Science Medicine Nursing
Shadow Health - Tina Jones, Health History exam with
solution
Students also studied
C
Terms in this set (351)
Subjective Data Collection - Checklist:
Chief Complaint
Finding: Established chief complaint
Finding: Reports pain (Found)Pro Tip: Initially Example Question: Do you have any pain?
establishing a chief complaint allows the
patient to express their reason for seeking
care, primary concerns, or condition they
are presenting with.
Finding: Reports foot wound (Found)Pro Tip: Example Question: What's causing your pain?
If a patient mentions pain, it's important to
determine what specifically is causing
her pain, if she knows.
History of Presenting Illness
Finding: Asked to rate current pain level on
a scale
Finding: Reports current pain is 7/10 Example Question: Can you rate the pain on a scale of 0
to (Found)Pro Tip: Asking your patient to rate 10?
her pain on a scale of 0 to 10 is important
to gauge how it ebbs and flows while she is
in your care.
,Finding: Asked for details about the pain
Finding: Reports pain is throbbing Example Question: Can you please describe the pain?
(Found)Pro Tip: Determining how your
patient describes the characteristics of
the pain can be important data to support
the cause of the pain.
Finding: Reports pain is sharp when she Example Question: What is the pain like when you stand
on attempts to stand (Found)Pro Tip: your foot?
Determining what physical activities and
movements exacerbate the patient's pain
can help you better understand the
problems and assess treatment needs.
This can also alert you if a patient's
activities of daily living are hindered.
Finding: Reports pain has increased in the Example Question: How has the pain changed over time?
past 2 days (Available)Pro Tip:Finding out
how the patient's pain has changed will give
you insight into the acceleration of infection.
Finding: Reports feeling pain radiating into Example Question: Does the pain radiate anywhere else?
ankle (Available)Pro Tip: Asking about where
else the patient's pain radiates can
help determine the progression of
infection.
Finding: Reports pain prevents bearing Example Question: Can you bear weight on your foot?
weight on foot (Found)Pro Tip: Determining
if your patient can bear weight on an injury
is important to determine their risk for falls
while in your care.
Finding: Asked location of wound
Finding: Reports right foot is injured Example Question: Which foot is in
pain? (Found)Pro Tip: Confirming which extremity
an injury is located is a best practice for
your patient's safety.
Finding: Reports wound is on the plantar Example Question: Where is the wound?
surface of her foot (Found)Pro Tip:
Confirming where a wound is located
ensures you are aware of your patient's
biggest complaint.
Finding: Asked details of the injury
Finding: Reports she scraped foot on Example Question: How did your injury happen?
bottom rung of a step stool (Found)Pro Tip:
Discovering how an injury happened
helps to assess your patient's risk factors for
injury.
,Finding: Reports injury occurred 1 week ago Example Question: When did your injury occur?
(Available)Pro Tip: Discovering how long
ago the pain began is the first step in
understanding whether the pain is chronic
or acute.
Finding: Denies other injuries besides foot Example Question: Did you injure anything besides your foot?
wound (Available)Pro Tip: Discovering
additional injuries can reveal more
information about the circumstances that
caused the presenting injury.
Finding: Reports being barefoot at the time Example Question: Were you wearing shoes when you fell?
of injury (Available)Pro Tip: Asking about
clothing, footwear, and other protective
elements being worn at the time of injury
helps you discover the totality of the
circumstances.
Finding: Denies seeing a healthcare provider Example Question: Have you seen a healthcare
provider for for the injury until now (Available)Pro Tip: It's this injury?
crucial to ask whether your patient has seen
another provider for the injury, because any
previous medical intervention will help you
understand the progression of the wound.
Finding: Asked about drainage from the foot
wound
Finding: Reports that the wound bled a littleExample Question: Did your foot bleed?
after sustaining the injury (Available)Pro Tip:
Asking about bleeding helps you determine
the characteristics of a wound.
Finding: Reports seeing pus draining from Example Question: Did you notice any discharge from the
wound (Found)Pro Tip: Asking about wound?
discharge helps you determine the
characteristics of a wound.
