Focused Exam-NR-509 Advanced Physical Assessment-End of Life-Completed-Shadow_Health.pdf.pdf

Cate gory 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. Chief Complaint Established chief complaint Reports painPatient Comfort and Status Asked about fluid intake and hydration Denies current thirst Reports very little water intake in the past week Reports a few sips of ginger ale today Asked about urinary comfort Reports last urination was around 10 AM Denies pain or burning with urination Asked about most recent meal Denies current hunger Reports no food intake todaycare Reports wanting to be in hospice care Asked about advanced directives Reports having an advanced directive History of Present Illness Asked about onset and duration of pain Pain became unbearable 2 days ago Reports pain increasing over the past 2 days Reports experiencing some pain most of the time Asked about location of pain Reports bone pain Reports pain in legsCate gory 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. Chief Complaint Established chief complaint Reports painPatient Comfort and Status Asked about fluid intake and hydration Denies current thirst Reports very little water intake in the past week Reports a few sips of ginger ale today Asked about urinary comfort Reports last urination was around 10 AM Denies pain or burning with urination Asked about most recent meal Denies current hunger Reports no food intake todaycare Reports wanting to be in hospice care Asked about advanced directives Reports having an advanced directive History of Present Illness Asked about onset and duration of pain Pain became unbearable 2 days ago Reports pain increasing over the past 2 days Reports experiencing some pain most of the time Asked about location of pain Reports bone pain Reports pain in legs