Shadow Health - Tina Jones, Health History Medication Exam Study Guide Solved 100%

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Medications - ANSWER Albuterol MDI, 2 puffs every 4 hours as needed for wheezing Acetaminophen 325 mg tabs by mouth, 2 tabs every 4 hours as needed for fever greater than 38.6C /101.5F Clindamycin 6... 00mg/50ml every 6 hours intravenously 0.9 NaCl intravenously 100 ml/hr continuously x2 Liters Lortab 5mg 1-2 tabs by mouth as needed for pain Oxycodone 5mg 1 tab by mouth as needed Insulin glargine 10 units at bedtime Health History Tips & Tricks: - ANSWER Student: Hello! - ANSWER Diana Shadow: Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. Student: What is the situation? - ANSWER Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Student: What are my objectives in this assessment? - ANSWER 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. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones' overall health. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones' health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. Student: What else will this exam involve? - ANSWER Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation. Student: How will I be evaluated? - ANSWER Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically. Student: How does this assignment prepare me for the real world? - ANSWER Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses. Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient's complete health history? - ANSWER Student: Getting a complete health history enables the nurse to make informed judgments about the client including formulating nursing diagnoses requiring nursing care, identifying collaborative problems requiring interdisciplinary care, medical issues requiring immediate referral, and the need for client teaching. Diana Shadow: Time to begin. - ANSWER Patient Exam - Vital Signs: - ANSWER Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98% Patient Exam - Interview: - ANSWER Student: Hello, my name is Rachel and I am your nurse today. - ANSWER Tina Jones: Hey. Student: Can you confirm your name? - ANSWER Tina Jones: Tina Jones:. Student: What brings you in today? - ANSWER Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. Student: Where is your wound located? - ANSWER Tina Jones: It's on the ball of my foot. Student: Which foot is injured? - ANSWER Tina Jones: My right foot. Student: I'm sorry to hear that. I'm glad you came in to get your foot evaluated. - ANSWER Tina Jones: Thanks a lot. Student: Can you tell me how you scraped your foot? - ANSWER I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! Student: Can you rate your current pain level on a scale of 0 to 10? - ANSWER Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. Student: Can you describe the pain? - ANSWER Tina Jones: It's throbbing and like, sharp if I try to put weight on it. Student: Have you had any other symptoms? - ANSWER 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. Student: When did you first notice the pus? - ANSWER Tina Jones: I noticed it about 2 days ago. Student: What color was the pus? - ANSWER Tina Jones: It's... white or maybe off-white. Student: Did your foot bleed? - ANSWER Tina Jones: It bled a little after I injured it. Student: How have you been treating your foot? - ANSWER Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it. Student: How have you treated the wound? - ANSWER Tina Jones: I've been taking Advil for my foot for a few days. Student: Was the Neosporin effective? - ANSWER Tina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk on your injured foot? - ANSWER Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: How effective was your pain medication at home? - ANSWER Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours. Student: Have you had any fever at home? - ANSWER Tina Jones: Yeah, I started to have one yesterday, and then it was a little better this morning. It kinda crept up all day. Student: Do you have any preexisting medical conditions? - ANSWER Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Student: I understand your foot hurts. We have to ask a lot of questions, but it's to ensure we treat your injury and anything else that could contribute to the problem. - ANSWER Tina Jones: That's kind of you. Student: When were you diagnosed with diabetes? - ANSWER Tina Jones: I was diagnosed when I was 24. Student: How do you manage your asthma? - ANSWER Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Student: What medications did you take for your diabetes? - ANSWER Tina Jones: It was metformin. Student: Do you currently take medicine for your diabetes? - ANSWER Tina Jones: No, I don't take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? - ANSWER 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. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Student: Do you monitor your blood glucose? - ANSWER Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Student: Do you get thirsty often? - ANSWER Tina Jones: You know, I did notice lately that I've been really thirsty. Student: How frequently do you urinate? - ANSWER Tina Jones: I don't know. Every hour or two when I'm awake? Student: What is your current diet? - ANSWER Tina Jones: It's pretty good, I think. I'm not a huge health nut or anything. Student: Have you had a change in appetite? - ANSWER Tina Jones: Yeah, lately I've definitely been much hungrier than usual. Student: Have you had any changes in your weight? - ANSWER Tina Jones: Yeah, I've lost some weight recently. Student: Do you know what caused your weight loss? - ANSWER Tina Jones: I don't know what caused it, I just lost weight. Student: How often do you have asthma exacerbations? - ANSWER Tina Jones: I haven't had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week. Student: What asthma symptoms have you experienced? - ANSWER Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. Student: Does anything else worsen your asthma? - ANSWER Tina Jones: