. (Clarified to what health problems run in my family.)

does you father have any medical issues

Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.

do you smoke?

No. I think it’s gross.

do you drink alcohol

I do sometimes, yeah, when I go out with my friends.

how many drinks do you have when you drink

Just a few. I’m not a big drinker.

do you take any illegal drugs

Well, I used to smoke pot. . . but I don’t do that anymore.

do your friends smoke pot

Yeah, a couple of my friends smoke when we go out. I don’t like being around smokers, though.

what do you plan to stop smoking with your friends

I’m pretty optimistic about the future actually. In a couple of months I’ll have my degree, and I’ll probably get my own place again. I’m planning on trying for one of the accounting jobs in our regional office, too. If that works out, I would like to start dating again… maybe I’ll find someone I want to marry, start a family with?

do you have shortness of breath

No, my breathing is fine right now.

are you in pain

Yeah, my foot’s really bothering me.

what makes it worse

I’d say the pain is at its worst when I have to put any weight on my foot. . . otherwise, it’s when the pain pills wear off.

can i take a look on your foot (Clarified to May I take a look at your foot now?.)

Ok. (Clarified to permission to examine my foot.)

tell me if you fill the pork (No matching questions found.)

tell me if you fill the prick (No matching questions found.)

how often do you take the pain medication

I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]

how old are you

I’m 28.

let me listen to you lungs (No matching questions found.)

Question

03/08/xx  4:11 PM PDT

do you have any problem with your eyes

Question

03/08/xx 4:12 PM PDT

I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.

have you seen an eye doctor

Question

03/08/xx 4:12 PM PDT

I have a couple times as a kid, by the school nurse. Not recently though.

do you wear glasses

Question

03/08/xx 4:12 PM PDT

I don’t wear glasses–or contacts.

do you have any chest pain

Question

03/08/xx 4:13 PM PDT

No, my chest feels tight when I have breathing problems, but it doesn’t hurt.

have you seen a heart doctor

Question

03/08/xx 4:13 PM PDT

No, my heart’s always been fine.

how is your abdomen

Question

03/08xx 4:14 PM PDT

My stomach feels fine.

have you heard any problems with elimination (Clarified to Do you have difficulty moving your bowels?.)

Question

03/08/xx 4:14 PM PDT

No. No problems like that. (Clarified to if I have trouble moving my bowels.)

any pain on urination

Question

03/08/xx 4:14 PM PDT

It doesn’t hurt or feel different when I pee.

do you check blood sugar (Clarified to Do you check your sugars often?.)

Question

03/08/xx 4:15 PM PDT

I don’t check it very often, honestly. . . I think the last time was about a month ago. (Clarified to if I check my blood sugar often.)

i see bs is 238 (No matching questions found.)

Question

03/08/xx 4:15 PM PDT

your blood sugar is elevated

Question

03/08/xx 4:15 PM PDT

They checked it last week at the ER, and they said it was high, but I don’t remember what the number was. I wasn’t thinking about my blood glucose; I was worried about my foot!

 Measured wound: 2 cm x 1.5 cm, 2.5 mm deep

Exam Action

03/08/xx 4:16 PM PDT

let me take look of your foot (Clarified to Can I look at your foot?.)

Question

03/08/xx 4:16 PM PDT

Sure. (Clarified to if I can show you my foot.)

i see it is open , let me know if you feel pain (No matching questions found.)

Question

03/08/xx 4:17 PM PDT

 Swabbed wound and sent to lab for C & S

Exam Action

03/08/xx 4:17 PM PDT

 Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

Exam Action

03/08/xx 4:17 PM PDT

i will take a look of your pupils is that okay (No matching questions found.)

Question

03/08xxx 4:18 PM PDT

you need to keep your foot off the ground

Educate

03/08/xx 4:19 PM PDT

Sure, I think I understand what you mean.

how long does the pain last

Question

03/08/xx 4:20 PM PDT

For the last couple of days, the pain is pretty much constant.

do you have any cough

Question

03/08/xx 4:26 PM PDT

I don’t have a cough, no.

any chills

Question

03/08/xx 4:26 PM PDT

I got some chills last night, before my fever really kicked in.

ear ache

Question

03/08/xx 4:27 PM PDT

No.

when was your last menstrual period

Question

03/08/xx 4:28 PM PDT

I don’t keep track very well because it’s kind of all over the map, but my last one was probably three weeks ago.

is it heavy bleeding or normal (No matching questions found.)

