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Health History Results | Turned In
Spring 2025 - NSG 323 - Session 1
Return to Assignment (/assignments/1087170/)
Your Results Student Results Book (/assignments/1087170/results_books/1087170?se
Lab Pass (/assignment_attempts/18271667/lab_pass.pdf)
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Nursing Notes Flowsheets
Education & Empathy
Documentation
Nursing Notes
Interpret Findings Student Documentation Model Documentation
SBAR Chief Complaint
Video Tutorial Scrape on ball of right foot that has been present for a Wound to right foot, pain, fever
week.
Health History Tips and Tricks
Reflection Questions
Ms. Jones is a 28-year-old female who presented to the
emergency department for evaluation of a right foot injury
and was admitted for IV antibiotics. She is a good
historian. She injured the plantar surface of her right foot
by scraping it on the edge of a metal step while changing
a light bulb.
The injury occurred about one week ago. She rates her
pain as 7/10. She states the pain has worsened over the
History of Present Illness past 2 days and is radiating into her ankle. The swelling
has persisted.
Scape on foot occured a week ago. As of two days ago,
patient noticed white pus coming from the wound, iis red She tried ibuprofen with minimal relief. The foot feels
and warm to the touch. The pain feels sharp and better when she rests, and it hurts more when she
throbbing. Over the past few days the patient has taken ambulates. She has been cleaning and bandaging the
ibuprofen with no relief. wound twice daily and applying bacitracin, neomycin, and
polymyxin B ointment without improvement.
She took her temperature at home and reported it was as
high as 38.9 degrees Celsius. She has not been eating
much and has been staying in bed the last few days, per
patient report. The scrape is red and swollen with
exudate and has no odor; she reports the swelling and
exudate started two days ago. Pain improved with
oxycodone.
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:28:33 GMT -06:00
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Allergies • Penicillin: rash
• Cats: wheezing, itchy watery eyes, snee
Cats and dust- triggers her asthma, causes wheezing, sneezing, itchy eyes • Dust: wheezing, itchy watery eyes, snee
Penicillin- broke out in hives after recieving it when she was two years old • No food allergies
• Not allergic to latex
Immunizations
States she has recieved childhood immunizations. Up-to-date. Received tetanus and HPV va
Received tetanus booster about a year ago. Received COVID vaccination. Denies rece
Has had covid vaccination.
Has not received the influenza vaccine
Medications • Albuterol 90 mcg/spray MDI, 1-3 puffs, a
• Acetaminophen 500 mg tabs by mouth,
Uses an inhaler for asthma. Occassional ibuprofen use for cramps. Denies or headache
use of supplements • Ibuprofen 200 mg tabs by mouth, 3 – 4 t
needed for pain
Asthma diagnosed at age 2 1/2. She uses
experiences exacerbations, such as from
more than twice a week. She was expose
Past Medical History to use her inhaler once. She is prescribed
having to use 3 puffs occasionally, but usu
Has asthma and diabetes. Is not taking medication to manage her diabetes hospitalized for asthma in high school. Ne
and is not regularly monitoring her blood glucose levels. diagnosed at age 24. She used to take me
to gastrointestinal problems. She doesn’t
last seen by a primary care doctor a few y
was over two years ago. Last eye exam w
Never married, no children. Lived indepen
lives with mother and sister to support fam
ago, anticipates moving out in a few mont
at home and denies any history of abuse.
She works 32 hours/week as a supervisor
company and is in her last semester of a b
Social History She hopes to advance to an accounting p
car, cell phone, and computer. She receiv
No tobacco or drug use. work, but is deterred from healthcare due
Drinks alcohol a couple times a month when out with friends.
She is very active in her Baptist church, fa
church community is a large part of her so
wears her seat belt, drives frequently. Gun
Occasional alcohol (10 - 12 drinks/month)
Occasional cannabis use from age 15 to a
caffeinated drinks/day (diet soda). No fore
in an intimate relationship. She plans on g
children someday. She denies suicidal an
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:28:33 GMT -06:00
2 2 first-attempt success and A+ Grade
https://www.cliffsnotes.com//study-notes/24378448
Health History Results | Turned In
Spring 2025 - NSG 323 - Session 1
Return to Assignment (/assignments/1087170/)
Your Results Student Results Book (/assignments/1087170/results_books/1087170?se
Lab Pass (/assignment_attempts/18271667/lab_pass.pdf)
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Nursing Notes Flowsheets
Education & Empathy
Documentation
Nursing Notes
Interpret Findings Student Documentation Model Documentation
SBAR Chief Complaint
Video Tutorial Scrape on ball of right foot that has been present for a Wound to right foot, pain, fever
week.