Cats are the worst for my asthma--no matter what, if I'm around cats, my breathing gets bad. But sometimes it gets bad from being around dust or having to run upstairs, too. Student: Do you have a rescue inhaler? - ANSWER Tina Jones: Yeah, I use it when my asthma acts up. Student: How many puffs do you take when using your asthma inhaler? - ANSWER Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What allergies do you have? - ANSWER Tina Jones: I'm allergic to cats. Student: How long have you had a cat allergy? - ANSWER Tina Jones: For as long as I've been around. Student: What medication allergies do you have? - ANSWER Tina Jones: I'm allergic to penicillin. Student: How old were you when you had an allergic reaction from penicillin? - ANSWER Tina Jones: I don't remember....I was really young. I must have been sick or something. Student: Do you have any food allergies? - ANSWER Tina Jones: Nope, no food allergies that I know of. Student: Are you allergic to latex? - ANSWER Tina Jones: Nope. Student: Are you allergic to dust, mold, or pollen? - ANSWER Tina Jones: Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. Student: Are you up to date on all immunizations? - ANSWER Tina Jones: I'm pretty sure my shots are current, yeah. Student: What immunizations have you received? - ANSWER Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I have a record somewhere at home. Student: Have you received a flu vaccine? - ANSWER Tina Jones: No. Student: The most effective way to prevent influenza is by getting a yearly influenza vaccine and using simple infection control measures such as washing your hands. There are also antiviral medicines that can also help prevent infection if you are exposed to the flu. - ANSWER Tina Jones: ok thanks for the tip. Student: The flu vaccine is especially recommended for adults and children with chronic diseases like diabetes, or chronic lung conditions like asthma. - ANSWER Tina Jones: Gotcha. Student: Have you had any prior hospitalizations? - ANSWER Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably sixteen, though. Student: What were you admitted to the hospital for previously? - ANSWER Tina Jones: For my asthma Student: Have you had any gastrointestinal problems? - ANSWER Tina Jones: No. I've never really had stomach or bowel problems. Student: Do you have a family history of psychiatric illness? - ANSWER Tina Jones: No. They're crazy, but nobody's diagnosed with anything. Student: Do you have any neck, throat or gland problems? - ANSWER Tina Jones: No, not that I noticed. Student: Any problems with your ears? - ANSWER Tina Jones: No. Student: Any problems with your eyes and vision? - ANSWER Tina Jones: I've actually been noticing problems lately. When I'm reading or studying I'll notice that things start to get kind of blurry. Student: Do you suffer from headaches? - ANSWER Tina Jones: I get headaches sometimes, but that's all. Student: Do you wear glasses? - ANSWER Tina Jones: No. Student: Any problems with sinuses or nose? - ANSWER Tina Jones: My nose is fine right now. Sometimes it runs, but not very often. Student: Do you have problems with your mouth? - ANSWER Tina Jones: No. Student: Do you have a history of cardiovascular problems? - ANSWER Tina Jones: My heart's fine, thank God! Student: Have you had any problems with your breasts? - ANSWER Tina Jones: I haven't noticed any pain there. Student: Have you had any reproductive problems? - ANSWER Tina Jones: I don't think I have problems in that area. I just get really bad periods, that's all. Student: Have you had any neurological problems? - ANSWER Tina Jones: No, I haven't. Student: Have you had any musculoskeletal problems? - ANSWER Tina Jones: No. Student: Do you have a history of skin disorders? - ANSWER Tina Jones: Um, I have acne, if that counts. Student: Does your mother have any health issues? - ANSWER Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. Student: Does your father have any health problems? - ANSWER Tina Jones: Well, he passed away. But he had a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure. Student: I'm sorry to hear about your father's passing. - ANSWER Tina Jones: Thanks. Student: How did your father pass away? - ANSWER Tina Jones: He died in a car accident. Student: When did your father's car accident happen? - ANSWER Tina Jones: It was last year... I guess a little over a year ago. Student: Do you know what caused your dad's accident? - ANSWER Tina Jones: He was driving to work, and it was raining...and his car hydroplaned. And hit a tree. So, it was really sudden. Student: How did you cope with your fathers death? - ANSWER Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months. Student: That must have been very tough for you and your family to go through. - ANSWER Tina Jones: Student: Does your paternal grandfather have any health problems? - ANSWER Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and...I'm pretty sure he had diabetes. And high cholesterol like everyone else in my family. Student: How is your paternal grandmother's health? - ANSWER Tina Jones: Granny's doing good. She's still living on her own. She's slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy. Student: How is your maternal grandfather's health? - ANSWER Tina Jones: Well, Poppa died about five years ago. Student: How is your maternal grandmother's health? - ANSWER Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. Student: Do you have any siblings? - ANSWER Tina Jones: I have two--a brother and my little sister. Student: Does your brother have any medical conditions? - ANSWER Tina Jones: No, I don't think so. He's a healthy guy. Kind of big like me. Student: How is your sister's health? - ANSWER Tina Jones: She's pretty healthy. She has asthma too, but she almost never has attacks. Student: Does your family have a history of obesity? - ANSWER Tina Jones: No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything. [Show More]

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