Question

03/08/xx 4:29 PM PDT

describe the bleeding to me (No matching questions found.)

Question

03/08/xx 4:29 PM PDT

are they regular (No matching questions found.)

Question

03/08/xx 4:30 PM PDT

do you have regular period

Question

03/08/xx 4:30 PM PDT

It’s not regular. Sometimes it’s every month, but sometimes it’s more like every two months. I don’t write it down or anything. I probably get…six periods a year.

do you have any other concerns

Question

03/08/xx 4:32 PM PDT

Um, the only things I know I’m diagnosed with are diabetes. And asthma.

have you been taking any OTC medication (Clarified to Do you take over the counter medications a lot?.)

Question

03/08/xx 4:35 PM PDT

No, I only take Advil when my cramps get bad, and sometimes Tylenol for headaches. Lately I’ve been taking Advil for my foot, too. (Clarified to if I take over the counter medication a lot.)

how many mg of tylenol

Question

03/08/xx 4:35 PM PDT

I take the extra-strength acetaminophen, the gel kind, 500 mg. It’s what we usually have around the house. [AUDIO COMING SOON]

how often do you take tylenol

Question

03/08/xx 4:36 PM PDT

I maybe take it once a week. Or less.

you mentioned you take advil how many mg? (Clarified to Can you tell me the dosage of the ibuprofen?.)

Question

03/08/xx 4:36 PM PDT

I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON] (Clarified to how many milligrams of ibuprofen I take.)

have you notice any weight gain in last month

Question

03/08/xx 4:37 PM PDT

Usually my weight’s pretty stable, but I’ve actually lost a little weight recently.

it is important to check your blood sugar often and record it

Educate

03/08/xx 4:44 PM PDT

OK, I understand.

try to not weight on your right foot while walking

Question

03/08/xx 4:45 PM PDT

No, I can’t. I can’t put any weight on it without like, shooting pain.

make sure you clean the wound with normal saline and cover it with clean dressing

Question

03/08/xx 4:46 PM PDT

Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.

you want to keep it as clean as possible (No matching questions found.)

Question

03/08/xx 4:46 PM PDT

report any drainage or any foul smell

Question

03/08/xx 4:47 PM PDT

Um, no, not that I know of… That sounds gross.

notify the clinic if you have a any chills

Question

03/08/xx 4:47 PM PDT

I got some chills last night, before my fever really kicked in.

always wear shoes when you are walking (Clarified to Are you able to wear shoes normally?.)

Question

03/08/xx 4:48 PM PDT

My sneakers are too tight, so I’ve been wearing flip-flops at home, or slip-ons. (Clarified to if I can wear shoes.)

inspect you feet daily since you are diabetic (No matching questions found.)

Question

03/08/xx 4:48 PM PDT

protect your feet from cold

Question

03/08/ 4:49 PM PDT

Not really.

you need to also wear comfortable shoes (No matching questions found.)

Question

03/08/20 4:50 PM PDT

do you have problem sleeping

I usually sleep pretty well, but the last couple nights the pain has made it hard to get good sleep.

 Measured wound: 2 cm x 1.5 cm, 2.5 mm deep

 Swabbed wound and sent to lab for C & S

 Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

 
Subjective Data Collection: 45 of 104 (43.3%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Found:
Indicates an item that you found.

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Available:
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

Finding:
Established chief complaint

Finding:
Reports pain
(Found)
Pro Tip: Beginning your conversation with your patient by asking an open-ended question is a best practice for gauging your patient’s general condition.
Example Question:
How severe is the pain?

Finding:
Reports open foot wound
(Found)
Pro Tip: If a patient mentions pain, it’s important to determine what specifically is causing her pain.
Example Question:
What’s causing your pain?

