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NUR 347-Health History | Completed | Shadow Health

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NUR 347-Health History | Completed | Shadow Health written by 33kris The Marketplace to Buy and Sell your Study Material On Stuvia you will find the most extensive lecture summaries written by yo... ur fellow students. Avoid resits and get better grades with material written specifically for your studies. www.stuvia.com Downloaded by: proffessor | [email protected] Distribution of this document is illegal 11/30/2017 Health History | Completed | Shadow Health 1/ 9 Health History Results | Turned In Return to Assignment Your Results Subjective Data Collection: 74 of 88 (84.1%) Lab Pass Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Indicates an item that you found. Indicates an item that is available to be found. Catego ry 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. History of Presenting Illness: Foot Wound Established chief complaint Reports pain Reports open foot wound Asked to rate pain on a scale Rates present pain at a 7 out of 10 Asked for details about the pain Describes the pain as throbbing Describes the pain as sharp when she attempts to stand Initial injury occurred 1 week ago Pain has increased in the past 2 days Reports feeling pain radiating into ankle Pain prevents bearing weight on foot Clarified location of wound Confirmed that right foot is injured Confirmed that wound is on the plantar surface of her foot Determined details of the injury Scraped foot on bottom rung of a step stool Reports no other injuries besides foot wound Was not drinking at the time of the injury Was not wearing shoes at the time of injury Has not seen a healthcare provider for the injury Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Hallway Self-Reflection Stuvia.com - The Marketplace to Buy and Sell your Study Material Downloaded by: proffessor | [email protected] Distribution of this document is illegal Stuvia.com - The Marketplace to Buy and Sell your Study Material Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the injury Reports seeing pus draining from wound Began noticing pus 2 days ago Followed up about character of drainage from the foot wound Describes pus as white or yellow in color Reports no odor from the wound Asked about home treatment of foot wound Describes wound care regimen of cleaning and bandaging Cleaned wound twice a day Cleaned wound with hydrogen peroxide Changed bandage twice a day Applied neosporin Asked about other foot wound symptoms Reports swelling around foot wound Noticed swelling getting worse in the past 2 days Reports redness around the wound Reports that the wound feels warm Explored impact of patient's foot injury on activities of daily living Pain a ects ability to walk ffects ability to walk Pain a ects job performance ffects ability to walk Pain prevented her from attending class Asked about recent fever Reports recent feverish episode Past Medical History: Diabetes Asked details about diabetes diagnosis Diagnosed as an adult Specific age of diagnosis is 24 years old Reports that her diabetes is Type 2 Asked about diabetes management through diet Reports that she tries to manage diabetes with diet Reports "staying away from sweets" Reports drinking diet coke instead of regular Asked about current diabetes medication use Does not currently take medication for diabetes Asked about past diabetes medication use Used to take diabetes medication Previous medication was prescription metformin Last use of medication was 3 years ago Downloaded by: proffessor | [email protected] Distribution of this document is illegal Stuvia.com - The Marketplace to Buy and Sell your Study Material Explored the reasons the patient stopped her diabetes regimen Reports that she "got sick of dealing with it" Downloaded by: proffessor | [email protected] Distribution of this document is illegal Stuvia.com - The Marketplace to Buy and Sell your Study Material shared via CourseHero.com This study resource was Reports disliking metformin side e ects Describes that she didn't like ffects ability to walk checking sugar and taking daily pills [Show More]

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