Health History Tips and Tricks
Reflection Questions
Ms. Jones is a 28-year-old female who presented to the
emergency department for evaluation of a right foot injury
and was admitted for IV antibiotics. She is a good
historian. She injured the plantar surface of her right foot
by scraping it on the edge of a metal step while changing
a light bulb.
The injury occurred about one week ago. She rates her
pain as 7/10. She states the pain has worsened over the
History of Present Illness past 2 days and is radiating into her ankle. The swelling
has persisted.
Scape on foot occured a week ago. As of two days ago,
patient noticed white pus coming from the wound, iis red She tried ibuprofen with minimal relief. The foot feels
and warm to the touch. The pain feels sharp and better when she rests, and it hurts more when she
throbbing. Over the past few days the patient has taken ambulates. She has been cleaning and bandaging the
ibuprofen with no relief. wound twice daily and applying bacitracin, neomycin, and
polymyxin B ointment without improvement.
She took her temperature at home and reported it was as
high as 38.9 degrees Celsius. She has not been eating
much and has been staying in bed the last few days, per
patient report. The scrape is red and swollen with
exudate and has no odor; she reports the swelling and
exudate started two days ago. Pain improved with
oxycodone.
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:28:33 GMT -06:00
1 1 first-attempt success and A+ Grade
https://www.cliffsnotes.com//study-notes/24378448
, Student
Start Documentation
your exams prepared!: 2026/2027// Q&A Model Documentation
2026///2027 #studyguide. // Start your exams prepared!
Allergies • Penicillin: rash
• Cats: wheezing, itchy watery eyes, snee
Cats and dust- triggers her asthma, causes wheezing, sneezing, itchy eyes • Dust: wheezing, itchy watery eyes, snee
Penicillin- broke out in hives after recieving it when she was two years old • No food allergies
• Not allergic to latex
Immunizations
States she has recieved childhood immunizations. Up-to-date. Received tetanus and HPV va
Received tetanus booster about a year ago. Received COVID vaccination. Denies rece
Has had covid vaccination.
Has not received the influenza vaccine
Medications • Albuterol 90 mcg/spray MDI, 1-3 puffs, a
• Acetaminophen 500 mg tabs by mouth,
Uses an inhaler for asthma. Occassional ibuprofen use for cramps. Denies or headache
use of supplements • Ibuprofen 200 mg tabs by mouth, 3 – 4 t
needed for pain
Asthma diagnosed at age 2 1/2. She uses
experiences exacerbations, such as from
more than twice a week. She was expose
Past Medical History to use her inhaler once. She is prescribed
having to use 3 puffs occasionally, but usu
Has asthma and diabetes. Is not taking medication to manage her diabetes hospitalized for asthma in high school. Ne
and is not regularly monitoring her blood glucose levels. diagnosed at age 24. She used to take me
to gastrointestinal problems. She doesn’t
last seen by a primary care doctor a few y
was over two years ago. Last eye exam w
Never married, no children. Lived indepen
lives with mother and sister to support fam
ago, anticipates moving out in a few mont
at home and denies any history of abuse.
She works 32 hours/week as a supervisor
company and is in her last semester of a b
Social History She hopes to advance to an accounting p
car, cell phone, and computer. She receiv
No tobacco or drug use. work, but is deterred from healthcare due
Drinks alcohol a couple times a month when out with friends.
She is very active in her Baptist church, fa
church community is a large part of her so
wears her seat belt, drives frequently. Gun
Occasional alcohol (10 - 12 drinks/month)
Occasional cannabis use from age 15 to a
caffeinated drinks/day (diet soda). No fore
in an intimate relationship. She plans on g
children someday. She denies suicidal an
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:28:33 GMT -06:00
2 2 first-attempt success and A+ Grade
https://www.cliffsnotes.com//study-notes/24378448