History of Present Illness

Finding:
Asked for details about the pain

Finding:
Describes the pain as throbbing
(Found)
Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.
Example Question:
Can you please describe the pain?

Finding:
Describes the pain as sharp when she attempts to stand
(Found)
Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.
Example Question:
What is the pain like when you stand on your foot?

Finding:
Initial injury occurred 1 week ago
(Found)
Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute.
Example Question:
When did the pain start?

Finding:
Pain has increased in the past 2 days
(Found)
Pro Tip: Finding out how the patient’s pain has changed will give you insight into the acceleration of infection.
Example Question:
How has the pain changed over time?

Finding:
Reports feeling pain radiating into ankle
(Available)
Pro Tip: Asking about where else the patient’s pain radiates can help determine the progression of infection.
Example Question:
Does the pain radiate anywhere else?

Finding:
Pain prevents bearing weight on foot
(Found)
Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care.
Example Question:
Can you bear weight on your foot?

Finding:
Asked to rate pain on a scale

Finding:
Rates present pain at a 7 out of 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:
Can you rate the pain on a scale of 0 to 10?

Finding:
Clarified location of wound

Finding:
Confirmed that right foot is injured
(Available)
Pro Tip: Confirming which extremity an injury is located is a best practice for your patient’s safety.
Example Question:
Which foot is in pain?

Finding:
Confirmed that wound is on the plantar surface of her foot
(Available)
Pro Tip: Confirming where a wound is located ensures you are aware of your patient’s biggest complaint.
Example Question:
Where is the wound?

Finding:
Determined details of the injury

Finding:
Scraped foot on a cement step
(Available)
Pro Tip: Discovering how an injury happened helps to assess your patient’s risk factors for injury.
Example Question:
How did your injury happen? shadow health Comprehensive Health History Assignment – NR 509 Week 1

Finding:
Reports mild ankle injury
(Available)
Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury.
Example Question:
Did you injure anything besides your foot?

Finding:
Was not drinking at the time of the injury
(Available)
Pro Tip: Finding out if alcohol is involved in an injury can give you insight into a patient’s potential substance abuse, and can uncover aggravating factors.
Example Question:
Did you have any alcoholic drinks before your injury?

Finding:
Was not wearing shoes at the time of injury
(Available)
Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances.
Example Question:
Were you wearing shoes when you fell?

Finding:
Asked about the assessment of the injury at the ER

Finding:
Went to the ER after sustaining the injury
(Available)
Pro Tip: Finding out how long ago a patient sought care helps you understand the evolution of symptoms.
Example Question:
When did you go to the ER?

Finding:
Decided to go because she suspected an ankle sprain
(Available)
Pro Tip: Asking why a patient sought care gives you more information about the initial injury and symptoms. shadow health Comprehensive Health History Assignment – NR 509 Week 1
Example Question:
Why did you go to the ER?

Finding:
Received an x-ray
(Available)
Pro Tip: Determining what procedures were done by other healthcare providers gives insight into the symptoms at the onset.
Example Question:
Did they xray your foot at the ER?

Finding:
X-ray showed no broken bones
(Available)
Pro Tip: Confirming the results of the x-ray gives you a subjective report of the seriousness of the initial injury.
Example Question:
What did the x-ray show?

Finding:
Received a prescription for pain pills
(Found)
Pro Tip: Finding out if the patient has been prescribed medications is an important piece of data for your own care plan.
Example Question:
Did you receive any pain medications at the ER?

Finding:
Asked about drainage from the foot wound

Finding:
Reports that the wound bled a little after sustaining the injury
(Available)
Pro Tip: Asking about bleeding helps you determine the characteristics of a wound.
Example Question:
Did your foot bleed?

Finding:
Reports seeing pus draining from wound

(Found)
Pro Tip: Asking about discharge helps you determine the characteristics of a wound.
Example Question:

shadow health Comprehensive Health History Assignment – NR 509 Week 1

Did you notice any discharge from the wound?

Finding:
Began noticing pus 2 days ago
(Available)
Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began.
Example Question:
When did you first notice the pus?