Finding: Reports noticing pus 2 days ago Example Question: When did you first notice the pus?
(Available)Pro Tip: Pinpointing exactly when
the patient noticed the arrival of pus gives
you an important data point for when
an active infection began.
Finding: Followed up on drainage
Finding: Reports pus as white or yellow Example Question: What color is the drainage from
your (Found)Pro Tip: The color of discharge from wound?
a wound can provide insight into its severity
and characteristics.
, Finding: Denies odor from the wound Example Question: Does the wound have an odor?
(Available)Pro Tip: The odor of discharge
from a wound can provide insight into its
severity and characteristics.
Finding: Asked about home treatment
of foot wound
Finding: Reports wound care regimen of Example Question: How often do you change your bandage?
bandaging (Available)Pro Tip: Asking
specifically how often a patient changed a
bandage will let you know if an infection
spread through improper hygiene, or for
other reasons such as uncontrolled blood
sugar.
Finding: Reports cleaning wound twice a Example Question: How often did you clean the wound?
day (Available)Pro Tip: Asking specifically
how often a patient cleaned a wound will let
you know if an infection spread through
improper hygiene, or for other reasons such
as uncontrolled blood sugar.
Finding: Reports applying bacitracin, Example Question: Did you use any ointment on the
wound? neomycin and polymyxin B (Neosporin)
(Found)Pro Tip: Determining what products
a patient used to sterilize or treat a wound
establishes home care routines and health
literacy.
Finding: Followed up on effectiveness of
ointment
Finding: Reports bacitracin, neomycin and Example Question: Did the ointment
help? polymyxin B (Neosporin) was ineffective
(Found)Pro Tip: Understanding the effect of
a home medication can help you determine
the severity of the wound. Tina's
diabetes
diagnosis will have a large impact on her
body's healing ability, which should be
taken into consideration during your
exam.
Finding: Asked about other foot wound
symptoms
Finding: Reports swelling around foot Example Question: Is there swelling around the wound?
wound (Found)Pro Tip: Asking about the
presence of swelling helps you gather
information about your patient's complaint,
as well as potential related illnesses.
Shadow Health - Tina Jones, Health History exam with
solution
Students also studied
C
Terms in this set (351)
Subjective Data Collection - Checklist:
Chief Complaint
Finding: Established chief complaint
Finding: Reports pain (Found)Pro Tip: Initially Example Question: Do you have any pain?
establishing a chief complaint allows the
patient to express their reason for seeking
care, primary concerns, or condition they
are presenting with.
Finding: Reports foot wound (Found)Pro Tip: Example Question: What's causing your pain?
If a patient mentions pain, it's important to
determine what specifically is causing
her pain, if she knows.
History of Presenting Illness
Finding: Asked to rate current pain level on
a scale
Finding: Reports current pain is 7/10 Example Question: Can you rate the pain on a scale of 0
to (Found)Pro Tip: Asking your patient to rate 10?
her pain on a scale of 0 to 10 is important
to gauge how it ebbs and flows while she is
in your care.
,Finding: Asked for details about the pain
Finding: Reports pain is throbbing Example Question: Can you please describe the pain?
(Found)Pro Tip: Determining how your
patient describes the characteristics of
the pain can be important data to support
the cause of the pain.
Finding: Reports pain is sharp when she Example Question: What is the pain like when you stand
on attempts to stand (Found)Pro Tip: your foot?
Determining what physical activities and
movements exacerbate the patient's pain
can help you better understand the
problems and assess treatment needs.
This can also alert you if a patient's
activities of daily living are hindered.
Finding: Reports pain has increased in the Example Question: How has the pain changed over time?
past 2 days (Available)Pro Tip:Finding out
how the patient's pain has changed will give
you insight into the acceleration of infection.
Finding: Reports feeling pain radiating into Example Question: Does the pain radiate anywhere else?
ankle (Available)Pro Tip: Asking about where
else the patient's pain radiates can
help determine the progression of
infection.
Finding: Reports pain prevents bearing Example Question: Can you bear weight on your foot?
weight on foot (Found)Pro Tip: Determining
if your patient can bear weight on an injury
is important to determine their risk for falls
while in your care.
