*NURSING > SHADOW HEALTH > Tina Jones _ Health_History_Shadow_Health | NURS 128A Shadow_Health_Subjective Data Collection: 88 o (All)

Tina Jones _ Health_History_Shadow_Health | NURS 128A Shadow_Health_Subjective Data Collection: 88 of 88 (100.0%)

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Tina Jones _ Health_History_Shadow_Health | NURS 128A Shadow_Health_Subjective Data Collection: 88 of 88 (100.0%) Health History Results | Turned In Health Assessment Lab - May 2020, NURS 198A Retu... rn to Assignment (/assignments/344427/) Subjective Data Collection: 88 of 88 (100.0%) Chief Complaint History of Presenting Illness Your Results Lab Pass (/assignment_attempts/7123602/lab_pass.p Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Care Plan Health History Tips and Tricks Self-Reflection Student Survey Indicates an item that you found. 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 yiel better patient data. The following details are facts of patient's case. Established chief complaint Reports pain Reports foot wound Asked to rate current pain level on a scale Reports current pain is 7/10 Asked for details about the pain Reports pain is throbbing Reports pain is sharp when she attempts to stand Reports pain has increased in the past 2 days Reports feeling pain radiating into ankle Reports pain prevents bearing weight on foot Asked location of wound Reports right foot is injured Reports wound is on the plantar surface of her foot Asked details of the injury Reports she scraped foot on bottom rung of a step stool Reports injury occurred 1 week ago Denies other injuries besides foot wound Reports being barefoot at the time of injury Denies seeing a healthcare provider for the injury until now Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the injury Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Support https://www.coursehero.com/file/65527118/Health-History-Tina-Jones-Shadow-Healthpdf/ This study resource was shared via CourseHero.com7/22/2020 Health History | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/7123602 2/9 Past Medical History Reports seeing pus draining from wound Reports noticing pus 2 days ago Followed up on drainage Reports pus as white or yellow Denies odor from the wound Asked about home treatment of foot wound Reports wound care regimen of bandaging Reports cleaning wound twice a day Reports applying bacitracin, neomycin and polymyxin B (Neosporin) Followed up on effectiveness of ointment Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective Asked about other foot wound symptoms Reports swelling around foot wound Reports swelling worsened 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 Reports pain affects ability to walk Reports pain affects ability to stand at work for long periods of time Reports pain prevented her from being able to walk to class Asked about preexisting medical conditions Reports diabetes Reports asthma Followed up on diabetes diagnosis Reports specific age of diagnosis was 24 Reports that her diabetes is Type 2 Asked about diabetes management through lifestyle changes Reports staying away from sweets Reports drinking diet coke instead of regular Asked about current diabetes medication use Reports that she does not currently take medication for diabetes Asked about past diabetes medication use Reports that she used to take diabetes medication Reports previous medication was prescription metformin Reports last use of medication was 3 years ago Followed up on stopping diabetes regimen Reports disliking diabetes medication side effects Reports that she didn't like checking sugar and taking daily pills Asked about blood glucose monitoring Reports infrequent blood glucose monitoring Reports she last checked blood sugar a month ago https://www.coursehero.com/file/65527118/Health-History-Tina-Jones-Shadow-Healthpdf/ Reports confusion about what the numbers mean This study resource was shared via CourseHero.com7/22/2020 Health History | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/7123602 3/9 Asked about thirst Reports increased thirst Reports increased water intake Asked about frequency of urination Reports more frequent urination Reports urinating every hour or two during the day Reports urinating 2 to 3 times during the night Asked about diet Reports eating a bowl of cereal for breakfast yesterday Reports eating mac and cheese for lunch yesterday Reports eating chicken and roll for dinner yesterday Asked about change in appetite Reports increased appetite Reports change in appetite began a month ago Asked about weight change Reports recent loss of 10 lbs Reports weight loss occurred over the past month Followed up on reason for weight change Reports weight loss was unintentional Asked about history of asthma exacerbations Reports last asthma attack was in high school Reports last exacerbation was three days ago Asked about asthma symptoms Reports chest tightness during exacerbation Reports difficulty breathing during exacerbation Reports wheezing during exacerbation Asked about prior hospitalizations Reports past hospitalizations Reports last hospitalization was for asthma Reports last hospitalization was age 16 Reports about 5 total hospitalizations for asthma as a child and teen Reports past nebulizer use Asked about asthma diagnosis Reports specific age of diagnosis is 2.5 years old Asked about asthma management Reports using an inhaler Reports inhaler is albuterol (Proventil) Reports last use of inhaler was 3 days ago Reports using inhaler no more than 2 times per week Asked about number of puffs when using asthma inhaler Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms Asked about asthma triggers Reports asthma triggered by cats https://www.coursehero.com/file/65527118/Health-History-Tina-Jones-Shadow-Healthpdf/ This study resource was shared via CourseHero.com7/22/2020 Health History | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/7123602 4/9 Reports asthma triggered by dust Denies seasonal triggers Asked about general allergies Reports allergy to cats Followed up on cat allergy symptoms Reports sneezing, itchy eyes, and wheezing Asked about latex allergy Denies latex allergy Asked about medication allergies Reports penicillin aller - - - - - - - Continued [Show More]

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