Finding:
Followed up about character of drainage from the foot wound

Finding:
Describes pus as white or yellow in color
(Available)
Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics. shadow health Comprehensive Health History Assignment – NR 509 Week 1
Example Question:
What color is the drainage from your wound?

Finding:
Reports no odor from the wound
(Found)
Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics.
Example Question:
Does the wound have an odor?

Finding:
Asked about home treatment of foot wound

Finding:
Describes wound care regimen of cleaning and bandaging
(Found)
Pro Tip: Listening to a patient’s wound care routine provides insight into the history of the wound, as well as the patient’s health literacy.
Example Question:
How did you treat your foot at home?

Finding:
Cleaned 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.
Example Question:
How often did you clean the wound?

Finding:
Cleaned wound with hydrogen peroxide
(Found)
Pro Tip: Determining what products a patient used to clean a wound provides insight into the history of the wound, as well as the patient’s health literacy.
Example Question:
What did you use to clean the wound?

Finding:
Changed bandage twice a day
(Available)
Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.
Example Question:
How often do you change your bandage?

Finding:
Applied neosporin
(Available)
Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy.
Example Question:
Did you use any ointment on the wound?

Finding:
Asked about other foot wound symptoms

Finding:
Reports swelling around foot wound
(Available)
Pro Tip: Asking about the presence of swelling helps you gather information about your patient’s complaint, as well as potential related illnesses.
Example Question:
Is there swelling around the wound?

Finding:
Noticed swelling getting worse in the past 2 days
(Available)
Pro Tip: Finding out how long swelling appeared will help you understand the timeline for the infection’s progression.
Example Question:
How long have you noticed swelling around the wound? shadow health Comprehensive Health History Assignment – NR 509 Week 1

Finding:
Reports redness around the wound
(Available)
Pro Tip: Asking about redness will help you understand the timeline for the infection’s progression.
Example Question:
Did you notice any redness around the wound?

Finding:
Reports that the wound feels warm
(Available)
Pro Tip: Asking about warmth will help you understand the timeline for the infection’s progression.
Example Question:
Does the wound feel warm?

Finding:
Explored impact of patient’s foot injury on activities of daily living

Finding:
Pain affects ability to walk
(Available)
Pro Tip: Learning the impact of your patient’s wound on daily activities helps inform your plan for care.
Example Question:
Does your injury impact your ability to walk?

Finding:
Pain affects job performance
(Available)
Pro Tip: Learning how severely the wound has interfered with an essential aspect of daily life, and can uncover a source of stress for the patient.
Example Question:
Does your foot pain affect your work?

Finding:
Pain prevented her from attending class
(Available)
Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don’t fall behind.
Example Question:
Has your injury prevented you from going to class?

Finding:
Asked about recent fever

Finding:
Reports a fever last night
(Found)
Pro Tip: The presence or absence of fever can indicate if an infection is approaching sepsis, a life-threatening condition. shadow health Comprehensive Health History Assignment – NR 509 Week 1
Example Question:
Are you feeling feverish right now?

Medical History: Medication

Finding:
Asked about use of pain medication

Finding:
Has been taking prescription pain medication
(Found)
Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury.
Example Question:
Have you taken any prescription pain medications? shadow health Comprehensive Health History Assignment – NR 509 Week 1

Finding:
Medication is Tramadol
(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.
Example Question:
What is the name of the pain medication?

Finding:
Asked about pain medication frequency

Finding:
Has been taking pain medication for 2 days
(Available)
Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury.
Example Question:
How many days have you needed pain medication?

Finding:
Takes dose 3 times a day
(Found)
Pro Tip: The frequency with which your patient takes pain medication can indicate the severity of her condition or injury.
Example Question:
How many times a day do you take pain medication?

Finding:
Last dose was this morning
(Available)
Pro Tip: Confirming the patient’s most recent dose sheds insight into her current pain level, and lets you know what substances may be in her system.
Example Question:
When was your last dose of pain medication?

Finding:
Asked about pain medication dose

Finding:
Dosage is 50 milligrams
(Available)
Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. shadow health Comprehensive Health History Assignment – NR 509 Week 1
Example Question:
What is the dose of the pain medication?