Finding: Asked location of wound
Finding: Reports right foot is injured Example Question: Which foot is in
pain? (Found)Pro Tip: Confirming which extremity
an injury is located is a best practice for
your patient's safety.
Finding: Reports wound is on the plantar Example Question: Where is the wound?
surface of her foot (Found)Pro Tip:
Confirming where a wound is located
ensures you are aware of your patient's
biggest complaint.
Finding: Asked details of the injury
Finding: Reports she scraped foot on Example Question: How did your injury happen?
bottom rung of a step stool (Found)Pro Tip:
Discovering how an injury happened
helps to assess your patient's risk factors for
injury.
,Finding: Reports injury occurred 1 week ago Example Question: When did your injury occur?
(Available)Pro Tip: Discovering how long
ago the pain began is the first step in
understanding whether the pain is chronic
or acute.
Finding: Denies other injuries besides foot Example Question: Did you injure anything besides your foot?
wound (Available)Pro Tip: Discovering
additional injuries can reveal more
information about the circumstances that
caused the presenting injury.
Finding: Reports being barefoot at the time Example Question: Were you wearing shoes when you fell?
of injury (Available)Pro Tip: Asking about
clothing, footwear, and other protective
elements being worn at the time of injury
helps you discover the totality of the
circumstances.
Finding: Denies seeing a healthcare provider Example Question: Have you seen a healthcare
provider for for the injury until now (Available)Pro Tip: It's this injury?
crucial to ask whether your patient has seen
another provider for the injury, because any
previous medical intervention will help you
understand the progression of the wound.
Finding: Asked about drainage from the foot
wound
Finding: Reports that the wound bled a littleExample Question: Did your foot bleed?
after sustaining the injury (Available)Pro Tip:
Asking about bleeding helps you determine
the characteristics of a wound.
Finding: Reports seeing pus draining from Example Question: Did you notice any discharge from the
wound (Found)Pro Tip: Asking about wound?
discharge helps you determine the
characteristics of a wound.
Finding: Reports noticing pus 2 days ago Example Question: When did you first notice the pus?
(Available)Pro Tip: Pinpointing exactly when
the patient noticed the arrival of pus gives
you an important data point for when
an active infection began.
Finding: Followed up on drainage
Finding: Reports pus as white or yellow Example Question: What color is the drainage from
your (Found)Pro Tip: The color of discharge from wound?
a wound can provide insight into its severity
and characteristics.
, Finding: Denies odor from the wound Example Question: Does the wound have an odor?
(Available)Pro Tip: The odor of discharge
from a wound can provide insight into its
severity and characteristics.
Finding: Asked about home treatment
of foot wound
Finding: Reports wound care regimen of Example Question: How often do you change your bandage?
bandaging (Available)Pro Tip: Asking
specifically how often a patient changed a
bandage will let you know if an infection
spread through improper hygiene, or for
other reasons such as uncontrolled blood
sugar.
Finding: Reports cleaning wound twice a Example Question: How often did you clean the wound?
day (Available)Pro Tip: Asking specifically
how often a patient cleaned a wound will let
you know if an infection spread through
improper hygiene, or for other reasons such
as uncontrolled blood sugar.
Finding: Reports applying bacitracin, Example Question: Did you use any ointment on the
wound? neomycin and polymyxin B (Neosporin)
(Found)Pro Tip: Determining what products
a patient used to sterilize or treat a wound
establishes home care routines and health
literacy.
Finding: Followed up on effectiveness of
ointment
Finding: Reports bacitracin, neomycin and Example Question: Did the ointment
help? polymyxin B (Neosporin) was ineffective
(Found)Pro Tip: Understanding the effect of
a home medication can help you determine
the severity of the wound. Tina's
diabetes
diagnosis will have a large impact on her
body's healing ability, which should be
taken into consideration during your
exam.
Finding: Asked about other foot wound
symptoms
Finding: Reports swelling around foot Example Question: Is there swelling around the wound?
wound (Found)Pro Tip: Asking about the
presence of swelling helps you gather
information about your patient's complaint,
as well as potential related illnesses.
