Health - Tina Jones, Health History ////// Health - Tina Jones, Health History ;///// Health - Tina Jones, Health His

Health - Tina Jones, Health History Medications ANS Albuterol MDI, 2 puffs every 4 hours as needed for wheezing Acetaminophen 325 mg tabs by mouth, 2 tabs every 4 hours as needed for fever greater than 38.6C /101.5F Clindamycin 600mg/50ml every 6 hours intravenously 0.9 NaCl intravenously 100 ml/hr continuously x2 Liters Lortab 5mg 1-2 tabs by mouth as needed for pain Oxycodone 5mg 1 tab by mouth as needed Insulin glargine 10 units at bedtime Health History Tips & Tricks: ANS Student: Hello! ANS Diana Shadow: Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. Student: What is the situation? ANS Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Student: What are my objectives in this assessment? ANS Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones' overall health. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM Jones' health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. Student: What else will this exam involve? ANS Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real- world counterparts, but they are not automatically graded by the simulation. Student: How will I be evaluated? ANS Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically. Student: How does this assignment prepare me for the real world? ANS Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses. Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient's complete health history? ANS Student: Getting a complete health history enables the nurse to make informed judgments about the client including formulating nursing diagnoses requiring nursing care, identifying collaborative problems requiring interdisciplinary care, medical issues requiring immediate referral, and the need for client teaching. Diana Shadow: Time to begin. ANS Patient Exam - Vital Signs: ANS Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98% Patient Exam - Interview: ANS Student: Hello, my name is Rachel and I am your nurse today. ANS Tina Jones: Hey. Student: Can you confirm your name? ANS Tina Jones: Tina Jones:. Student: What brings you in today? ANS Tina Jones: I got this scrape on my foot a CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM while ago, CLASSROOM and it got really infected. It's killing me. CLASSROOM CLASSROOM Student: Where is your wound located? ANS Tina Jones: It's on the ball of my foot. Student: Which foot is injured? ANS Tina Jones: My right foot. Student: I'm sorry to hear that. I'm glad you came in to get your foot evaluated. ANS Tina Jones: Thanks a lot. Student: Can you tell me how you scraped your foot? ANS I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! Student: Can you rate your current pain level on a scale of 0 to 10? ANS Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. Student: Can you describe the pain? ANS Tina Jones: It's throbbing and like, sharp if I try to put weight on it. Student: Have you had any other symptoms? ANS Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on. Student: When did you first notice the pus? ANS Tina Jones: I noticed it about 2 days ago. Student: What color was the pus? ANS Tina Jones: It's... white or maybe off-white. Student: Did your foot bleed? ANS Tina Jones: It bled a little after I injured it. Student: How have you been treating your foot? ANS Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it. Student: How have you treated the wound? ANS Tina Jones: I've been taking Advil for my foot for a few days. Student: Was the Neosporin effective? ANS Tina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk on your injured foot? ANS Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: How effective was your pain medication at home? ANS Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours. Student: Have you had any fever at home? ANS Tina Jones: Yeah, I started to have one yesterday, and then it was a little better this morning. It kinda crept up all day. CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM Student: Do you have any preexisting medical conditions? ANS Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Student: I understand your foot hurts. We have to ask a lot of questions, but it's to ensure we treat your injury and anything else that could contribute to the problem. ANS Tina Jones: That's kind of you. Student: When were you diagnosed with diabetes? ANS Tina Jones: I was diagnosed when I was 24. Student: How do you manage your asthma? ANS Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Student: What medications did you take for your diabetes? ANS Tina Jones: It was metformin. Student: Do you currently take medicine for your diabetes? ANS Tina Jones: No, I don't take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? ANS Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Student: Do you monitor your blood glucose? ANS Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Student: Do you get thirsty often? ANS Tina Jones: You know, I did notice lately that I've been really thirsty. Student: How frequently do you urinate? ANS Tina Jones: I don't know. Every hour or two when I'm awake? Student: What is your current diet? ANS Tina Jones: It's pretty good, I think. I'm not a huge health nut or anything. Student: Have you had a change in appetite? ANS Tina Jones: Yeah, lately I've definitely been much hungrier than usual. Student: Have you had any changes in your weight? ANS Tina Jones: Yeah, I've lost some weight recently. Student: Do you know what caused your weight loss? ANS Tina Jones: I don't know what caused it, I just lost weight. CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM Student: How often do you have asthma exacerbations? ANS Tina Jones: I haven't had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week. Student: What asthma symptoms have you experienced? ANS Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. Student: Does anything else worsen your asthma? ANS Tina Jones: Cats are the worst for my asthma--no matter what, if I'm around cats, my breathing gets bad. But sometimes it gets bad from being around dust or having to run upstairs, too. Student: Do you have a rescue inhaler? ANS Tina Jones: Yeah, I use it when my asthma acts up. Student: How many puffs do you take when using your asthma inhaler? ANS Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What allergies do you have? ANS Tina Jones: I'm allergic to cats. Student: How long have you had a cat allergy? ANS Tina Jones: For as long as I've been around. Student: What medication allergies do you have? ANS Tina Jones: I'm allergic to penicillin. Student: How old were you when you had an allergic reaction from penicillin? ANS Tina Jones: I don't remember I was really young. I must have been sick or something. Student: Do you have any food allergies? ANS Tina Jones: Nope, no food allergies that I know of. Student: Are you allergic to latex? ANS Tina Jones: Nope. Student: Are you allergic to dust, mold, or pollen? ANS Tina Jones: Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. Student: Are you up to date on all immunizations? ANS Tina Jones: I'm pretty sure my shots are current, yeah. Student: What immunizations have you received? ANS Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I have a record somewhere at home. Student: Have you received a flu vaccine? ANS Tina Jones: No. CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM Student: The most effective way to influenza vaccine and using prevent influenza is simple in