NR 509 SHADOW HEALTH FOCUSED EXAM CASE: COMPREHENSIVE HEALTH HISTORY: LATEST,CHAMBERLAIN COLLEGE OF NURSING

NR 509 SHADOW HEALTH FOCUSED EXAM CASE:
COMPREHENSIVE HEALTH HISTORY ASSIGNMENT


Comprehensive Health History Assignment Results | Turned In
Advanced Health Assessment - Chamberlain - June 2019, NR509-June-2019
Return to Assignment




Your Results
Overview Lab Pass


Transcript

Subjective Data Collection Transcript
All Lines (291) Interview Questions (245) Statements (34) Exam Actions (12)
Objective Data Collection
Started: Jul 10, 2019 | Patient Exam Time: 124 min

Education & Empathy

Documentation
Exam Action
Information Processing Height: 170 cm 07/10/19 6:45 PM
CDT
Health History Tips and Tricks

Self-Reflection Exam Action
Weight: 90 kg 07/10/19 6:45 PM
CDT


Exam Action
BMI: 31 07/10/19 6:45 PM
CDT


Exam Action
Random blood glucose: 238 07/10/19 6:45 PM
CDT


Exam Action
Temperature: 101.1 F 07/10/19 6:45 PM
CDT


Exam Action
Blood pressure: 142/82 07/10/19 6:45 PM
CDT


Exam Action
Respiratory rate: 19 07/10/19 6:45 PM

1/34

,CDT




2/34

, Exam Action
07/10/19 6:45 PM
CDT


Exam Action
Heart rate: 86 07/10/19 6:45 PM
CDT


Greet
hello. My name is Tneshia Richards. I will be your provider today.
07/10/19 6:47 PM
CDT


Hey.




Question
07/10/19 6:47 PM
What is your name CDT




Tina Jones.


Question
what is your date of birth Mrs. Jones
07/10/19 6:47 PM
CDT




February 17th.


Question
what year were you born in
07/10/19 6:47 PM
CDT


I was born in . . . [Ms. Jones reports correct birth year.]



Question
what brings you in today?
07/10/19 6:48 PM
CDT

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 pre




Empathize
I'm sorry to hear that you are having pain.
07/10/19 6:48 PM
CDT


I appreciate you saying that.



Question
which foot did you scrape
07/10/19 6:48 PM
CDT




3/34

, My right foot.



Question
when did the scrape occur
07/10/19 6:49 PM
CDT

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




which part of the foot is the scrape on (Clarified to Where is the cut on your foot?.) Question
07/10/19 6:49 PM
CDT

It's on the ball of my foot. (Clarified to where the scrape is on my foot.)




Question
what is your pain level
07/10/19 6:50 PM
CDT


I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet.



Question
describe how the pain feels
07/10/19 6:50 PM
CDT


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



Question
what makes the pain worse
07/10/19 6:51 PM
CDT

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 pi




Question
what makes the pain better
07/10/19 6:51 PM
CDT


The pain pills help for a few hours.



Question
does resting the foot help with the pain
07/10/19 6:51 PM
CDT

Putting my foot up helps a little I guess, but the only thing that makes a real difference is the pain pills.



where did you get pain pills from
Question
07/10/19 6:52 PM
CDT


4/34