Finding:
Takes 2 pills each time

 
Education & Empathy : 2 of 11 (18.2%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

 1 Expression of pain
Followed Up

 Description: Tina expresses frustration about her level of pain.

how are you doing today?

Question

03:45 PM PDT

Not so great… My foot really hurts right now.

im sorry to hear that can you tell me more about it

Empathize

03:46 PM PDT

I appreciate you telling me that.

 Model Statement: “I’m sorry to hear that your pain is returning. We want you to be in as little pain as possible. Together we can figure out the best way to reduce your pain quickly.”

 2 Impact of injury on daily life
Not Encountered

 3 Gaps in health literacy around diabetic diet
Not Followed Up

 4 Lack of treatment with diabetes medication
Not Followed Up

 5 Lack of blood glucose monitoring
Followed Up shadow health Comprehensive Health History Assignment – NR 509 Week 1

 Description: Tina reveals that she does not check her blood sugar.

do you check blood sugar (Clarified to: Do you check your sugars often?)

Question

04:15 PM PDT

I don’t check it very often, honestly. . . I think the last time was about a month ago. (Clarified to: if I check my blood sugar often)

your blood sugar is elevated

Question

04:15 PM PDT

They checked it last week at the ER, and they said it was high, but I don’t remember what the number was. I wasn’t thinking about my blood glucose; I was worried about my foot!

let me take look of your foot (Clarified to: Can I look at your foot?)

Question

04:16 PM PDT

Sure. (Clarified to: if I can show you my foot)

you need to keep your foot off the ground

Educate

04:19 PM PDT

Sure, I think I understand what you mean.

 Model Statement: “I understand how it can feel like a frustrating chore to check your sugar every day. But it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more about what the numbers mean.

 
 
Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation
Model Documentation

Identifying Data & Reliability
Tina is a 28 year old female with chief complaint of right foot wound
shadow health Comprehensive Health History Assignment – NR 509 Week 1

Return to Canvas to complete your SOAP note for this assignment shadow health Comprehensive Health History Assignment – NR 509 Week 1

General Survey
patient has wound to the bottom of the foot, complains of pain when she bears weight

Return to Canvas to complete your SOAP note for this assignment

Chief Complaint
right foot pain

Return to Canvas to complete your SOAP note for this assignment

 
 
 
Information Processing

Each relevant diagnosis is scored on a four-point scale:

Priority (1 point): the correct priority of the diagnosis was chosen
Evidence (up to 2 points): the strength of the patient cue(s) selected as evidence for the identified diagnosis

Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points
Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point

Planning (1 point): the plan proposed to address the diagnosis includes at least one correct component

Relevant Diagnoses

 1. Acute pain of the foot
2 of 4 points

Priority 1 / 1

Student Response:  High
Correct Priority: High

 Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain.

Evidence 0 / 2

Relevant
(None provided)
Irrelevant
“Measured wound: 2 cm x 1.5 cm, 2.5 mm deep”

 Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute.

Planning 1 / 1

Relevant
Educate – Medication: Educate the patient on medications used for pain relief.
Educate – Medication: Educate the patient on non-pharmaceutical methods to reduce pain intensity.
Irrelevant
Assess – Integumentary: Assess wound parameters (size, depth).
Intervene – Labs: Obtain a wound culture.
Intervene – Labs: Obtain blood for culture x2 (blood from two sites).
Intervene – Labs: Order a complete blood count test (CBC).
Intervene – Prescribe: Prescribe antibiotics.

 Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation). shadow health Comprehensive Health History Assignment – NR 509 Week 1

 2. Local infection of skin and subcutaneous tissue of the foot
2 of 4 points

Priority 1 / 1

Student Response:  High
Correct Priority: High

 Priority Pro Tip: Treating this infection is a high priority, as failure to treat the infection may lead to it spreading to surrounding tissues or systemically. Treating the infection can prevent adverse events such as osteomyelitis and bacteremia.

Evidence 0 / 2

Relevant
(None provided)
Irrelevant
“M

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